Health at Every Size is a set of principles that focus on promoting overall health rather than weight loss in both children and adults. Research indicates it could be more effective than focusing on weight.
Amanda Raffoul, PhD, who studies health at every size policies and is an instructor in the Department of Pediatrics at Harvard Medical, and Stephanie Campbell, a Hawaii-based researcher with a doctorate in school psychology who studies weight-related stigma in the school setting, explain more about Health at Every Size and what it means for educators.
What is Health at Every Size
“Health at every size is a philosophy or a movement that reaches back decades and works under this core foundational element that weight is not the only or even a reliable determinant or indicator of a person's health,” says Raffoul. “Health at Every Size addresses that health and well-being are more holistic than just physical. It includes social-emotional health, and even physical health doesn't need to be determined by or limited by how high a person's weight is.”
Raffoul began studying Health at Every Size because her work focuses on preventing eating disorders. Her research indicates that Health at Every Size policies in school settings can do a better job of promoting health in young people while avoiding the unintended consequences of weight-focused interventions, which may include an increased chance of developing eating disorders and other negative outcomes.
Health at Every Size policies have gotten more attention in relation to schools and young people because the philosophy stands in stark contrast to the American Academy of Pediatric’s recently updated clinical practice guidelines in regard to children with obesity. Those guidelines call for intensive interventions for overweight children and adolescents, prescription treatments, and even surgery in some instances.
What Role Do Schools Currently Play in the Conversation Around Health?
Weight-related challenges are not often directly taken on by most schools.
“Despite their negative effects on the emotional, physical, and social wellbeing of students, weight stigma and anti-fat attitudes are rarely systematically addressed in schools or within school psychology,” Campbell wrote in one paper. “Weight-based oppression is regarded differently than other domains of prejudice.”
Campbell believes it is difficult for schools to overcome these stigmas because of how systemic weight-related stigma is in society, and it’s often hard even for progressive educators to understand their prejudice around weight, which she is dedicated to changing.
“We cannot be emotionally and mentally healthy when we're living under this deep oppression where we're forced to feel self-hatred and all these things that create really unhealthy habits," she says. "Youth eating disorders are extremely common in a way that I don't think we understand and measure because we don't have good data on that. But the data we have is already pretty damning.”
How Should These Policies Shift?
Raffoul says school policies can shift in a positive direction. “When we make the core focus of school programming reducing students’ weight or a students’ body mass index or BMI, we might be unintentionally promoting students to engage in unhealthy behaviors to achieve that weight loss,” Raffoul says. “We're also underselling students on the value of engaging in behaviors, like physical activity or healthful snacking, and the benefits they can present besides weight loss."
Even small tweaks in presentation can make a big difference. "So for example, when we reframe something like physical activity and instead of saying, 'Physical activity is a good way to lose or keep off weight,' we say, 'Physical activity will help you sleep better at night, or it might help you focus better on homework,' or 'Physical activity is a really good way for you to make friends by joining a running club or joining a soccer team.' Those types of reframing can have positive implications for the way people connect to food and exercise too.”
But Isn’t Weighing Less Healthier?
Weighing less is not necessarily healthier, say Health at Any Size advocates. “There are studies showing that having a higher weight is associated with some health consequences, but we have to dig a little bit deeper into why that is,” Raffoul says. “People with higher weights face a lot of discrimination, and studies have shown that that discrimination is associated with what we call an increased allostatic load, which is a physical indicator of stress. And we know from the literature on discrimination that people with higher allostatic loads will have worse cardiovascular and health outcomes because they're experiencing stress.”
This association between stress and health is perhaps better understood in the context of race, in which discrimination has been shown to take a physical toll and help fuel health disparities.
“Many studies show that people with higher weights face so much discrimination in medical settings, that they almost fear going to see the doctor and that avoidance of healthcare is associated with much worse health outcomes," says Raffoul. "One example of this is a couple of papers show that for women with higher weights, especially racial minority women with higher weights, they avoid going to the doctor for cervical cancer screening, and that actually means that they have have higher rates of cervical cancer.”
What Else Can Schools and Educators Do?
Educators being more mindful of how they talk about food in front of students is important, Campbell says. One progressive former teacher of Campbell’s who she still admires would regularly say problematic things about food without realizing it. “She'd say in front of a student like, ‘Oh, I'm gonna eat this cake, but I'm going to eat salad later, so it's okay,'” Campbell says. “[She was] accidentally putting these moralizing terms of what's good and bad on food in ways I think we don't realize can be pretty damaging, especially from a social justice perspective. We know that children especially don't have a lot of control over which foods they eat, or can access, or their parents can afford.”
Raffoul adds that existing research can help guide school policies around health and weight discussions to focus less on weight loss. “Talk more about things like body ideals and how they can be harmful and how your self-worth is not tied to your weight or your appearance,” she says. “Focus on the benefits of physical activity and nutrition for health.”
Additionally, she’d like to see more training for educators on how to detect potentially harmful weight engagement and for weight- and appearance-based bullying to get more attention alongside other types of bullying.
“I know that lots of schools and educators care a lot about preventing bullying or detecting bullying when it comes to gender, ethnicity, sexual orientation, but I don't know that a lot of the anti-bullying policies really zone in on weight or appearance-based bullying,” she says. “Improving those types of policies can help make schools more Health at Every Size-aligned.”