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editorial
. 2021 Jan 6;112(3):493–497. doi: 10.17269/s41997-020-00445-9

(Re)claiming our bodies using a Two-Eyed Seeing approach: Health-At-Every-Size (HAES®) and Indigenous knowledge

Monica Cyr 1,✉, Natalie Riediger 1,2
PMCID: PMC8076392  PMID: 33410123

Abstract

We originally proposed a study to examine changes in disparities in “obesity” between Indigenous and non-Indigenous Canadian populations, as called for in the Truth and Reconciliation Commission, Article 19 (2015), which calls for ongoing monitoring of disparities in health outcomes. Instead, we questioned the importance of reducing the prevalence of “obesity” as a health goal for Indigenous peoples. This critical commentary provides an overview of Canadian Indigenous populations’ weight, its relationship with health outcomes, and weight stigma and discrimination, using an Indigenous feminist lens. We introduce the applicability of a Two-Eyed Seeing approach utilizing a Health-At-Every-Size (HAES®) model and Indigenous ways of knowing, as a starting point, to understand weight, health, and our bodies. A new paradigm is needed to identify and close health gaps as noted in Article 19 of the Truth and Reconciliation Calls to Action (2015). We respectfully call upon health professionals and public health bodies to acknowledge the harm of weight stigma and discrimination in their practice and policies, and we encourage Indigenous peoples to (re)claim and (re)vitalize body sovereignty.

Keywords: Obesity, Diabetes, Indigenous, HAES, Weight stigma and discrimination

Introduction

We originally undertook a study to examine changes in disparities in “obesity” between off-reserve Indigenous1 and non-Indigenous populations in Canada in 2004 and 2015, using the Canadian Community Health Survey – Nutrition (CCHS). Though this study was undertaken to develop goals to close health gaps, as called for in Article 19 of the Truth and Reconciliation Commission of Canada (2015), we found ourselves increasingly questioning the importance of reducing the prevalence of “obesity”2 as a health goal for Indigenous people. Focusing on weight detracts attention from other more detrimental inequalities currently negatively affecting Indigenous peoples’ health, such as racism, and economic and social disparities. Furthermore, weight-neutral scholars firmly posit that stigmatizing effects associated with weight bias stem directly from the biomedical “obesity” narrative (Bacon 2010; Bombak 2014; Aphramor 2009; Brady and Beausoleil 2018, p. 631). We argue that classifying Indigenous peoples as “obese” opposes reconciliation, and instead propagates cycles of colonial violence, perpetuating shame and stigma, on an already oppressed population (Warbrick et al. 2018).

In this critical commentary, we, a Métis scholar, Registered Dietitian, and Director of Primary Care and settler academic in the disciplinary area of public health nutrition, discuss (i) diabetes and “obesity” among Canadian Indigenous populations; (ii) weight and its relationship with health outcomes among Indigenous peoples; (iii) weight stigma and discrimination; and (iv) the proposal of a new approach using Two-Eyed Seeing, including Health-At-Every-Size and Indigenous perspectives. We propose a new approach in the interest of (re)embracing and (re)vitalizing Indigenous epistemologies to improve health and well-being. Throughout, we apply an Indigenous feminist lens, which offers a powerful anti-colonial critique in the lives of Indigenous women (Suzack 2010; Czyzewski 2011).

Diabetes and “obesity” among Indigenous populations

“Obesity” is primarily a concern because of its purported relationship with type 2 diabetes, the prevalence of which is significantly higher among First Nations populations compared with non-First Nations (Dyck et al. 2010; Oster et al. 2011). Notably, unlike non-First Nations populations, First Nations women experience a higher burden of diabetes compared with First Nations men (Dyck et al. 2010; Oster et al. 2011).

Though “obesity” prevalence has been reported to be increasing among Canadian Indigenous populations (Kolahdooz et al. 2017), differences in body composition between Indigenous and non-Indigenous populations have also been noted. Specifically, Indigenous people have been observed to have a more central body fat distribution (Chateau-Degat et al. 2011; Oster and Toth 2009), and to which metabolic disturbances have been attributed, rather than weight per se. In this way, many have argued for ethnic specific cutoff values for both body mass index (BMI) and/or waist circumference, which include lower cutoffs for Indigenous people whereby risk is increased (Lear et al. 2007; Genest et al. 2009). By using lower cutoff values, in essence, more Indigenous bodies are pathologized. This interpretation, as a matter of assumptions, rejects the notion that weight may not be causally related to, or a main causal factor for, metabolic disease among Indigenous people.

Weight, diabetes, and health

While research among Indigenous populations is limited, we have previously reported that neither BMI nor waist circumference was a significant, independent predictor of incident diabetes in a First Nation cohort (Riediger et al. 2017a). Furthermore, in the same cohort, two thirds of participants with diabetes lost weight, including nearly one third who lost more than 10 kg; uncontrolled blood glucose, as measured using HbA1c, was positively associated with weight loss (Riediger et al. 2017b). Similarly, among First Nations children and adults with type 2 diabetes, BMI was significantly lower among those who also had a particular genetic variant (Sellers et al. 2002; Hegele et al. 1999). β cell dysfunction, or deficiencies in insulin secretion, were found to be the main driver of type 2 diabetes among First Nations people with this genetic variant (Sellers et al. 2002; Hegele et al. 1999), NOT insulin resistance, which is more commonly associated with “obesity.” All these results suggest that, within Indigenous populations, measures of body weight may not be particularly useful in predicting the risk of type 2 diabetes.

That excess weight leads to increased morbidities and mortalities is the relentless messaging ascertained by the dominant hegemonic “obesity” framework, despite substantive evidence discrediting such claims (Monaghan et al. 2018; Ellison et al. 2016; O’Hara and Taylor 2018). The pursuit of weight loss persists even though treatments for weight loss have proven to be mostly ineffective and harmful (Bacon 2010; Bacon and Aphramor 2011; O’Hara and Taylor 2018). Moreover, it could be argued prescriptive weight loss in the name of health is steeped in colonial hypocrisy; for Indigenous peoples, historically, losing weight was symptomatic of numerous starvation tactics deployed through colonization. For example, survivors of Canadian Residential Schools attest to starvation tactics such as being fed rotten food, food that was devoid of nutrition, and food low in calories (Cyr and Slater 2016). Moreover, Mosby and Galloway (2017) ascribe long-term biological effects of malnutrition among Residential School survivors that clearly links starvation tactics with increased risk of acquiring diabetes later in life. Therefore, by focusing on weight loss as a positive step towards diabetes management or prevention, we are overlooking profound historical trauma and political oppression that has yet to be reconciled.

Weight stigma and discrimination

Discrimination is defined as societal perceptions and biases that unfairly disadvantage one or more groups over another (Warbrick et al. 2018). Weight discrimination, by extension, is the prejudicial biases held against the attribute of excess body weight or “fatness,” in which those who reside in larger sized bodies experience social devaluation, internalized shame, and disgrace, known as stigma (Bacon 2010; Tomiyama 2014). As a result, the waged war on “obesity” has created a disturbingly socially acceptable form of prejudice against larger sized bodies (Tomiyama 2014; Warbrick et al. 2018). Moreover, weight stigma hurts women much more than men, which stems directly from oppressive patriarchal masculinity (Boisvert 2012). Yet to be explored are the unheard voices of Indigenous women and how weight stigma and discrimination further exploit Indigenous women’s and girls’ nationhood and sovereignty using an intersectional lens (Clark 2016; Crenshaw 1989; Combahee River Collective n.d.f).

Personal responsibility framing promulgates the obesity narrative (O’Hara and Taylor 2018), echoing the burdening and demoralizing message—if you are fat, it’s your fault. For Indigenous groups, blame and shame are hardly new narratives steeped in settler dissatisfaction. However, Warbrick et al. (2018) point out “Indigenous blaming” is not a solution nor advances Indigenous health outcomes. For example, personal responsibility framing is seen among health promotion recommendations such as Canada’s Food Guide – First Nations, Inuit, and Métis, which urges Indigenous people to incorporate more traditional foods, or land-based foods, as a means to preserve health (Government of Canada 2010); however, returning stolen lands so that traditional food restoration can begin is anything but on the radar of an actionable pursuit in Canadian politics (Yellowhead Institute 2019).

Two-Eyed Seeing: Health-At-Every-Size and Indigenous perspectives

Two-Eyed Seeing, or Etuaptmumk, as proposed by Mi’kmaq Elder Albert Marshall (Hatcher et al. 2009), is an epistemic concept aimed to create an equally shared understanding that both Western science and Indigenous science have strengths that when combined have the power to elevate health initiatives and overall well-being for Indigenous peoples and communities. Martin (2012) posits that only until we work together inviting the richness from diverse worldviews, inside dominant Western perspectives, will we seek to ask different questions and by extension find alternative health solutions.

Here, we introduce Health-At-Every-Size (HAES)® and aspects of Indigenous philosophies that are relevant to how we view Indigenous bodies. The principles of HAES® are housed by the Association of Size Diversity and Health (ASDAH), an international community whose purpose is to change societal perspectives attached to body shape and size by supporting a global transformation in the ways in which people see and treat other people (ASDAH n.d.). Rather than fixating on weight or BMI, deeply ingrained Western concepts attached to health and beauty, the five main principles of HAES® are rooted in alternative approaches to weight centeredness. The principles are: size acceptance; advocating for equitable health policies; working towards dismantling biases, stigma, and discrimination associated with weight; promoting holistic eating practices not based in weight control; and supporting enjoyable movement that people choose (ASDAH n.d.). We also acknowledge critiques of HAES® for its tendency to lean towards healthism and individualism (Brady et al. 2013; Bombak et al. 2019), where healthism is “the preoccupation with personal health as a primary – often the primary – focus for the definition and achievement of well-being” (Crawford 1980, p. 368). Indigenous perspectives do not disregard individual responsibility for health, rather health and well-being are individual, as well as family, community, and societal responsibilities that must be balanced. This is how we view Indigenous perspectives in building on the principles of HAES®.

Indigenous feminism is about building solidarities and advocating for similar actions under the umbrella of social justice (Green 2017). Indigenous epistemologies such as reconnecting with land, reconnecting with ways of knowing through Indigenous languages, facing fear through spiritual stamina, regaining self-sufficiency and health through traditional means, and restoring learning-teaching relationships to foster family and community strength (Alfred and Corntassel 2005) can enhance an HAES® approach for Indigenous people. Importantly, in the Prairies, many ancestral Nations were historically governed by Clan Mothers, and pragmatic solutions to decrease the rampant spread of diabetes within Indigenous populations exist through matrilineal ancestral knowledge systems. According to the Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls (MMIWG 2019), including the voices of Indigenous women, girls, and 2SLGBTQQIA must be propelled to the forefront, especially for matters concerning body sovereignty.

Conclusion

The greater the disconnect from cultural connections, the higher the burden of disease among Indigenous populations. Rather than focusing on “obesity,” another area where Indigenous people are “failing” to improve their own health outcomes, according to compounded racialized perceptions from society and the biomedical community, there needs to be a focus on self-determination, self-love, healing mechanisms, and (re)connecting to cultural health. The “obesity as disease” position is not, in our view, a productive approach to wellness for Indigenous peoples, contrary to recent national guidelines (Wharton et al. 2020). More research is needed to reveal the extent to which weight stigma affects Indigenous people. We also need to further document and develop Indigenous knowledges and frameworks proposed in this paper and by Indigenous scholars to advance reconciliation and spur intergenerational healing and love within our bodies, families, and communities.

Acknowledgements

We would like to acknowledge the partnership, support, and guidance for this work by Jeff LaPlante, Executive Director of the National Indigenous Diabetes Association.

Funding

This work has been funded by the Canadian Institutes of Health Research (CIHR), Canadian Community Health Survey Nutrition Analysis (Grant #151546). NDR is the recipient of a CIHR Early Career Investigator Award (2018-2022; grant #155435).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

1

Indigenous People in Canada are comprised of First Nations, Métis, and Inuit. Where applicable, we have used the most specific name to refer to the Indigenous group or population.

2

We have included “obesity” in quotations to signify its medicalized and contested use (Meadows and Danielsdóttir 2016).

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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