Archive for July, 2011

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July 25, 2011

the Haes files: public health authorities need to be held accountable

by healthateverysizeblog

 by Lily O’Hara, Section Head for Health Promotion, Health Authority – Abu Dhabi

The dominant health paradigm  governing public health action from government departments and health care organisations is the weight centered health paradigm, where body weight is positioned as the single biggest problem in health today. But is this paradigm consistent with the values and principles of modern health promotion?(good rhetorical questions) Shouldn’t government departments and health care organisations be engaging in the most up to date practices? Would we accept other forms of health care that were based on outdated knowledge and beliefs? As our scientific and other forms of knowledge grow, sometimes exponentially, health care practices change and develop to take account of the new knowledge. This is what happens in most of the health care world EXCEPT in the area of weight.  

 Modern health promotion is the process of enabling people to increase control over the determinants of health. Research over the last 100 years has taught us that the determinants of health are extensive, multilayered and interconnected. Determinants are biological (such as genes and age), cognitive or psychological (such as knowledge, attitudes and beliefs), behavioral (including physical, mental, social and spiritual practices), and environmental (social, cultural, economic, political, natural and built environments). These determinants operate at the individual, family, group, community, population and global levels. In ecological science, these levels are referred to as nested hierarchies and the interconnections are referred to as feedback loops. So we know that health is complex.

 But that’s not the message we hear from our public health authorities. In fact, it’s just the opposite. Health is simple – it’s about how fat you are. And the answer is simple – eat less bad/wrong/unhealthy food, eat more good/right/healthy food, and move more and you will lose weight and therefore be healthier. Unfortunately for the authorities that is Just. Not. True. And saying it is will not make it so.

 Clearly body weight casts such a long dark shadow over the practice of modern health care that it has effectively created an enormous blind spot. Otherwise thoughtful and evidence based health practitioners still uncritically buy into the fat=bad story and act accordingly.  

 In my own field of health promotion, the big picture story since 1978 at least, when the World Health Organisation adopted the goal of Health for All by the Year 2000, has been the need to address systemic health inequities within and between countries by focusing on the environmental determinants of health – commonly referred to as the social determinants of health – which are basically all of those factors beyond the control of the individual. Major conferences have been devoted to the social determinants of health, and there was even a World Health Organisation Commission addressing them. When it became clear we would not achieve health for all by 2000, the goal became Health for All by the 21st Century.

 Although criticized for being unrealistic, this aspirational goal has sought to focus our attention on reducing health inequities through addressing the structural determinants of health. As a result you’d think that modern health promotion practice would be focused on addressing poverty, reducing income inequity, creating peace, improving social relations, social security and social justice, empowering women, respecting human rights, and creating healthier, sustainable environments in which we live, work, play, learn and love. These are the health determinants that all countries participating in the World Health Assembly made a legal commitment to address through health promotion programs.

 But they are not living up to this commitment. A significant chunk of the global, national, state and local health promotion effort is still directed towards trying to change behaviors, and a narrow range of behaviors at that – what people eat and drink, how much they move and what drugs they use. These are the holy trinity of health promotion that you will find on the agenda of pretty much every health promotion government department, conference or journal.

 Many practitioners that are vociferous and outspoken advocates for programs that address the social determinants of health can somehow also engage in ‘obesity prevention’ practice. In the past few years ‘obesity prevention’ at a public health level has broadened to address the ‘obesogenic environment’. The rationale is that by altering the environment then the behaviors that ‘create obesity’ will be altered. So what sounds on the surface like a more sophisticated argument about the role of the environment in creating health, basically boils down to the same simplistic beliefs about body weight.

 It doesn’t seem possible that the same articulate and passionate health promotion practitioners that advocate for a socio-ecological approach to reducing structural inequities in health are the same people arming up in the ‘war on obesity’. The dissonance between the two approaches seems so obvious to me and everyone else using the HAESSM approach, but it’s a great big blind spot for them. I guess you just can’t see what you can’t see.

 The Health at Every Size® principles advocate practices that are known to enhance the health of people of ALL sizes (In addition the HAESSM approach opposes practices that perpetuate body size oppression. This means any form of oppression including bias, exploitation, marginalisation, discrimination, powerlessness, cultural imperialism, harassment or violence against people based on their body image, body size or weight. Furthermore, the HAESSM approach opposes any approach to health, eating or exercise, the provision of products, services or amenities which focuses on body weight or perpetuates body size oppression.

 Body size oppression is a social determinant of poor health. Public health authorities are supposed to improve the social determinants of health, not make them worse. They are meant to be working towards health for ALL people.  Governments have signed up to this through a succession of charters at the World Health Assembly. It’s time we held them accountable and demand the adoption of modern health promotion practice that is enhances health for all.

Posted in Lily O'Hara | 3 Comments »

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July 22, 2011

the HAES files: work of art or paint-by-number?

by healthateverysizeblog

by Michelle May, MD.

There is a harmful meme* (an idea gene; see additional definition at the end of this article) that has become so widespread, so ubiquitous, that it is accepted as normal. It has subtly integrated itself into our society’s beliefs, thoughts, language, behavior, and reality. It’s so pervasive that it has become “conventional wisdom” and therefore it is rarely questioned.

This meme is so insidious that most people who have it don’t even realize it. Even the people responsible for spreading it don’t recognize its potential for long term damage. In fact, most believe that they’re actually helping others when they pass along this meme. They might even feel defensive or irritated when they read this post. Hopefully they’ll keep reading anyway.

 So what is this Meme?

 This meme is the belief that restriction is healthy. It usually starts with information about nutrition or weight management that mutates into rules and restriction. But the blurring of the line between healthy eating and restrictive eating is the difference between a work of art and paint-by-number. Either way, you end up with a nice picture—until you get up close to take a look.

Healthy       vs.     Restrictive
In Charge   In Control
Nourishment    Diet
Fuel   Calories
Quality   Points
Healthy    Skinny
Aware   Preoccupied
Conscious    Consumed
Mindful   Vigilant
Information    Dogma
Guide   Rules
All foods fit    Good or bad
Balance   Perfection
Variety   Temptation
Moderation   Deprivation
Choosing    Earning
Deciding    Rationalizing
Flexible    Rigid
Hunger based    By the clock
Comfort   Portion sizes
Physical Activity   Penance
Effortless    Willpower
Trust   Fear
Learning   Failing
Self-acceptance   Condemnation
Enjoyment   Guilt
Pleasure   Shame
Freedom   Bondage

The main reason that this meme is so powerful is that it has a built-in protective mechanism: the underlying belief that being overweight is a sign of weakness and due to lack of self-control and gluttony. This belief ensures the survival of the meme because when one tries to restrict themselves (or others) it actually leads to feelings of deprivation and cravings for foods labeled as “bad.” That eventually leads to overeating which appears to prove the underlying beliefs. That leads to guilt, more restriction, and perpetuation of the meme. (I’ve called this the eat-repent-repeat cycle.)

One of the reasons that the meme is so successful at replicating itself is that it initially appears to be beneficial to its host so people intentionally seek it out. The empires of Weight Watchers®, Jenny Craig® and NutriSystem® (to name just a few) were built on their ability to successfully transfer this meme to millions.

For those that promote weight loss, “lifestyle change” and “healthy eating” have become euphemisms for “you’re going to be on this diet for the rest of your life.” I’m not trying to be critical; the meme is so subtle and so ingrained that they usually don’t even realize that restriction is at the core of their message.

How is this meme spread?

People are most prone to this meme if they weigh more than society says they should (or think they do). Everybody else that has the meme tries to pass it on to them in an effort to “help” them (or sell them something). It takes the form of rational suggestions, loving advice, and even harsh criticism. 

The meme spreads vertically through advertising, television, magazines, books, the Internet, and medical research. It is propagated by marketers, models, celebrities, reporters, experts, bloggers, legislators and academicians. It is then spread horizontally from doctor to patient, dietitian to client, friend to friend, wife to husband, and parent to child.

Some people who spread the meme are carriers but don’t actually manifest it themselves. For instance, some health and fitness professionals eat without restriction and participate in enjoyable physical activity but spread the meme when they put their patients or clients on diets and rigid exercise regimens.  

This meme is also swiftly moving from the United States to the rest of the world. Clearly, the meme hasn’t helped Americans and it won’t help overseas but it will continue to propagate itself until society recognizes its dangerous nature.

How do you get rid of this meme?

One way to cure this “restrictive is healthy” meme is to replace it with a new meme called Health at Every Size℠. This idea gene has the potential to paint a new picture of health. In my next post, I’ll talk about a few key steps for creating your own masterpiece!

* What’s a meme?  According to http://dictionary.reference.com/browse/memea meme is a unit of cultural information, such as a cultural practice or idea, that is transmitted verbally or by repeated action from one mind to another. Memes are the cultural counterpart of genes. According to Wikipedia http://en.wikipedia.org/wiki/Meme, like genes, some ideas will propagate less successfully and become extinct, while others will survive, spread, and, for better or for worse, mutate. Memeticists argue that the memes most beneficial to their hosts will not necessarily survive; rather, those memes that replicate the most effectively spread best, which allows for the possibility that successful memes may prove detrimental to their hosts.

Posted in Michelle May | 8 Comments »

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July 15, 2011

the HAES files: honey, I can’t shrink the kids – why the Obamas need a new doctor

by healthateverysizeblog

by Linda Bacon, PhD

 In a well-meaning attempt to improve the health of our nation’s children, Michelle Obama took Americans into her daughters’ pediatrician’s office. A few years back, she recollected on the Yahoo “Shine” website, their doctor warned her the girls’ BMIs were edging up. In other words, they were getting fat.

 “I certainly didn’t know that even a small increase in BMI can have serious consequences for a child’s health,” Obama confessed. The doctor urged attention to the quality of the girls’ diets, an appropriate health consideration for any patient. But why would he need to know a child’s BMI before advising her mom to switch from soda to water? Should thinner children just drink the sugar?

 Like most nutrition scientists and physiologists, I salute the First Lady’s ambition to help. Her “Let’s Move” program advocates many basic, low-cost lifestyle changes that could improve kids’ lives and health. Encouraging veggie plots in schools? Great. A model organic farm at the White House? Love it! Advocating for more parks and phys-ed classes? Brava.

 But, basing health care on routine BMI testing from the age of two? Bad—bad science, bad medicine, bad idea. So long as it’s framed around “ending obesity,” the otherwise admirable Let’s Move initiative is doomed to fail. “Fighting fat” for its own sake is futile and lacks scientific basis.

 There’s ample peer-reviewed evidence that eating and exercise have far more impact than weight on individuals’ health status. And that social injustice may trump them all as a health deterrent. Moreover, for all we know, fat may actually provide us with some protection: the Centers for Disease Control mortality analysis, consistent with the bulk of research on the topic, shows “overweight” people actually outlive those in the “normal” BMI range.

 The White House recommendation of BMI as an exam-room benchmark would place doctors on the cutting edge of statistical medicine—circa 1850. That’s when a Belgian astronomer first conceived the height-weight ratio. BMI has its uses for aggregate population studies, but as an individual diagnostic tool, it boasts all the predictive utility of discredited standbys like cranial measurements and the Four Humours. Proving just how arbitrary BMI-based categories can be, the National Institutes of Health adjusted its “normal” range downward in 1998, causing about 35 million Americans to “become overweight” overnight. They set the cutoff for overweight at 25 and for obesity at 30, yet the only relevant peer-reviewed research they cited didn’t find a statistically significant relationship between BMI and mortality until BMIs in excess of 40. Raising the standards would have been a more astute application of the science.

 The BMI back story is even more pathetic when applied to kids. Cutoff points for “overweight” and “obesity” were arbitrarily assigned based on comparison to what kids weighed a few decades back, without even the pretense of considering health data.

 Let’s Move’s fat-focus fails by inserting bogus BMI numbers and body-size bias into what is really a dialogue about health. Yes, many Americans of all ages eat too much that doesn’t nourish them and too little that does. As Ms. Obama rightly notes, our children are more familiar with fast food than family dinners and spend too much time watching screens. But the danger in all this isn’t fat; it’s disease. And the goal is not creating thinner citizens, because thin people get sick, too (and don’t necessarily enjoy lower mortality).

 BMI testing is worse than ineffectual – it’s damaging. The last thing kids need today is more body shame in a culture already hung up on celebrity waistlines and skeletal fashion templates. As a teen recently asked me at a school with an active obesity prevention campaign, “Don’t they understand how it feels to walk through the halls and be confronted with signs that say, ‘we don’t want anyone to look like you’?”

 Fitting into size-4 jeans confers little protection from body anxiety, either. Most thinner people also struggle with their weight demons. Whether from Let’s Move or The Biggest Loser, the “Be thin!” message hurts us all.

 Obesity alarmism impedes sound medicine in other ways too: People of all sizes deserve evidence-based care and remedies that, unlike weight-loss advice, are proven to work.

 Why let size bias and its damaging rhetoric undermine the best of Ms. Obama’s potentially powerful leadership on health? Instead, “let’s move” forward using sound science, without the BMI bugaboo and obesity distractions. By encouraging healthy behaviors for their own merits, rather than to fight fat, we can help children of all sizes and shapes achieve happier, healthier futures.

Posted in LInda Bacon | 8 Comments »

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July 3, 2011

the HAES files: call up your surly adolescent

by healthateverysizeblog

by Deb Burgard, PhD

In late June the FDA announced they would start placing gruesome photos on packs of cigarettes to depict “the negative health consequences of smoking.”  They apparently did research to find out which images were the most memorable and disturbing, but they failed to do research that demonstrated such images had any influence on quitting behavior – or, for that matter, buying behavior.

I can guess that this is exactly the sort of “intervention” that will backfire spectacularly, especially with teenagers.  Call up your inner Surly Adolescent, and what is her reaction to gore and guts and diseased lungs on a cigarette package?  “Bring. It. On!”  There will be competitions for who gets the grossest packs, which brands have the most disgusting pictures, and general “You Are Not the Boss of Me” behavior that is now even more compelling since she’s now here to prove a point.

So why do public health agencies continue to use money on corporate marketing techniques, rather than seeing what actually affects the frequency of quitting attempts and the length of smoking cessation following quitting? 

The parallels with messages about fear-and-loathing of fatness are striking.  In both cases, the authorities within public health agencies continue to assume that fear messages change behavior.  But the declines in overall smoking occurred during the period when laws were enacted banning smoking in most public places, while the fear messages have been a constant drumbeat for decades.  Behavior changes when environments make specific behaviors more inconvenient, or more convenient.   Punishing, on the other hand, has been shown over and over to result in unpredictable outcomes, often an increase in the behaviors targeted for elimination.

If we want people  – of all sizes – to do the practices that support health, like quitting smoking, moving their bodies, sleeping restfully, getting good medical care, eating better fuel for their bodies, loving and feeling loved, we need to make it easier to do those things.  We need to make access to those practices something available to anyone at any time, not just wealthy people with plenty of time on their hands.  And we need to help all people feel like they are worth this effort.  Instead we are practicing a policy of shaming and threatening, a message of, “if you look like this, you’re a loser.”  And we shouldn’t be surprised that people react to being shunned with anger and rebellion.

I actually love that most of us have an Inner Surly Adolescent, because she is the guardian of freedom, a True Patriot, and the surprising source of a lot of our mental health.  Surly Adolescents fight against rejection, bullsh*t, and tyranny.  But they have a vulnerability, which is that they tend to be surprisingly manipulate-able.  They do the opposite of what they’re being coerced or nagged to do, whether they want to do that behavior or not. 

So the Surly Adolescent, who might love to dance, will sit with her arms crossed on the sofa watching TV if she is told she should exercise.  She might love cantaloupe but if that’s what the diet allows, it will be the last thing she wants when she is proving that she gets to eat whatever she wants. 

So if you want her to thrive and use her energy for good, the last thing to do is use coercion or shaming, or even fear.  You have to show her respect.

We just adopted a couple wonderful little dogs.  Taking them to “obedience school” (what a throwback that phrase is) has been a great review of behavioral learning theory.  The course teaches the humans to think about how to arrange the environment so that it is easier for the dog to do what you are asking than not to.  It teaches the humans not to ask the dog to do something that isn’t realistic.  It reminds humans to keep the faith that the dog would rather find a way to behave that results in happiness and harmony.   I would like to send anyone who makes public health policy through obedience school. 

I think they would come out a lot more interested in Health at Every SizeSM.

Posted in Deb Burgard | 5 Comments »

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