the HAES® files: Speculations on Healthism & Privilege

by Health At Every Size® Blog

by Fall Ferguson, JD, MA

Every once in a while – most often on Facebook or in the online comments to a blog post – I encounter the idea that the “health” part of the Health At Every Size® model is inherently oppressive and healthist. This criticism makes me uncomfortable, and I find myself bristling a bit. These are important signs that I have learned to recognize as signals of some unexamined and unprocessed privilege. I have written about healthism and the HAES model before, but maybe it’s time to take another look at healthism, this time in light of the concept of privilege.

The Nature of Healthism

Healthism was originally defined by Robert Crawford as a “preoccupation with personal health as a primary – often the primary – focus for the definition and achievement of well-being.” It has evolved into the often unspoken idea that there is a moral value to health; it emerges as the assumption that people should pursue health. It’s the contempt in the non-smoker’s attitude toward smokers; it’s the ubiquitous sneer against couch potatoes.” Healthism includes the idea that anyone who isn’t healthy just isn’t trying hard enough or has some moral failing or sin to account for.

Consider: how many times have you heard or said the words “I’m so bad” in reference to eating a sugary dessert or to choosing to stay home rather than go to the gym? The recent kerfuffle over Maria Kang’s “What’s Your Excuse?” viral Facebook message shows that the forces of healthism are alive and well in our culture (though it was refreshing to see how many people called out Kang’s bully tactics).

healthist memes

More subtly, healthism represents the widespread ethic of individual responsibility for health in our culture. In the debate over U.S. health care reform, we obsess over the health of individuals, whether it’s reshaping individual behavior to our liking or finding ways to pay for the expensive treatment protocols that we see as being needed because of people’s personal “failure” to care for their own health.

All of this ignores the global consensus that social determinants of health influence our health more than individual behaviors (see this and this, for example). Indeed, healthism obscures both the existence and the nature of health inequities. Even within the U.S. health care power structure, if you look closely enough, there is an acknowledgement that social and environmental factors affect health more than our individual health choices, as shown in this graph from the website of the Centers for Disease Control and Prevention (CDC):

determinants-pop-health

Unfortunately, this point is largely lost on us, if our public conversations about health are any indication. In my own field of health education/health promotion, there is a disturbing disconnect between the evidence about the social determinants of health and the profession’s focus on changing individual health behaviors. Even “ecological” approaches to health education, which are inspired by systems perspectives that highlight the interconnected web of health causes, tend to focus on the end result of changing individual behavior rather than collective solutions to health issues. A 2012 article in Health Education and Behavior reviewed 20 years of reported ecological health education interventions; the article acknowledged the field’s shortcomings in this arena, and noted that in addition to certain structural barriers, we may need to move past our own training: “health educators may not have the training or resources to successfully plan and implement institutional-, community-, or policy-level programs.”

Maybe it’s more than just our training that holds us back. Maybe we need to acknowledge our basic healthism instilled by our cultural milieu as well as our professional training. And maybe we need to unpack the privilege that has allowed us to focus so much attention on the role of individual behavior in health.

The Nature of Privilege

It seems to me that healthism is reflective of deep privilege; it is (in my opinion) a classic “first-world” problem. Healthism can only thrive in a culture where the dominant groups do not have to worry about such things as famine, infectious disease, war, poverty, and hatred as factors that affect their health. It’s privilege that allows us to make health a “project” that we can judge others for not taking up.

I understand the concept this way: Privilege consists of unearned advantages of members of certain social groups solely because of their membership in those social groups, and at a cost to corresponding marginalized groups. Privilege is generally invisible to the privileged individual or group. Privilege can exist on the basis of just about any type of social difference, including race, ethnicity, gender, sexual orientation, socio-economic status, education, ability, and size, among others.

Is it appropriate to talk about privilege in the context of healthism? Does it fit? My thinking goes something like this: participation in the discourse of individual responsibility around health is only possible for those who do not feel subject to the collective determinants of health. I happen to think it’s beyond argument that we are all subject to a variety of collective determinants of health. Americans, especially, find this idea distasteful, no doubt because we tend to espouse a profoundly individualistic approach to life and prefer to believe we control everything about our own lives.

Nevertheless, many citizens of industrialized democracies experience themselves as beyond the social and environmental influences on health and instead experience themselves as – for better or worse – empowered around their individual health. Healthy? Good job! Well done! Keep up the great work! Unhealthy? Lazy! Glutton! You should have eaten more kale!

This experience of empowerment sources a healthist privilege. We like to pretend that our social and natural environments have nothing to do with our health outcomes, regardless of what those outcomes are.

Questions

I confess that my sense of privilege as important to understanding how healthism works is as much intuitive as it is logical at this point. Do you agree that there is a privilege component to healthism? And if there is, how is this insight useful? How does healthism apply to the HAES model?

For example, by making them part of the HAES principles, are we tacitly conveying a moral duty to engage in intuitive eating and joyful movement practices? Surely not every instance in which we recommend a particular health-related practice is automatically healthist, but I do think we need to talk about this. Do we need an asterisk on every health recommendation – an implied “but only if you want to”? Are there other hidden sources of healthism in how we use and apply the HAES model?

28 Responses to “the HAES® files: Speculations on Healthism & Privilege”

  1. Dear Mr. Ferguson:  Great post!  I agree with you 100 percent.  One of the worst days of my life was when I had to testify at a trial for a child who had been taken away from his mother “because he was too fat.”  I had been working with the mother.  She was doing an excellent job making positive nutrition changes….i.e., she would bake her chicken, instead of frying it…which is a huge change in the South, where I reside.  They were using tax dollars to send Child Protective Workers into her home to “inspect” her cupboards.  Well, horror of horrors, they found Chef Boyardee ravioli cans in the cupboard.  (As a Registered Dietitian, I was not invited to inspect the cupboards, but someone with no nutrition expertise did the inspecting).  At the trial, the Prosecuting Attorney shamed the mother on the stand, snarling at her saying, “AND YOU SERVE YOUR CHILD CHEF BOYARDEE RAVIOLI?  YOU THINK THAT IS NUTRITIOUS!?!  Of course, this was a low-income mother.  I donate money to a program called Backpack Meals.  It provides meals to school age children so they can have something to eat on weekends.  One of the foods we put in is cans of  Chef Boyardee ravioli….we give foods that do not have to be refrigerated and are easy to fix.  My particular program gives out 100 back packs per month.  We can not keep up with the demand for this service.  My friend is involved in this program in another local city.  She, too, says the demand outstrips what we can provide.  So yes, Healthism and Privilege is alive and well in America.  I could provide a zillion more examples.   Thanks for letting me vent.  Have a good day y’all!  Julie Drzewiecki, RD                        

    “Health At Every Size® Blog\”” <comment-reply@wordpress.com comcast.net Sent: Tuesday, November 19, 2013 5:04:05 AM Subject: [New post] The HAES® files: Speculations on Healthism & Privilege

    Health At Every Size® Blog posted: "by Fall Ferguson, JD, MA Every once in a while – most often on Facebook or in the online comments to a blog post – I encounter the idea that the “health” part of the Health At Every Size® model is inherently oppressive and healthist. This criticism mak"

  2. I have a strong family history of heart disease (as well as a gene implicated in obesity) and although I was an activist in the FA movement from the 80s, once I was diagnosed with heart disease and had my quadruple bypass surgery at the age of 42 I began to feel estranged from the movement. The protestations of health that I had formerly used as a shield from fat oppression were no longer available to me and as others continued to use them I felt left behind and unwanted by the movement. We unhealthy fat people feel disavowed. We feel like we are viewed as the FA movement’s dirty secret.

    Although I remember making the point as a body image educator that we all deserve to be treated with respect regardless of anyone’s beliefs about health and fat, regardless of lifestyle, it feels like too few believe that wholeheartedly.

    I am clear that my habits as a fat person were pretty healthy and my genetics caught up with me–but I operate in a world that sees fat as the sole cause of my heart disease with all the judgment that goes along with that. I was told by my cardiac surgeon if I didn’t get down to my “normal” weight I wouldn’t make it to fifty. I am about to turn 55 next month. I believe fat acceptance ultimately delayed the onset of heart disease by giving me the courage to reclaim a joy of movement, swimming, walking, water aerobics and other activities. But even if I had not been a vegetarian for many years, even if I ate tons of fat and empty calories, I do not deserve to be shamed and abused by society. Nothing about verbal abuse enhances health. I recall my friend Ruah having things thrown at her when she rode her bike, in addition to the fat-shaming insults. The notion that we are being fat shamed for our own good is contradicted by abusing someone who is in fact getting exercise. It’s a lie, plain and simple.

    If not “HEALTH at every size” how about living well at every size? Pushing the medical profession to leave the fat shaming out of our treatment plan is a good start. It only contributes to depression which severely hampers our ability to manage chronic illness. http://www.leaderpost.com/health/Obesity+expert+rejects+shaming/9173879/story.html is a great start. Anti-fat bias in medicine kills us before our time–and then we bear the sole blame.

    • Yes, exactly! Just as soon as I tried to get involved with the FA movement, I realized that I was unwanted by it. My choices were to either deny that my weight was exacerbating my heredity back problems or just accept the way I am and not discuss it or expect fellow fatties to not stigmatize me for decisions I have personally made in an effort to relieve my back pain. I can totally relate to what you have said here! It’s sad that from the 80s till now, that underlying disconnect still exists.

    • Thank you so much for this response. I agree.

  3. Fall, I think you’ve hit on something very important here. Thank you for your blog post.

    The first commenter also pointed out something that cannot be said often enough. People look down their noses at “canned food” as somehow being automatically “bad” — and sure, if you have the time and the facilities to shop for fresh ingredients every day and create maaaaahvelous healthy chef-like dishes from scratch for each meal — great, but it takes some amount of privilege to be able to do that. Some lower income people don’t even have time (or facilities) for cooking (such as, a working stove and refrigerator) or storing fresh “unprocessed” foods from which to make something “from scratch” every day.

    Another part of that “privilege” is “thin privilege.” If I go to my doctor with anything less obvious than a nail sticking out of my head, the advice is virtually always, “You need to lose weight.” If my thin co-worker goes to the doctor with vague symptoms like, “feels tired a lot of the time and just doesn’t have as much energy as she’d like to have,” the doctor (same health insurance plan, BTW) runs a battery of tests and keeps working at it until they find something that can be addressed or until my co-worker feels better. For me it ends at, “Well, I know you don’t want to hear this but you need to lose weight.”

    If I ask whether there are any tests they would run on a thin person with the same symptoms, the answer is, “Well, possibly, but that’s not you. You need to lose weight and a thin person doesn’t.”

    Another kind of “privilege” is the 2-adult household in which one adult devotes all his or (usually) HER time to cooking and cleaning. Obviously if there is no adult chef at home full time to cook fresh “unprocessed” foods every day, sometimes the household member(s) will eat “processed” foods. My grandmother lived with us when I was growing up and she cooked fresh “unprocessed” foods every single day for dinner. She usually started cooking dinner by 1 or 2 in the afternoon to have a fresh hot piping meal on the table by 5:30 or so. If a person works 9 hours and spends another 3 hours/day commuting, and then spends another several hours each day shopping for, chopping, dicing, preparing and cooking “fresh unprocessed foods” for dinner each night — UH OH, then she doesn’t have time for that 30 or 60 or 90 (or however many) minutes of HEALTHY exercise she is supposed to get each day too.

    You just can’t possibly look at all these “healthy lifestyle” recommendations without thinking, my Gosh, they want to turn us all into a nation of Yuppies. ‘Cuz only then, if you happen to get a health problem, can it not be ascribed to being “your own fault.”

  4. As a health educator and recent convert to the HAES way of thinking, I have felt “healthism” to be incredibly oppressive. (I did not know this term exists, but I’m so glad it does!) I have written about how the individual behavior change approach is not always appropriate and I am incredibly frustrated by the unintended consequences of such health messaging, which are most often shame and blame.

    You might be interested in this post I wrote about the problem with the individual behavior change approach as applied to sleep: http://talkinreckless.com/2013/06/18/addressing-the-sleep-deficit-not-one-person-at-a-time/

  5. Hmmm. The posts I’ve seen here have never struck me as being inherently healthist. For instance, I’ve seen stuff written by “Beauty Redefined” which is another great blog, more focused on media and body positivism, but good because they do push the negative effects of stigma on a person’s health. However, the main difference is that when they talk about eating right and exercise, they do so in the context that it is something that people SHOULD do, but women often don’t because they are stigmatized. So they point out that stigma can cause bingeing or other eating disorders but with the underlying message that if a person can get past that, they will suddenly do what is good for their health. There is something about the language of that message that really makes me bristle. My response, and I’m paraphrasing here, was basically “it’s pretty screwed up to expect a paraplegic to ‘get out and walk more'” because to me, that is the underlying stigma of healthist or abelist speech, the assumption that we can all DO DO DO the same. So, what I saw was healthism and a sort of privilege in that message, because it seemed like the only issue that needed to be combated was negative self-esteem based on looks. WRONG!

    Because of my own problems with “morbid obesity” (I’m actually metabolically healthy but I’ve had people assume I’m diabetic/sick) and severe, often debilitating back problems (again, assumed to be caused by my fat, and not the spinal stenosis I was diagnosed with, a congenital problem I was told) I’ve realized just how completely screwed up the attitudes of my fellow Americans are toward the “disabled”. You know, those people who are just different from the most privileged word in our language, the “normal”. Everything from blindness and deafness to developmental “disorders” to mental “illness” to chronic illness… it’s all the same. All defined as being that which is not “normal.” Never mind the fact that for those who have these problems, it IS normal.

    To me, healthism is the PEAK of privilege. Since health or the lack of it can and often is inherent to a person expectation that we should all be X-level of healthy seems almost Nazi-like in its audacity. We all have to be “super men” in terms of health, impervious to disease, age, and injury, or changes in our metabolism. Those who can’t be this way are burdens on society. When I see studies about the genetics of “obesity” now, and trying to “cure” it, I see something akin to eugenics. The fat can’t be killed enmasse, because that’s wrong, but we can be expunged from the human genome in other ways.

    So, yeah, not seeing healthism on THIS blog. But I have an unusual perspective.

    In terms of privilege, language is everything, and the devil is in the details. Healthist messages are bigoted, and seek to undermine individual’s personal empowerment. HAES and actual “healthy” messages really do try to empower people like me! I think that your group really IS working to empower individuals to think about their health in a different way, and thus act in a different way, change their own attitude toward their own health, and in doing so, more than likely improve their health just through that positive outlook. I think the idea of “individual control” is the biggest fiction being pushed by “fitspiration” messages today, and thus it makes that message stand out from the HAES message. “Individual control” depends on the underlying belief that none of us have control. Those who are told they do and who are allowed to feel as if they do are those who have completely surrendered every aspect of their individual selves to a socially constructed idea of what is “right.”

    So, I agree with a lot of what was said above, but I think the discussion can go deeper. Of course, the fact that HAES, unlike other sites or blogs or whatever, is actually daring to not just talk about the issue, but to talk about it is talked about, is such an awesome step forward! Thank you for this! I hope it helps to enlighten a lot of people, and not just about privilege.

  6. They’re related, but I feel like it’s important not to conflate Fat Acceptance and HAES. For me, HAES is something I do because it makes me feel good and I enjoy it. I recognize that my practice is quite privileged! On the other hand, FA is something I practice primarily externally, advocating for respect for fat people, regardless of their health status, and fighting discrimination based on size.

    HAES teaches that healthy habits are available to people of all sizes, but I don’t feel like it’s prescriptive. Is there a strong HAES contingent that is completely decoupled from FA? It seems like if you take the compassion and respect for one’s body out of HAES, then you’re left with what looks a lot like the standard healthist approach– HAES with its heart torn out.

  7. Great post Fall – I find it helpful when thinking about healthism – which I have been writing and speaking about for almost 2 decades now – to use other than the traditional definitions of health from CDC, WHO, etc. because as you have so eloquently described, they are all so one-sided towards the individual responsibility side of things – here is the one from WHO – “ Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” – yikes!! – any takers?
    – so – for instance this definition from Illich (MD) from 1975 in his article – Medical Nemesis: “Health is not freedom from the inevitability of death, disease, unhappiness and stress but rather the ability to cope with them in a competent way.” Aside from the fact that this appropriately (IMO) rues out the ridiculous and impossibly unattainable concept of “optimal health” which people in the health promotion are constantly discussing as if it were helpful or possible – for me it also puts things into the proper perspective as it is clear that the “ability to cope” with adversity is inextricably interconnected within the social/cultural bigger picture. – thanks for focusing on this so important topic – Jon

  8. I couldn’t disagree more with this article. You have taken research and twisted it to support your ideological ends. Why did you even bother listing sources if you don’t select any portion of them to support your POV? You post a link to a book and a report, both of which are many times the length of your article and don’t appear to directly support it, either. Are you claiming that social determinants are more important than individual behaviors regarding INDIVIDUAL health outcomes in modern, industrialized countries? That is illogical because much of the effect of the social determinants, even in the sources you included, have to do with how they affect individual behaviors. The chart you posted that emphasizes the social determinants of health is more applicable to comparing different societies or individuals living in societies in which the poor have difficulty providing for their basic needs, not to pointing out privilege within American society where the standard of living is worlds above many other countries for even its poorest members. Every individual in American society has privilege enough such that individual behaviors can, for most people, be a deciding factor for if that individual is healthy or unhealthy. By the way, the “health behaviors” that the graph is referring to are things like “alcohol use, injection drug use (needles), unprotected sex, and smoking.” These are all things that have an immediate and obvious affect on health. Healthy behaviors such as exercise and a good diet are largely subsumed by “social determinants” because the ability to eat properly, for instance, can be impinged by socio-economic factors such as individuals being unable to afford proper nutrition. This is exceedingly rare in the United States compared to many other countries. There is nothing wrong with emphasizing individual behaviors in the US. That is doubly true with regards to obesity and fitness. The changes in the US population regarding these has not been the result of a lowering in the standards of living. The trend in standards of living and obesity are divergent. The changes in the rates of these health risk factors are caused by cultural changes which influence individual behaviors, not a lack of privilege for Americans or members of other first-world countries.

    Also, what’s a “coach potato?”

    • Thanks for pointing out the typo Nick, the author if course meant couch potato and as the blog moderator and one of the editors I should have caught that. Good eye!

    • “By the way, the “health behaviors” that the graph is referring to are things like “alcohol use, injection drug use (needles), unprotected sex, and smoking.” These are all things that have an immediate and obvious affect on health.” – I disagree. These things do not necessarily have an immediate or obvious affect on health, that is a reach.
      Also, if you have an issue regarding the science behind any of the claims on this blog I recommend you take yourself to pubmed and do some research regarding health and body size. You may be in for a rude awakening.
      Regarding social determinants (total ecology) and health, the vast pollution brought about industrialization and modern farming are likely to have an affect on all of our health despite body habitus and individual habits. Again, pubmed the effect of these chemicals and hormone disruptors on our bodies.

  9. Nick – are you joking or do you seriously not know what the term “couch potato refers to? – Jon

  10. I did not notice it either – good catch!

  11. So, Nick – I am not sure where you are living but – , yes, the biggest risk factor for poor health in this country and everywhere else in the world is poverty and particularly economic disparity. There is plenty of it to go around right here in the good old USA and it is not getting better. Your claims are directly contradicted by the data – one out of 6 adults and one out of 5 kids living below the poverty line and millions more barely making it. To view the most recent data I suggest you check out the CDC’s most recent report from Morbidity and Mortality week of Nov. 22 – 2013. Directly from the report:

    “The socioeconomic circumstances of persons and the places
    where they live and work strongly influence their health. In
    the United States, as elsewhere, the risk for mortality, morbidity,
    unhealthy behaviors, reduced access to health care, and poor quality
    of care increases with decreasing socioeconomic circumstances.
    This association is continuous and graded across a population and
    cumulative over the life course.”

    Dr. David Katz, director of the Yale University Prevention Research Center commented on the latest data saying:

    “We have huge disparities in health, because we have huge disparities in everything from income to education…We will best eliminate health disparities not by improving disease care, but by improving equity.”

  12. Not to put too fine a point on it, but “healthism” has been around since the beginning of time. Disease, disability, death and illness in many times, places and cultures have been attributed to “demons” or “bad living” or individual or collective moral failings or not adopting the “right” religious beliefs and practices, etc., etc. We conveniently believe that it is only the naïve and unsophisticated people from “other” times and places who believe that disease, disability, death and illness are punishments for moral failings of various sorts. But I’d say that in spite of all our lip service to science, those beliefs are still quite alive and well – in the form of “healthism” – in our own culture, including among a fair number of health professionals.

  13. Related article about “nutritionism” which I believe to be closely related to healthism:

    http://www.nytimes.com/2007/01/28/magazine/28nutritionism.t.html?pagewanted=all&_r=1&

  14. I think Bourdieu’s concept of symbolic power is a great device to explore this subject. The claim that an individual’s healh is primarily the result of personal choices, and that he/she is responsible for pursuing the healthy road on a daily basis, seems to me a clear, unequivocal ideological statement of privilegie through which the upper classes manage to further exclude and marginalize the rest of the population.

    And as it happens with most instances of symbolic power,this claim is simply cruel. It’s just cruel to blame people who live incredibly stressful lives with very few financial, social and emotional resources for their poor health. How can one blame a mother who works two jobs, to make ends meet and is in constant and understandable fear that things may fall apart at any time for, say, developing major anxiety disorders and all the problems consequent to them? Just think about acute high blood pressure, which has been proven to be caused also by anxiety/stress and which, if inadequately treated, is as harmful to one’s health as chronic high blood pressure.

    This is just an obvious example, but one could go on and on. Besides, after working the whole day without having been able to do one single thing for yourself, will you spend your very scarce free time preparing elaborate foods or obsessing about healh and dieting? It really baffles me that one could apply to these people the same standards one applies to privileged individuals who have easy access to great doctors, fancy gyms, personal trainers, quality food and live in fine neighbourhoods where they can walk leisurely and safely.

    Normann Cohn

    • This is very astute (thanks).

      And the “moral failing” one commits by NOT dropping all those other barely-hanging-on life-sustaining behaviors is that you did not “CHOOSE” to put your health first.

      If you ever notice the language of attempts to make people alter their diets to lose weight, it is all “choose”, “choose”, “choose this instead of that”, “choose this tasteless piece of cardboard instead of that yummy steak”, “CHOOOSE” to walk to the store instead of driving, choose, choose, choose, choose, choose. They even say it with an inflection that must be taught in dietitian-school. Its not just “choose”, its said louder than all the other words in the sentence and it sounds more like “Cheeuuuse” [whatever]. (The implication, of course, is that everything you do is a matter of choice, and your “failing” to “cheeuuuse” the right choices is your own moral failing.) If you try to say that, “Yes, but I need to earn a living…” they will call that an “excuse” and tell you to “stop making excuses.” They *DO* expect you to drop everything else (even if it means literally becoming homeless) so that you can focus 100% on diet and exercise (in your cardboard box down by the river, I guess).

  15. Fall,

    Thanks for this great post. I have been following this blog for a few months now, learning more about HAES as an approach to integrate into my work in community health research. As a self-identified fat person who has come to understand fatness as a personal-political identity, some of the concepts of HAES and FA have been a part of my life for a long time, although not necessarily under those titles. This post addresses some of the questions I’ve had lingering just under the surface, the more I’ve learned about these movements.

    My understanding of systems is deeply rooted in a model that highlights the intersections of oppression, which includes for myself efforts to be constantly aware of the interplay between my own privilege, oppression, access, and inclusion. As a white queer person engaged in this process, I feel keenly aware of both my privilege and oppression in a variety of different spaces and I’ve often wondered about how exactly this plays out the HAES movement.

    I am so glad to read and think about healthism in the HAES movement, in part because I am learning more about the strengths and struggles of this community. But also, I feel glad to read that taking an account of one’s privilege as individuals and recognizing and addressing the privilege in language and message of the movement is part of the process. This doesn’t always happen in every space – it’s a hard thing to do and I appreciate very much that it’s happening here.

    M. Lee

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