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May 8, 2012

the HAES files: Stereotype Management Skills for HBO Viewers

by healthateverysizeblog

by Deb Burgard, PhD

I don’t know what HBO’s series, The Weight of the Nation*, is going to say, but if the previews are representative, you might want to use this handy “viewers’ guide” to conserving sanity points.

Critical Thinking Skills 101

The main flaw in the traditional view is to think that if an event happens in the life of fat people, it is because they are fat.  All of us are trained to think this way, but there are some questions to ask that can help reverse the brainwashing:

“Does this happen to thin people too?”

  • I eat too much.
  • My doctor tells me I have diabetes.
  • That person I was attracted to rejected me.
  • I can’t get down on the floor and play with my grandchildren.

Fat is blamed for almost anything negative that happens in life.  But thin people don’t have their fatness to blame, so when those same things happen to them, they have a whole universe of possible solutions.  Those same solutions should be available to fat people – why would we think the only solution is to turn them into thin people?

There is a version of blaming fat where the very presence of fat people in society is enough to blame them for the society’s problem.  The question to ask here is,

“If everyone was thin, would we still have this social problem?”

  • There are problems with the way we produce food, and inequities in how we distribute food.
  • We are living in an environmentally unsustainable way.
  • We don’t have a functional healthcare system.
  • The baby boomers are a big demographic group who are living longer and will cost more in their final phase of life.
  • Our schools are struggling to feed, educate, and exercise our children with too few resources.
  • The demands of making a living leave little time for caring for ourselves and each other.

Blaming fatness keeps us from addressing the root causes of our problems, and is clearly unfair to fat people.  Many powerful people understand this, but find it expedient to frame a problem in terms of fat in order to bring attention to it.  They don’t think people will just attend to the real issue unless they whip up the fat panic.  Whether it is being pessimistic that people will exercise if it is not in the context of a weight-loss effort, or being pessimistic that people will care about our food environment if it is not in the context of a moral panic about fatness, the justification for whipping up the fat hatred is the same.  I say, have the courage to make your argument about the real issues and stop doing it on the backs of fat people.

Arm Yourself with the Facts

Here are some other key facts to keep in mind while you are watching:

  • The “epidemic” refers to a rise of 10-15 pounds in the average weight of US adults between 1980 and 1999.  The rise was over before most of the “obesity epidemic” rhetoric began.
  • The pictures illustrating “two-thirds of US adults are overweight or obese” are almost universally of people who represent less than 1% of the population.  People at a BMI over 50 are so rare that the CDC cannot estimate their actual prevalence in the population.  The photo that would actually represent the headline would be of someone the size of Will Smith or Tom Cruise.
  • We can re-cast public health authorities’ notion that we are “in denial” about our fat as their complaint that we are not buying into the BMI categories, which is actually a triumph of common sense, since BMI is such a lousy proxy for health, appearance, and even degree of actual fatness.  There is a fog of confusion around BMI—supposedly educated people seem to think that squaring, dividing, and converting to metric units adds more information than the height and weight data you started with.
  • The range of weights considered problematic in children was tripled in 2007 for no scientific reason, from the 95th percentile and up, to the 85th percentile and up.  This allows for dramatic statements like, “1 in 3 children in Georgia are overweight or obese,” even though pediatricians agree that even the 95th percentile and higher does not necessarily signify ill health.
  • Despite the alarm, Type II diabetes in children is so rare that the CDC has not been able to accurately estimate prevalence.  We need to focus on the lack of access to good medical care for many of these children and their families, rather than using them as poster children for public hate campaigns.

Challenging the Untested Assumption

The entire health argument for weight loss is based on a single untested assumption:

A weight-suppressed fat person has
the medical risk profile of a thin person.

Think about it.  There are no data for this, because there are so few weight-suppressed fat people who maintain weight suppression long enough to find out.  Instead, we have the illusion from medical data 6 months or a year into weight loss (which reverses with weight regain) that temporarily shows improved risk factors, like lower cholesterol or better fasting glucose levels.  If research was required to be at least 2-5 years in length, we would lose our illusion that weight loss is a solution, because neither weight loss nor health benefits last.

Fortunately, we have a more reliable way to obtain those improved medical outcomes for people who lose no weight but increase their movement levels or nutritional quality, and the physiological improvements last with the ongoing practices.

And if fat tissue loss was the key solution, why do we see no medical improvements with liposuction?

Follow the Money

When you are evaluating the claims made in the series, remember to follow the money.  Historically, every time the public appears to be getting hip to the fact that “diets don’t work,” there are massive responses from the weight cycling industry.  Their target this year is clearly communities of color and men, and their campaigns seek to shame people who are “in denial” about their weight.  One can picture the marketing execs around the table: “We got white women to hate their bodies – but we saturated that market long ago!”

Big pharma is constantly trying to create new markets, so making people who are not sick need treatment for “pre-diabetes” and “pre-hypertension” is a great money-maker.  The health insurance industry has always gotten away with discriminating against fat people and will politically get away with flouting the new healthcare law – should it survive – by charging higher premiums for the two-thirds of the country who are “overweight.”  My own profession of psychology is seeking to enshrine the current ineffective weight change interventions to make ourselves the “weight loss experts” who get the Medicare reimbursements.

All of these interests stand to lose billions of dollars if they tell the truth.  So remember, people are getting paid to hate you.

Stereotype/Stigma Management Skills

A worksheet for cultivating Stereotype Management Skills. (Please click on link at right for entire document.)

Critical thinking skills are all well and good, but there is another difficult aspect of public hate campaigns, which is of course, these are real people being obnoxious and mean to us.  We can be armed with all the facts in the world but the social reality is that it really sucks being the target of hate and bullying.  This handout provides a worksheet for cultivating Stereotype Management Skills.

When people are mean, we have to be especially careful not to blame our bodies. There is nothing about us or our bodies that deserves scorn or derision.  Take special care to honor your body and its wondrous capacities and gifts.  The problem lies outside of you and your body, with the bullies and the forces that benefit from fat hatred.

One of the most important things we can do when we are experiencing discrimination is to seek out our tribe.  This is the time to talk about what you are experiencing—in person, or on the listservs.  Also, ASDAH is preparing materials designed to help viewers understand and critique the rhetoric of WOTN documentary—to be posted soon. [Update: ASDAH's response has now been posted: www.debatetheweight.com]

Time for a Party!

It looks like WOTN plans to hit all the major “obesity” memes, like, “this generation of children’s lifespans will be shorter than their parents,” “obesity will bankrupt our healthcare system,” and “by 2050 our entire country will be obese.”  We could not have a better opportunity to plan big parties and play Fat Hate Bingo!  HBO says we have to lose to win, but we say, all you have to lose is your hate.

* The Weight of the Nation (WOTN) is scheduled to air on HBO on May 14 & 15, 2012.

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March 27, 2012

the HAES files: How to Photoshop a Research Study

by healthateverysizeblog

[as demonstrated by Rock et al. (2010) on weight loss results of the Jenny Craig® program]

by Deb Burgard, PhD

1. Publish in a peer-reviewed, respectable journal like JAMA. The average person has no idea they are willing to publish research sponsored by industry, so the fact that Jenny Craig paid for this will stay buried in the fine print on page 1810.

2. You’re the researcher, so you get to choose who can be in the study. Forget the bother of a representative sample.  Make sure you eliminate at least 20% of your interested participants right off the bat, even though you don’t do that with your customers.  Who’s going to notice that you don’t have even a representative sample of your customers, let alone a representative sample of the “obese and overweight women” of your title?

3. Don’t bother to test your actual program−too many people would drop out.  Instead, pay your participants for showing up to clinic visits, and give away your diet food.  Readers won’t realize that you are not really testing your real-world program, which costs $100/week.  Don’t report on (or maybe even bother to track) the percentage of people who actually chose to eat the (free!) food−just track whether people showed up at the center or talked on the phone.  Don’t report on the percentage of people who would not eat Jenny Craig food even when it is given away.

4. Identify the study participants to your staff, for no discernible reason.  Could it be so they can be sure to work extra hard to get the desired results?  But report on how you told them to treat everyone the same, as if that is an accepted research procedure.

5. Say your study tests maintenance of weight loss, but don’t ever stop your intervention.  Who’s going to notice the difference between a two-year study of continuous dieting vs. a study that actually follows up, i.e., shows what happens two years after the intervention is over?

6. Report in BMI, kg, and means so that readers won’t do the math and translate into what is familiar to them.  Who’s going to go back and look at the average baseline weight of 92 kg and multiply by 2.2 then figure out what 5% of that would be (about 10 pounds) to understand that this statement, “By study end, more than half in either intervention group (62% [n=103] of center-based participants and 56% [n=91] of telephone-based participants) had a weight loss of at least 5% …” means that 59% of the people who showed up at clinic visits were at least 10 pounds lighter at two years out, going from an average of 203 pounds to 193 pounds?  Who’s going to subtract to figure out that even when they were getting paid and the food was given away for free, 41% of the participants could not maintain even a 10 pound average loss?

And really, who would actually divide to notice that it took an average of $6958 over two years to return an average weight loss of 15 pounds, or $463.87 per pound all while losing your sanity points being on a continuous diet for two years?

7. Count on no one noticing that even when you are paying people over $3000/year in food products and counseling rather than asking them to pay over $3000/year in the real world, the average weight trajectory is on the way back up after month 12.

8. Claim in the results section that the intervention groups reported better quality of life and reduced depression at 12 months; maybe people won’t notice that sure enough, at 24 months there were no significant changes from baseline in physical fitness or psychosocial measures.

9. Make sure to end your study at the point when you stop paying people, but describe the study in the abstract as “conducted over 2 years with follow-up between November 2007 and April 2010.”  Who reads the actual article anyway?

10. Make sure you publish your study side-by-side with an independently-conducted study but make sure that one stops at the 12-month point in the process where people tend to have maximum weight loss and benefits, even though studies consistently show this reverses over the next year.  That way your sponsoring company can send out its press release mashing everything together and imply all kinds of results no one found in either study, like you had a “two-year independent, multi-site clinical trial” (OK, the independent trial was a only a year and only one site) and “those who took part in the Jenny Craig program adopted healthier eating habits and meaningful health benefits for overall improved quality of life” (OK, the quality of life changes were not significant at 24 months) and “those following the program reduced risk factors that can lead to chronic disease including depression, diabetes, cancer and even stroke” (OK, there were no significant changes at 24 months in total cholesterol, LDL cholesterol, HDL cholesterol, or triglycerides, or step test fitness measures, or any psychosocial measures including depression).

Hey, if Vogue can get away with it, why not JAMA?

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February 28, 2012

the HAES files: can you tell anything at all by a person’s weight?

by healthateverysizeblog

by Deb Burgard, PhD

If you have grown up in this culture, you probably associate quite a few things with fatness and quite a few of the opposite traits with thinness.   Almost every audience comes up with the same lists:

Fat: Thin:
Lazy
Depressed
Sick
Out of control
Loser
Bad		 Productive
Confident
Healthy
Disciplined
Sexy
Good

Even though these associations are not something people from other cultures (or other times in history) believe, they are so strong and unquestioned in our own time that they form the basis of our weight stereotyping, bias, and stigma.

To test your own associations, go take the Weight version of the Implicit Attitudes Test.  The test does not measure whether you inflict weight bias on people, but rather how strongly you have been taught to  associate certain concepts with weight. 

It might be surprising to know that weight stigma hurts both thin and fat people.  In my work with people of all sizes who are struggling with disordered eating, it is clear that a huge factor in their misery is almost always the worry that they will be humiliated and rejected because of their weight – no matter what their weight is.  I have had people sitting in my office who look like they walked straight out of a fashion magazine who are convinced they are not thin enough, not perfect enough, and not good enough (and some of them are absolutely accurate about the impossible standards of their world of ballet or modeling or a really bad relationship).  Others have endured a lifetime of negative stereotyping and discrimination as fat children or adults, and can’t imagine loving the bodies they blame for the meanness of other people.   Still others have witnessed the humiliation of a friend, a parent, a sibling – and are petrified about such a thing happening to them.   

So some of them have had actual experiences of weight stigma, some of them give themselves the experience of stigma within their own minds, and some are convinced that it is only a matter of time before the axe falls unless they perfect their bodies to some mythical state.   No one feels safe, because everyone has times when we feel something from the “fat” column.  Busted! 

When I work with clients, we have to figure out a way to handle both the real and the self-inflicted experiences of weight stigma, so that they  can get unstuck and recover.  Part of this work is for the client to change his/her own mind about what fat and thin means.  Part of it is to change other people’s minds.

And so today in the spirit of changing other peoples’ minds, I ask that we stop for a moment and question this weight stigma stuff, and why we keep it around. 

 It seems obvious that the diet (i.e., the weight cycling) industry wants to keep it around, because how else would you sell a program that never works, over and over again, and not worry about the consumer getting hip to the fact that it is useless?  But even though it is a big honking industry (most recently estimated at over $60 billion), most of us are not making money from it and would be fine if it suddenly went out of business.   In fact, most of us would be much better off economically with our $500-1000/year safe in our own pockets rather than handing it over to Weight Cyclers.

So what about the rest of us who aren’t profiting off this industry? Why would we perpetuate weight stigma? When you look at the lists of traits associated with “fat” and “thin,” what strikes me is that they are such normal human states and traits.  Is there a week that goes by when you don’t feel like some of Column A and some of Column B?  But the “fat” traits are painful to experience – they are the things we feel when we miss the deadline, can’t get motivated, find ourselves rejected, or are diagnosed with a health problem.  We would prefer not to feel them at all, and when we are promised that just by losing weight, we will become a Whole New Person (free of all the “fat” traits!), we think that would be a pretty great deal.  That promise sucks us in.  We cave to the illusion that life does not have to sometimes feel bad, and we perpetuate the myth that by changing our bodies, we can avoid feeling bad.   In fact, according to the myth, if you feel bad, it must be your own fault for not working hard enough to get the right body.

The truth is, few people live only in the “Thin” column.  And actually, when you think about it, doing so might make you pretty insufferable.   It may be the reason some people can be so immensely clueless about the weight stigma they are inflicting on others – being cut off from your own human vulnerability makes it more possible to justify “punishing” other people.  Only someone who refuses to identify with the person across from her who is suffering, would add to that suffering. 

There are people who understand that weight stigma is causing suffering but feel like it is somehow going to make people care about their health.  Like a person will start exercising to lose weight, but not to become more healthy, so we have to keep trying to stigmatize higher weight and promote weight loss.      

It is true that people are social animals, and are very punished by being stigmatized.  But punishment is famously unpredictable as a motivator.  The things people do to leave the stigmatized group are often not at all conducive to their health.   Injecting poison into your skin, slicing up healthy body organs, starving yourself, taking drugs, and even repetitive weight loss attempts, are things that make people sicker.  Even though I don’t think people would go through half of what they do in the name of weight loss just to have lower blood pressure or better triglycerides or a lower risk of a stroke, I would argue that the net effect of the attempt to leave the stigmatized group is actually less health.  Weight loss is not like trying to quit smoking.  Weight cycling makes you sicker and fatter.  And if your weight loss takes the form of an eating disorder you have a one of the deadliest psychiatric illnesses to battle. 

And what about the health burden of weight stigma itself?  Historical studies of cultures where higher weight is not stigmatized show that people at higher weights were just as, or even more, healthy than the thinner members of the community.  And perhaps the most robust finding in all of epidemiology is that social support is the holy grail of health.  How can removing social support – and making people sicker – be a path to making people healthier?  How can the US government telling people that we are trying to eliminate them in a generation make them healthier? 

The truth is, there is no reason to demonize people of certain weights.  The far more effective message is that people can find things to do that support their health at whatever size they are.  After all, the same practices and environments support health for thin or fat people.  If the same cafeteria feeds the thin kids and the fat kids, why can’t we talk about what is on the menu that supports the health of all the kids?  Why do we have to argue that the food has to change so we can have no fat kids?  Why can’t we argue that the food should be healthy for the kids – period?   We can work to create environments that support people in their efforts to thrive and make lasting efforts to take care of their bodies.  Part of creating that environment is ridding it of the pollution of weight stigma.

I grew up during times of great social upheaval, and I have seen a lot of change when it comes to social stigma.  Though the world is far from perfect, it is a very different place now than it used to be if you live together without being married, or get divorced, or have a baby as a single parent, or work as a female airline pilot, or get around in a wheelchair, or raise kids as gay parents, or love someone of a different race or religion.  Stigma is a kind of fashion.  We can change what is fashionable.  We can make weight stigma incredibly uncool.  Because it is.

So what are you going to do today to end weight stigma, in your mind, and in the world?

 National Eating Disorder Awareness Week

 is February 26-March 3!   Get involved!

Everybody Knows Somebody.  Visit the NEDAwareness Week homepage  to register today and learn more about how you can do just one thing to help raise awareness about eating disorders and become part of the solution. NEDA’s Helpline number is: 800 931-2237

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January 10, 2012

the HAES files: how to tell if you are getting a diet-in-haes-clothing

by healthateverysizeblog

by Deb Burgard, PhD

Along with the increasing public recognition of the Health at Every Size® model, there is some confusion about what the HAES SMmodel is and is not.  Some discussions of the HAES approach are omitting or distorting aspects that are critical to its practitioners.  There are several renditions of the model’s tenets (listed at the end), but first I would like to offer some critical questions to ask when you see it being discussed in the media. 

If you can answer “yes” to these questions, you may be reading an inaccurate or at least incomplete presentation of the model. 

Does the account you are reading:

Perpetuate the Pursuit of Weight Loss, e.g.:

  • Promise weight loss?
  • Fail to recognize the harms for people of all sizes of the existing interventions for changing weight?
  • Create a new set of “rules” about how to eat?
  • Shame some aspect of our inner selves by trying to “get rid of it, starve it, cut it out, imprison it”?

Perpetuate Healthism, e.g.:

  • Present only fat people who are healthy as “poster children”?
  • Create a class of “Good Fatties” vs. “Bad Fatties”?
  • Collude with the notion that healthier people are morally better?
  • Fail to demand quality medical treatment for fat people with health challenges?
  • Fail to critique the moral corruptness of trying to eliminate health costs by eliminating people with health challenges?

Reduce the model to Individual Choices, leaving out the critique of Weight Stigma, e.g.:

  • Omit any reference to the environmental sources of ill health, especially weight stigma?
  • Fail to propose any policy or institutional solutions to the problem of weight stigma?
  • Propose that individuals solve the problem of institutionalized weight stigma and shaming by losing weight and leaving the stigmatized group?
  • Fail to connect the dots with weight loss efforts of people across the weight spectrum, including people who have disordered eating from the pursuit of weight loss?

Perpetuate the Misclassification of Diversity as Disease, e.g.:

  • Explicitly or implicitly condone the use of BMI categories to classify people?
  • View higher-weight people as “diseased” based solely on weight?
  • Attribute any health problems at higher weights to being at a higher weight, and fail to treat health problems regardless of weight?
  • Overlook the health problems or fail to consider the health status of lower-weight people?
  • Assume that thinner is healthier?

Perpetuate a Short-Term vs. Sustainability Focus, e.g.:

  • Present as a “makeover”?
  • Fail to incorporate the question of what is sustainable for unique individuals?
  • Focus on outcomes rather than the quality of day-to-day life?
  • Reduce the profound idea of body acceptance to the notion of “confidence”?

Perpetuate “Expertism,” e.g.

  • Fail to include the input from members of the community itself, especially members who are trying to change institutionalized weight stigma?
  • Place “expert” knowledge above people’s felt, embodied experience?
  • Propose a specific eating regimen for all people that fails to incorporate the individual’s physical and psychological experience of food and eating?
  • Fail to expose public policy and medical practice to the test of whether they themselves promote weight stigma?
  • Present a “one-size-fits-all” perspective that is closed to update and revision, especially to the lived experiences of the community members?

Perpetuate a War with the Body, e.g.:

  • Place more confidence in the mind’s ability to regulate eating and weight (ie “discipline”) than the body’s?
  • Label normal body processes as diseased?
  • Propose as “cure” the disruption of normal functioning of healthy organs?
  • Fail to appreciate the biological value of having some members of our species be fatter/more fuel-efficient?
  • Prescribe a particular body size that is not attainable through healthy living?

The people who have developed the Health at Every Size model have integrated decades of experimental and epidemiological research and clinical practice, as well as the lessons of many social justice and civil rights movements, to find a path that reconnects us with our bodies, our life purposes, and each other.  We ask that presentations of the HAES® model be as complete and nuanced as possible, and avoid the aforementioned pitfalls and mischaracterizations.

Additional sources of information on the HAES Tenets:

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December 13, 2011

the HAES files: truth in advertising

by healthateverysizeblog

by Deb Burgard, PhD

Why do we call it the “weight loss industry” when what we really get for our time, sacrifice, and money is weight cycling? 19 times out of 20, what we are really purchasing is the experience of weight loss and regain.

Imagine if we called it the “weight cycling industry,” and “weight cycling programs.”  Would you participate in Weight Cyclers at work?  Buy food from NutriCycle?  Hire a trainer from the Biggest Weight Cycler?

As a physician, would you prescribe weight cycling for your patients?  As a Human Resources director, would you encourage/incentivize/coerce your employees to embark upon a bracing round of weight cycling this year?  As a parent, would you send your child to weight cycling camp?

Because that is what we are doing, folks.  Better face the facts:  Of 100 people trying to lose weight, the vast majority of people will regain weight. Some significant group – perhaps a third – will gain more weight than they lost.  Some tiny number (7? 5? 3?)  will maintain their weight loss, and of that group, some number from 0-4 of them will be flirting with, developing, or fortifying an eating disorder.  Yes, you read me right.  The 1-year prevalence data for adolescents and adults is 2-3% for adolescents and 3-4% for adults – and though it is not impossible to develop an eating disorder without having first dieted, it is the norm to do so.  If you read the practices of the people quoted in the Weight Management Registry, a group of several thousand people who have lost at least 30 pounds for at least 1 year, you will see some of the same practices and preoccupations we diagnose in people with eating disorders, including daily weighing, immediate compensation on the occasion of weight gain, logging every bite of food, exercising more than 90 minutes/day, etc.  Even people in the Registry regain weight and apparently are allowed to continue being members as long as they once lost 30 pounds and kept it off for a year.

It is an odd requirement, because one year is not rational criterion of “weight maintenance.”  Of the few studies that follow people at least 2 years, the 2-5 year range is the critical time period when almost everyone has regained.  It is odd that any studies of weight loss shorter than 2 years are published, since all that interesting data in the differences in what happens at 6 months or a year are all wiped out by 2 years anyway.  Yet the NIH apparently rarely funds studies – even weight loss studies – for longer than 1 year.

Our tax dollars go to funding study after study of this or that factor which results in faster weight loss, weight loss for more participants, fewer dropouts, etc., all of which becomes moot since almost everyone regains weight shortly after the study ends when no one is watching.  In this era of fiscal anxiety, surely it would be a no-brainer to only fund studies that have a follow-up period for all participants of at least 2 years.  It seems like a good minimum length for publishing studies in journals as well.  And imagine if everyone demanded to see evidence from the weight cycling industry of 2-year follow-up data before they hand over a penny.  We would have over $60 BILLION back in our own pockets.

You might be thinking, but I know someone who kept weight off.  You might be that person yourself. 

And as long as that person is (or you are) not struggling with disordered eating or some other kind of unacceptable drain on your life energy, s/he/you are probably pleased with that outcome.  There are certainly times that people lose weight by recovering from an eating disorder, or being more aware of their bodies’ appetite cues, or finding a passion (not a compulsion) for a physical activity, or changing to a less sedentary job, or changing medications, or just feeling more able/willing to feed themselves the kind of fuel their bodies thrive on.  Weight loss itself – or weight gain – is not the issue.  When people adopt those practices they might lose or gain weight or stabilize their weight.  It is the practices that people adopt in the pursuit of weight loss that are the problem, because for the 95 out of 100 people who regain weight during a diet, when the practices are not sustainable they lead to more physical and psychological illness.

The Health at Every Size® model is weight neutral.  People using this approach are not pro- or anti-weight loss, but they are mindful that the pursuit of weight loss is usually harmful, unlike the cultivation of sustainable practices that feel life-affirming and support your health.  In keeping with the “truth in advertising” theme, the Health at Every Size model does not insist that everyone is healthy at every size, or that anyone anytime is necessarily the size that optimizes their health.  “Health” in this context means that whatever size you are, there are practices that will support your health. There are environments that celebrate diversity, free of weight stigma, that will be the healthiest for people of all sizes. Concentrating on those practices and environments are a far better investment than anything the weight cycling industry has to offer.

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October 17, 2011

the HAES files: can i love my body and still want to lose weight?

by healthateverysizeblog

 by Deb Burgard, PhD

Many people who are intrigued with the Health at Every Size® approach find the notion of “weight neutrality” the hardest aspect to accept. “Loving your body” is not too controversial, unless your body is not a “correct” body.  If your body is a non-conforming body, then there is real debate about how much you should “love” it, especially if that means rejecting the assignment to try to lose weight. 

People who are trying to love their bodies need to be curious, not ashamed, about the desire to lose weight.  It is not a surprise to find ourselves fantasizing about weight loss.  All the triggers for wanting to lose weight that have always been there are still there polluting our environment.  We are told to lose weight to make sure no one will reject us.  To comply with our doctor’s orders.  To fit into plane seats.  To be able to get a sense of control.  To become a “whole new person!” To buy the social approval that we are at least “trying.”  To participate in the workplace dieting along with everybody else.  And as of this fall in some states, maybe even to be able to qualify for health insurance.

“Love Your Body Day” represents a movement to challenge all the messages that our bodies are not good enough.  But even organizations that support “self esteem” and “body acceptance” seem to get confused about the part about pursuing weight loss.  For example, the National Eating Disorders Organization (NEDA) has partnered with the “Stop Obesity Alliance” (an organization trying to frame fatness as a disease in order to create markets for “weight loss” drugs and surgery) to sponsor events to reframe the pursuit of weight loss as “not about appearance but rather about health.”   These actions have been the cause of confusion and concern among NEDA members, who are wondering how the very same practices that are diagnosed as eating disorder behavior at one weight are being prescribed to people at a higher weight.

So what does “loving your body” mean?  And is it ever compatible with pursuing weight loss?

Loving your body means you don’t blame it for the cruelty of other people.  Loving your body means you appreciate that wherever you were before you were born and wherever you go after you die, the chance to live your human life depends on this body.  Loving your body means you try to care for it as best you can.  Loving your body means you respond to its signals for sleep, water, food, stimulation, pain, movement, pleasure, as best you can.  Loving your body means you negotiate for what you need from people whose agendas may not be in your best interest – that you are willing to make some fuss to be sure you are safe, cared for, listened to, etc.

Loving your body does not mean you are always “confident,” whatever that is.  It does not mean you think every part of your body is pretty. 

Do all the actual people you love have to be pretty?  No. Do you even have to like all the aspects of the people you love?  No.  Loving is not shallow.  The people you love, and the body you love, are not perfect, and you can have mixed feelings about them and still love them.  It’s about the relationship, not the visuals.  It is about the effort, commitment, nurturing, appreciation you bring.

One way to answer the question of whether it could ever be loving to try to lose weight is to imagine someone who supposedly loves you telling you to lose weight.  Does it feel loving?  Could it?  Would you ever tell someone you love to pursue weight loss?

I actually would not tell anyone to pursue weight loss, whether I loved them or not.  We have plenty of evidence that the practices associated with pursuing weight loss make people sick.  For almost everyone, weight “loss” is really weight cycling.  For some of the “maintainers,” maintenance is really an eating disorder.  I know people who have ended up at a lower weight as a side effect of other changes that have been important to them, and they are doing just fine.  But I don’t know people who have lost weight by organizing their lives around it who are really at peace with food and their bodies.  They are not fine.

But that does not mean I would never encourage someone I loved – of any size – to feel entitled to treat herself well, to care about the practices that make her feel better in her body.  Those practices are worth doing regardless of weight outcomes, and I think they are more likely to become sustained efforts when people find intrinsic reasons for doing them, rather than associating them with the pursuit of weight loss. 

It also does not mean I would never speak up to someone I loved – of any size – about practices I might believe are harming her.  “Loving your body” does not mean ignoring disordered eating, addictive and compulsive acts, self-harm, or neglect.  But none of that is necessarily linked to a particular weight.  And the great news is that many many people recover from these kinds of struggles when they get enough support.

The Health At Every Size model criticizes promoting weight loss as an iatrogenic cause of ill health across the weight spectrum.  So it is clearly not consistent with the HAESSM model to link it to the promise of weight loss.  But weight stigma is quite real, and most people rightly want less weight stigma in their lives, which they expect to diminish with weight loss.  They are also being told by every conceivable source that they will be healthier if they weigh less, whether there is evidence for that promise or not.  So people wonder, “Am I practicing the HAES approach if I am trying to lose weight?”  Or maybe they even wonder, “Am I practicing the HAES approach if I am glad if I lose weight?” 

I would answer these two questions differently.  In the first situation, the overt goal of “trying to lose weight” conflicts with the focus on what you find sustainable on a day-to-day basis.  We help people look at what practices make sense in their individual lives with their individual preferences and limitations, and then ask them to trust their bodies to reveal the weight that their genetics dictate as the result of those practices.  This focus on the truth of what is possible for you to choose, on a long-term basis, is the exact opposite of organizing your life around the temporary attainment of a specific number on the scale, come hell or high water.  In this respect, the HAES model demands an ambitious degree of trust that your body really is in charge of regulating your weight, while you are in charge of regulating your acts of self-care, to whatever degree is possible and sustainable in your individual life. The HAES model is weight neutral: not for or against weight loss, but rather for a focus on the practices that support your well-being.

For the second question, the answer is more complicated.  It is hard to imagine someone who would not be relieved to face less weight stigma, less stereotyping, less medical profiling, or fewer experiences of not fitting, not belonging, not being considered in the design and size of the physical world.  It is hard to imagine someone who would not be relieved to have more social power.  All of these things are valuable changes that could make an individual’s life a little better even if the broad conditions of weight stigma did not change.

But it is also true that a part of us identifies with our fatness – regardless of how much that “fatness” exists in the real world.  Contrary to the diet industry rhetoric, that part never goes away – because it is connected to universal human feelings of vulnerability.  If you give yourself more value when you are thinner, it backfires, because that is exactly the same experience for your “fat self” as weight stigma was in the bigger world.  It’s like the internal version of being less valued in the world for being fat. So being glad about weight loss is tricky.  It is sometimes hard to be glad about an easier life without granting more value to your thinner body. 

Perhaps one reason it is hard to be glad about having an easier life without granting more value to your thinner body is that from the beginning, we are trained to see our bodies as the reason that we are treated well or poorly by other people, rather than holding the other people responsible for their actions.  It takes the awareness of weight stereotyping, stigma, discrimination, and of thin privilege, to begin challenging our body blame.  If we experience weight loss, it is seductive to give our bodies credit now for the friendlier reception we get; but it is really not about our bodies at all.  It is about stigma and privilege.  Stigma and privilege are not fair; they are not earned.  Moreover, we all have so much experience with weight cycling, we rightly feel wary about gaining thinness privilege when we could lose it so easily.  Better to solve the problem of weight stigma by fighting weight stigma than leaving the stigmatized group.

So it behooves us to be careful not to reproduce the external conditions of weight stigma in our internal life.  It also behooves us to remember that as long as we are trying to solve the problem of the way people treat each other by changing our bodies, we fail to address the actual problem of the way people treat each other.  This is another way that the HAES model is different from approaches that only focus on individual choices.  Individual choices are certainly part of it, but it is only the focus on changing weight stigma and all the environmental, economic, cultural, and social problems that affect our well-being that will make it possible for each person to achieve their potential and purpose.

So can you love your body and still want to lose weight?  You tell me.


This post is part of the 2011 Love Your Body Day Blog Carnival

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September 27, 2011

the HAES files: when health speech is hate speech

by healthateverysizeblog

by Deb Burgard, PhD

Can you support people’s health while rejecting their bodies? 

The public health authorities seem to think so.  Calls for the “prevention and elimination” of “obesity” are coming at us at unprecedented rates.  Fatness – that is, fat people – are being blamed for just about everything vexing about modern life.  Even the public health programs that acknowledge weight stigma don’t acknowledge their own stigmatizing messages.  Fat people are told to solve the problem of weight bias, bullying, discrimination, and violence by disappearing.

And many fat people are trying to disappear.  In fact, people of all sizes are trying to disappear.  The quest for a body that can disappear – disappear from the view of the stigmatizers – fuels a $60 billion weight loss industry.  Americans are spending more money every year on trying to disappear than we spend on college.  It must be pretty damned important to us.

But no, the public health authorities protest, we are not trying to get rid of you, we are trying to get rid of your disease.  You know, your FAT.

Ah, but there is the problem, isn’t it?  Because fat is not a germ, fat is not a tumor, fat is not a parasite.  Fat is an intrinsic and essential part of our human bodies. 

But no, the public health authorities protest, we are not trying to get rid of all of your fat, just the “too muchness.”

Ah, but there is another problem, isn’t it? Because we can’t decide how much is too much.  The public health authorities can decide on an arbitrary BMI, but it fails to predict who will be sick or well.  It fails to predict longevity.  It even fails to predict how much fat tissue someone has. 

But no, the public health authorities protest, it’s fine then to just try to minimize it.

Ah, but there is another problem, isn’t it? Because people who are trying to minimize their fat are actually dying.  Their treatment is so expensive that insurers try every tactic not to pay for it.  So there really is a “too little” fat problem that begs the question, how much is the right amount?  When there are people sick and dying of “too little” and “too much” fat at a wide range of weights, maybe there isn’t a global “right amount” of weight.  Maybe it is an individual thing, inherited by each of us from our ancestors who survived a dazzling range of environmental challenges.  Maybe we are supposed to be a diverse range of sizes!

BMI is clearly a terrible proxy for health, but is there an “ideal” BMI that keeps a person safe from weight stigma?   How much is the right amount of disappearing  to keep from being a target of hate?  How much of you has to disappear to qualify for insurance without being forced to participate in Weight Watchers at work?  To keep you from being called a fatty during “Childhood Obesity Awareness Month”?  To prevent a weight loss lecture when you go in to see your doctor for a strep throat?  To keep you from being the one the other kids blame because there are no more cupcakes allowed at school?  How much of you has to disappear to make sure you can get a knee replacement without having to first mutilate your stomach?  To keep your school from sending your parents a failing “BMI report card”?  To keep you from worrying that the state will remove your children from your custody?  

Disappearing is the road to death, not health.  But it can seem like a good idea when your body is a target for the haters.  And it is particularly difficult to untangle when the haters claim to be asking you to disappear “for your health.”  Not only do people feel the hate, they feel the prohibition on naming it as hate, because it is delivered in the guise of something that is supposed to be good.

Let us remember that we do not talk about “having” fat, we talk about “being” fat.  We identify with our bodies, even more than our homes or cars or jobs.  When there is a rejection of our bodies, we experience it as the most profound rejection, because we understand that no matter how much weight we lose or plastic surgery we get, we still identify with those original body images.  Even weight loss surgery does not reliably make fat people thin people (rather than temporarily-less-fat people), and even while people are thinner they realize they are the same person as before. Listen to the language of the makeover and you hear the relentless drumbeat of, “I am a whole new person!” because in fact, makeovers are fairy tales and we all understand that.  “I disappeared myself!” is a fairy tale, not a solution.  Disappearing is a death – in fact, a murder. 

It is critical for the public health authorities to understand this psychological truth.  When you hate fat, you hate a part of a person that they identify with.  As a fat person, it is impossible not to perceive the hate in these messages.  It is not a health-promoting sentiment.  It is a violence that is being done, not just to fat people, but to anyone who has a part of themselves that identifies with fatness. That’s pretty much everyone these days, since fat is loaded with meaning in our culture. 

Fat is supposed to represent being ugly, needy, out of control, depressed, vulnerable and so on. Our culture teaches us to relegate these all-too-human feelings to the shadows of our psyches, to strive to be everything that “fat” is not.  So people work very hard at not being “fat” -  all those virtuous meals and workouts and sacrifices are designed to hold the things we fear at bay.  But of course even if today you do not feel ugly, needy, out of control, depressed, and so on, there is still the lurking threat of those feelings emerging tomorrow.  And here is the kicker: You are very likely to feel one of those feelings if someone stigmatizes you.  You are very likely to “feel fat” if someone rejects or shames you.

 So the cycle continues – people being mean to other people, who translate the meanness into a problem with their bodies and blame their bodies.  The problem, people, is meanness.  The problem is hate.

 If you are a public health authority, you have power and you have responsibility.  Even if it is the norm for all of us to hate and fear the feelings that are associated with fatness, even if it is the norm to feel pride in a thin body, you need more insight into your own professional and personal beliefs and how they are organized by the cultural and economic forces of your time.  You need to understand these beliefs so you will do no harm.

I ask you to stop running from or attacking what you fear.  Listen to your public health messages with the ears of your fat loved ones and colleagues.  Let them help you to understand how it feels to be hated and threatened.   Can you really believe this is healthy for anyone?  When you stop trying to make fat people disappear, you might be able to actually have a wonderful conversation about health.

The Health at Every Size® model teases out the hate speech from the health speech.  It protests asking people to disappear in the name of “health.”   It asserts that people become healthier when they stop living in fear, when they have environments free of hatred, when they can use the energy that was going into the effort to disappear to instead care for the body they were taught to starve, imprison, surgically restrict, or run into the ground.  It asserts that people become healthier when they SHOW UP.

 It is time for us all to refuse to disappear.  Refuse the path of death.  Care about, and care for, those who have felt rejected, inside you and outside of you.  At any size, at every size, we are worthy.  May we all SHOW UP and take our place at the table.

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August 26, 2011

the HAES files: JAMA proposes a medical mugging

by healthateverysizeblog

by Deb Burgard, PhD

A recent JAMA editorial calls for government intervention – i.e., foster care – for “severely overweight children.”  The authors position state-sponsored kidnapping as a humane alternative to bariatric surgery, whose “long-term safety and effectiveness … remains unknown, and serious perioperative and long-term morbidity and mortality have been reported.” 

Interesting tactic.  Is a medical mugging (“your stomach or your home!”) really the best we can do?

When I read this sort of proposal I feel like the air gets sucked right out of the room.  I can’t decide if I get that reaction out of horror, terror, or being stunned by the arrogance of anyone thinking that they can read a parent’s actions from the size of a child’s body. 

For medical professionals and legal professionals and child welfare professionals to believe that parental neglect or abuse is the explanation for a child being very fat confounds me.  Where are the data?  As far as I can see, we don’t really know why some human bodies are phenomenally gifted at making fat from food.  And we don’t really know how to transform those bodies into thin bodies.  And though I can conceive of it, I am not aware of any documented psychopathological syndrome where a parent force-feeds a child to immobilize them.  And I am not aware of any medical intervention that transforms fat kids into thin kids that parents should be following to prove they are not neglecting their child.

I wonder if the JAMA authors could imagine a scenario where patients are removed from a clinician’s practice if they do not become thin from their weight loss intervention.  No provider who could not demonstrate lasting weight loss would be allowed to have patients.  Would they like to be held to the standard they are asking of parents?   

The only way I can make sense of this is to imagine that these professionals really believe that if people eat normally and exercise, we would all be average size.  Or they believe that because it would be unimaginably hard for them to reach a weight that high, it must be the case that this child is ingesting phenomenal amounts of food that “any reasonable parent” could modulate.  One would hope that any “expert” in the field would have abandoned these childlike notions long ago.

I can attest to the fact that there are certainly humans that ingest phenomenal amounts of food – but they come in all sizes.  Would we kidnap the average-sized 17-year-old adolescent whose family can’t stop her from binging and vomiting?  The emaciated 15-year-old who binges in the middle of the night and then goes out running unbeknownst to his parents? Families are begging for help for their children with eating disorders, which insurance companies routinely refuse to cover.  I don’t see JAMA editorials outlining this problem.  The medical problems and risks that these children face are far more immediate and deadly than someone who does not binge but is fat and runs a moderate risk of developing diabetes 30 years from now. 

Most of the very fat children discussed in the JAMA editorial have no current medical problems.  It is their weight that people are worried predicts future medical problems.  A few of the very fat children discussed in the JAMA editorial have current medical problems, as do a few of the children in any weight class.  There are no medical problems that fat people have than thin people don’t have – but when fat people have them, it tends to be blamed on their fat.

The good thing is that most medical problems have treatments.  For example, lots of children, fat and thin, have sleep apnea.  To kidnap a child and put them on a diet so they won’t develop sleep apnea is silly.  Why not just test for and treat the sleep apnea?

In my experience treating people with eating disorders, it is almost always the case that dieting precedes binging.  To fault a family for not putting a child on a diet is unfair and unscientific.  When families try to make their children lose weight by putting them on diets, it turns into a monumental power struggle that results in more binge eating and a more protracted struggle around food for that child that can last for the rest of their lives. 

Let us face the facts.  Being very fat is still a very rare situation, despite the images of the very fat people side-by-side with proclamations that “two-thirds of US adults are overweight!”  If the photos were commensurate with the statistics, the picture would show a person about 15 pounds heavier than they would have been a generation ago. But that doesn’t make for very dramatic news.  To become very fat requires a large number of factors that all point in the same direction, which is why so many people in our “obesogenic” environment are not fat. It is why not even all the children in a family with a very fat child are likely to be fat.  We don’t understand all of these factors and haven’t even identified some of them.  Ironically, one of them may be trying to become thinner.  Another may be being targeted for shaming about weight.  Above all, we won’t know until we have an intervention that makes fat people thin whether that is a good thing for them.  We are assuming that thin fat people would have the same risk profile as thin thin people, but no one knows. 

So until we have a very clear idea of what is going on and what, if anything, is problematic about what is going on, and what, if anything, is going to make a situation better, we should be very, very humble about yanking a child out of his or her home and subjecting him or her to something as barbaric and likely to fail as a diet. 

It really is chilling to imagine the trauma of being removed from your family, being placed with an unknown group of strangers with no necessary attachment to you, who will control all of your food access, with the demand that you be starved until your body is acceptable.  The authors seem to ignore all the potential psychological sequelae of such an “intervention.”  They also seem to ignore the implications for the civil rights of the child.

Healthcare-by-BMI is making us sick.  Of course we should care about the quality of life of our children and intervene when children are being neglected or abused.  But why we should think that a child’s body size is evidence of any particular parental behavior is as clueless and simple-minded as thinking that an adult patient’s body size is evidence of their eating or exercise practices.  This is weight stereotyping, not medicine.

There is a rational and humane way to support children and families in optimizing their health and well being.  It does not come from a short-term, dramatic “rescue” of a child from what outsiders, based solely on a child’s body size, conclude must be an unsafe environment.  It comes from long-term, broad policies that create a society that allows  parents to give their children nutritious food, loving attention, a safe place to live and play, and the skills to make friends, whatever their body size.  It is odd that so little thought or resources have been given to how to make movement opportunities more possible, pleasurable, and accessible for fatter people.  We also know that strong relationships support physical health, so whatever we can do make family attachments stronger and more loving is a lot more likely to benefit a child than demonstrating to him or her that nothing, not even having a home, is as important as losing weight.

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August 9, 2011

the HAES files: loving your body won’t kill you, but being targeted for a curse might

by healthateverysizeblog

by Deb Burgard, PhD

If you haven’t read Jess Weiner’s article in Glamour, “Loving my Body Almost Killed Me,” go do it now and then come back so we can discuss it intelligently.

Back? OK.

I met Jess earlier this year at a couple conferences where she spoke.  I like her.  She obviously has the right to do whatever she needs to when it comes to taking care of herself.  She says she feels better doing these practices (eating less processed food, doing water aerobics, going to therapy) than she felt before, so that is great.  These practices, for her, appear to be associated with medical tests results that are solidly normal (instead of mostly normal – but hey, that is a meaningful difference to her).  She describes the triggers for her doubts and they were experiences of weight stigma.  So I can understand her wanting to be thinner.  Most people want to experience less weight stigma and that is a healthy thing to want.

She got worried in the first place because she got blasted with public humiliation by the lady in the audience who sneered that she couldn’t be healthy and fat, and then she got told by her doctor that her mostly normal tests portended diabetes.  I believe it is most accurate to describe this pronouncement as a curse (albeit delivered in a most kind and warm manner), since it was reportedly worded, “If you don’t lose some weight and watch your sugar intake, you will get diabetes.”  Not: “well, the statistics show the risk of developing diabetes in the next 5 (10, 25) years with your numbers is x,” which would be accurate and descriptive and what I, at least, expect doctors to provide as my medical consultants. 

 For the record, there is no research that shows that 100% of the people at Jess’s weight will get diabetes in their lifetime.  According to one representative national sample, for a white woman at midlife in the highest weight range (BMI>35), the chance of her getting diabetes sometime in the next 40 years before she dies is 58%.  The longer she goes without a diagnosis, the less likely she is to be diagnosed; for example, the risk falls to 35% at age 65. So Jess got a very scary medical message that does not sync with the epidemiological research on diabetes.  I do not say this to impugn her very nice doctor, but rather to highlight that even very nice doctors with great relationship skills are giving us mainstream information that may not be unbiased.

 Now here’s the real problem.  Jess seems to be equating “loving her body” with “being passive about health.”   She implies that body acceptance kept her from instituting the health practices that she has since made a part of her life.  She is saying that she almost died from “loving” her fat body.

 It is not my intention to call out anyone over her good-faith efforts to figure out how to best care for herself.  However, I do want to call out the act of equating body acceptance with a death wish.

Body acceptance is only a death wish for the weight loss industry.

I think this is a massively confusing article because Jess is setting up an equation between “caring about your health” and pursuing weight loss – and yet much of what she is actually doing is solidly within the Health at Every Size® model – i.e., finding out what food proves to be great fuel for your particular body and how to listen to its cues, giving yourself pleasurable exercise, figuring out what else you need when it isn’t food, getting help for disordered eating symptoms if you have them, and so on.  I honestly don’t know why Jess thought engaging in these practices would be somehow betraying the body she was trying to love. 

 OK, maybe it is the part about focusing on weight loss, insisting on losing even more weight despite her normal medical tests, and “exercising when exhausted.”  But more about this in a moment.

 At any rate, apparently when Jess does these practices as a whole, her weight settles at a lower number.   Who cares?  Well, Jess is worried about body acceptance activists caring, but I am more worried about all the people who care because they want to perpetuate the idea that the pursuit of weight loss is the path to one’s optimal health. 

 The Health at Every Size® model challenges this position and demands data for it.  HAESSM  is weight neutral.  Let’s say that again: Weight. Neutral.  The model addresses both the big societal concerns like weight stigma and social justice, and the choices that individual people have a chance to make for themselves.  As far as that goes, the focus is on the practices that help you care for your precious body, and whatever your weight is when you do them, fine.  Some people find they lose weight doing those practices.  Fine.  Some people stabilize or gain weight, especially if they were just coming off a weight loss diet.  Fine.  Until someone has 2-5 year follow-up data that contradicts what study after study has shown for the last century, the Health at Every Size® model takes the empirical data on pursuing weight loss and reports it honestly – it is a bad experience for most people.  But pursuing weight loss is different from trusting your body to find its balance and change its weight if necessary while you try to figure out what practices suit you, make you feel good, and are sustainable in your unique life.

So I feel really, really disappointed that Jess doesn’t seem to perceive body acceptance as including the practices that make her feel better, and that she has portrayed it that way for the millions of Glamour readers who have probably never heard of  the Health at Every Size® approach.  I feel really, really disappointed that she framed her experience of trying to love her body as almost killing her  – as if that was keeping her from caring for her body – and as if loving your body is a terribly dangerous act.  And I feel really, really disappointed that she seems to think that there is something magical about a lower number on the scale – rather than the actual health behaviors she is doing – that is causing her to feel better.   And I am really, really disappointed that she is holding up this frame around her experience when the vast majority of people who pursue weight loss find that it harms them.  I can’t speak for all body acceptance advocates, but the critique of the pursuit of weight loss is not just about self-acceptance.  It also a critique based on the experience of most people that it does more harm than good to their physical and mental health.  And finally, may I also say that by equating having a risk of developing diabetes with “almost dying,” she insults the experience of people who are actually living with diabetes. 

Jess, I wonder if your “before” numbers had been presented to the average MD as those of a thin person, whether she would have trotted out the curse.   Your lipid panel and blood pressure numbers were almost all in the normal range and if not, barely in the “could develop into a problem but not now” range.  In recent years we have seen all sorts of risk factor “sprawl” where doctors and insurance companies can tag you for being “pre-risk-factor.”  I believe your experience of being not even “pre-diabetic” but “pre-pre-diabetic” and still eliciting the curse is a great example of weight stereotyping in medical care.  As you yourself note in the article, there are quite a few fat people who have normal metabolic numbers at every stage of life.  But a lot of people, fat and thin, develop “risk factors” as they age, and, even more of us will have numbers in the “pre-risk-factor” range, creating glorious new markets for all kinds of industries.  Part of the stereotype management skill set as a fat person is trying to parse the standard medical advice, which quite often is delivered in the form of a curse rather than an accurate portrayal of statistical risk.  A curse offered with the best of intentions, perhaps, but one that sends most patients down paths of failed diets, avoiding doctors, giving up health practices when there is no weight loss, disordered eating, etc.  You yourself talk about your disappointment that you “only lost 25 pounds.”  When people tie the practices to weight loss, they are vulnerable to fatigue, hopelessness, and overwhelm.  Taking care of yourself is hard enough work as it is.  Do you plan to stop the practices when you reach your weight goal? If not, why worry about a weight goal? 

 Aside from the massive influence of genetics, class, and culture, it is the practices that matter, not the weight loss.  No one who gets liposuction improves their lipid numbers, but formerly sedentary people who get more regular exercise improve their numbers whether they lose weight or not.

 The other concern for me is that as an eating disorders specialist, I see medical authorities essentially prescribing for fat people what gets diagnosed as eating disordered behavior in a thin person.  Why should it be “healthy” for a fat person to focus on the numbers on the scale, eat in a way that feels unsustainably restrictive, exercise “when exhausted,” etc.?  All of that is quite different from trusting your body to figure out your healthy weight, eating in a sustainable way, and exercising for the pleasure and skill it gives you.  Imagine if “pre-disordered eating” were added to the list of risk factors doctors screen for!  According to my MD colleagues who specialize in eating disorders, most doctors do not even integrate the fact of a patient’s eating disorder history into their treatment recommendations because they are simply not trained to.

 In fat acceptance circles, we have been talking for decades about the pressure to be a “poster child” for glowing health if we are fat.  It’s a stereotype management thing.  In the eyes of a dubious public, we are split into “good fatty” and “bad fatty” camps depending on whether we eat our vegetables and have normal blood glucose values.  When we age and develop the diseases that people across the weight spectrum develop (yes! there are no diseases that only fat people have!), when they are conditions modestly correlated with higher BMI, we feel like we are BUSTED.  That emotional experience rocks our faith in our own experience, that dieting has left us with more physical and psychological problems, not less; and we are vulnerable to the “solution” of weight loss because it is scary to get older and less physically resilient.  We forget that these experiences of aging happen to everyone – and everyone wants to feel like they have something tangible they can do.  Pursuing weight loss is the great global cultural response to just about anything that ails you – and hey, we are all pre-death.

 I have questions for us and for Jess. Why did Jess not feel us having her back when the mean audience lady and the nice doctor lady said things to her that threw her into a tailspin?  Why does Jess worry that if she loses weight, we won’t like it, or her?  Why did it seem like loving her body was dangerous rather than the path to the loving practices?  Why does she feel like it is weight loss – rather than the practices and her own body’s capacity for healing and health – supporting her well-being now?  How do we support people – whether they have “normal” lab tests or not – and create environments that support – the practices that they decide make them feel best?

 I also have some suggestions for us.

 First of all, if you have had or now struggle with disordered eating, give your doctor this booklet on medical risk management.

 Read Jerome Groopman’s fabulous book, “How Doctors Think” and use his suggestions to help your doctor reason better.

When a doctor tells you you are “pre-whatever,” ask him or her for an actual statistical probability that someone with your numbers will develop a problem in the next x years.  When a doctor tells you to lose weight, ask for documentation of any approach with 2-5 year follow-up data showing that people maintain weight loss as well as health improvements.  When a doctor tells you that losing weight will lower your risk factors, ask if the data for that recommendation is based on actual fat people who have lost weight, and kept it off more than 2-5 years, or on the risk profiles of people who were always thin.  When a doctor tells you you will get a disease, ask him or her to take you step-by-step through the reasoning.  Would the same numbers in a thin person be grounds for this prediction? 

 And when a doctor tells you something you deem a credible piece of information, understand that your body may be becoming more vulnerable, less resilient, more dependent on your choices to feel good.  Do you have to adopt some draconian set of health practices?  Of course not – that is not likely to be sustainable.  Are you a moral failure if you react by sitting on the sofa?  Of course not – having a health challenge is not a moral failing.  Are you faced now with some things to sort out about what feels sustainable to do, in your life, for the duration?  Yes, if you want the benefits those practices will bring.  Are you going to have to sort out what you can do that won’t trigger a bunch of associations to dieting and punishment?  Yes, which is one reason why this weight loss stuff is so toxic.

 Finally, let’s keep talking about all of these struggles. I think Jess has struck a huge nerve because many people are trying to manage all sorts of conflicting feelings.  It does seem like it is  harder to talk about than it should be.  Let’s hope that we can keep talking and valuing each other without throwing body acceptance under the bus.

 Jess, I hope hope hope that this is just a brief stop for you on the way to integrating both the practices that make you feel good and the unconditional love for your body, whatever size it may be at any given time, rather than feeling like there is some tension between these two.  

 May we all have the best health possible – and may we acknowledge that those of us with health challenges are every bit as valuable as anyone else.  May we remember that the two possibilities are getting older or dying, which, you know, puts getting older into perspective.

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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.

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