Archive for August 9th, 2011

August 9, 2011

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

by Health At Every Size® Blog

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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