Fierce Freethinking Fatties
Trigger warning: Brief mention of weight loss.
Stars, please shine the way for me
Show the one that I have followed
To see how far I’ve come.
~ Dawes, “How Far We’ve Come”
When I first started blogging, I had a great big bucket of fucks to give. About everything. Those of you I’ve known from the beginning have seen me spreading fucks around like I was Johnny Fucking Appleseed.
Feminism. Fashion. Politics. Race. You name it, I gave a fuck about it. Today, I still give a fuck, but my views have been shaped by conversations I’ve had with people I’ve disagreed with online.
I can be confrontational, stubborn, abrasive, rude, arrogant, and irritating, all in the span of a single paragraph. Although some may see my troll-like stance as a lack of empathy or compassion, I see my approach as forging my beliefs in the fire of confrontation. If my opinions can’t withstand the heat of dissent, then they probably aren’t right. I can’t exactly explain why, but I get a lot of psychological satisfaction from being right.
Now, I don’t just mean right, as in I can outargue you. In my experience, people very rarely “win” arguments. Two people come together, exchange beliefs, then go back home with pretty much the same belief system they brought to the table. We live in a society where intransigent beliefs are a virtue. There’s nothing more righteous than accepting a belief as true and then never yielding your position.
I find intransigent beliefs to be a trap. Too much certainty in something that is nothing more than an opinion can lead to intellectual stagnation. But whether we’re talking about politics, religion, health — it doesn’t matter — there is always more we can learn and understand and incorporate into our worldview. To say, “I accept these truths and no more” is to say “I’m done learning.” And people who are done learning have stopped living.
To me, being right means that you are constantly in search of the most complete answer. This blog began as a search for the truth about weight and health, as viewed through the lens of Health at Every Size® (HAES).
Prior to blogging about HAES, I subscribed to the mainstream belief that bodies are pretty malleable through diet and exercise. The very genesis of this blog was due to an offhand comment that if I went on a heart-healthy diet that I would lose a lot of weight.
Due to its strict anti-diet talk policy, I was kicked off the Fatosphere feed, which compiled Fat Acceptance blog posts. I handled my expulsion with dignity and grace … just kidding, I dropped F-bombs like they were snap-pops and posted a photo of a Sumo wrestler’s ass, inviting people to kiss it in lieu of my own.
Fierce, Freethinking Fatties was the blog that rose from the ashes of my self-immolation. And in the Spirit of Not Getting It, I proudly began by published my confrontational interview with MeMe Roth, which ended with me saying “Fuck you” (Yay!) followed by some unnecessary body shaming (Boo!).
Five years later, I look at MeMe Roth and she makes me more sad than angry. Yeah, she was an insufferable hydrant of hatred who inexplicably earned a national platform to spew her toxic brand of intolerance. But that hatred was always a projection of her own fears of getting fat.
Look at her now. Go to the website of her National Action Against Obesity site and check out the “In the News…” section. The last article is from 2008. MeMe Roth Nutrition Help is DOA. The only peep there’s been from MeMe is on her Wedding Gown Challenge page, which has an entry from August 2014 that reads:
Okay, so this wasn’t easy this time. I really can’t put on another ounce if I expect to get the zipper up next year. I’ve had to watch my weight since I was about 12. And I see no signs that it will get easier. I run daily, eat right, and also eat oh so wrong..! I better cut back on that last category. Hope whatever you tried on today still fits. And if not, let’s go for next year..! All my best, MeMe
Of all the projects MeMe worked on, the Wedding Gown Challenge seems the most important to her, as she’s kept it up for six years straight. And just look at the self-recrimination — if anyone needs the Health at Every Size® (HAES) approach to self-care, it’s MeMe Roth.
And I believe that because I’ve spent the past five years trying to figure out what the right answer is with regard to weight and health. I believe HAES is the right answer because virtually all the evidence says (as our readers are no doubt sick of hearing by now) that the vast majority of people who adopt healthy lifestyle changes will lose about 5-10% of their starting weight, which researchers define as “clinically significant weight loss.”
If you lose more, great. But most people find weight loss of 10% or more nearly impossible to sustain in the long term. That’s the reality that obesity researchers have come to accept, while the rest of world is gradually catching up.
I’ve played my part in spreading that message, but there’s only so many times you can say “most people who adopt healthy lifestyles lose about 5-10% of starting weight” before you start to feel like a verbal lawn sprinkler.
I think what I’m trying to say is that I’m burnt out.
I’ve been writing one thing or another my entire life. I love writing. It’s my original passion in life. And when I started blogging in 2009, I hadn’t planned on doing any of this. One of my favorite posts that I did back then was mocking a bunch of album covers from the Christian music I used to listen to as a geeky God-boy: Jars of Clay, DC Talk, Michael W. Smith. You know, the good shit.
I was mainly doing stream-of-conscious blather as my third attempt at blogging (the first two being on OpenDiary), when I happened upon some of Kate Harding’s posts on Shapely Prose and got inspired to write about Fat Acceptance.
The rest is a long and brutal history of me pissing people off left and right as I blustered my way through the unpacking of my privilege. If I had one wish with regards to this blog, it would be that I could go back to the beginning with all the experience and understanding I have now. Not to say I wouldn’t fuck up again, but it probably wouldn’t be so disastrous or so often.
The result of all that damage is that Fierce Fatties became a kind of island unto itself. We’ve always been a part of the Fat Acceptance discussion, but we were distinct from the real thought leaders of the movement. My temperament and attitude has probably done more damage to this blog than anything, and yet we have a wonderful group of faithful bloggers and readers who have stuck by me through the worst of it. For that, I’m eternally grateful.
But what really brought home the self-inflicted divide was the response to our fundraiser. It was a bittersweet victory. We raised just enough money to pay for the website to be upgraded, but only raised half of our goal, so our options are severely limited.
I didn’t know what to expect when we launched our fundraiser. We’ve been around a long time and have a lot of readers, but how many would invest money in its future is a totally different story. In the end, 17 people donated rewards, while 50 people donated a total of $1,026 because they believe in the mission of Fierce Fatties. I feel incredibly honored that all these people (some I know, some I don’t know, and nobody I’ve ever met) believed it was important enough that they donated money during the holiday season.
What hurt was when we asked for help, the broader Fat Acceptance community pretty much ignored us, including people I thought supported us. Quite frankly, I can’t blame them. I’ve long accepted where I stand. And thanks to my thoroughly Catholic upbringing, I feel tremendously guilty for inflicting the collateral damage of my ego on my co-bloggers. Although I’ve certainly had a prolific five years, I’ve also been a significant drag on the success of Fierce Fatties.
Although I know I’ve been a part of the Fat Acceptance journey for some readers, I can’t help but feel that my own contributions are largely unnecessary for the broader movement. Most recently, as I put together the HAES roundtables on the social determinants of health (SDH), I was put through the wringer just to publish what I did.
The final straw was when I was criticized by the person who recommended I put together the SDH impact roundtable for not paying the participants. Perhaps if I had ever made a single dime from this blog that criticism would make sense, but the implication is that if I can’t afford to pay people for their opinions, then it is wrong to ask their opinions in the first place.
I believe that above and beyond my own writing, this blog is my contribution to the movement, and perhaps without me at the helm it can become part of the larger conversations happening.
So, I have asked Jean Braithwaite, an incredibly skilled writer and editor whose views align much with my own, to be my successor as Chief Fatty. Even more important, she has the deeply-considered thoughtfulness needed to take Fierce Fatties to the next level.
She agreed, but due to a preexisting project, she can’t start just yet. She hopes to be able to take over Fierce Fatties this Summer.
We would also welcome a co-editor to divide up responsibilities. If anyone is interested in becoming co-editor with Jean, please feel free to email me at atchka at hotmail. Bloggers as well. Because even though I’ve exhausted my supply of fucks on this subject, you haven’t. It’s time for you all to step up and start giving fucks for the state of fatness today. You have a voice that needs to be heard, a viewpoint that needs to be shared. Everyone does.
In the meantime, we’re going to put the blog into a state of Hypno-Helio-Static-Stasis. If you’ve just started reading, we have a vast archive of content that can tide you over in the coming months.
As for me, I will continue to write and incorporate everything that I have learned into my work. I believe that perhaps I can still serve the movement through some other writing project.
For one, what I love writing most is fiction. It’s been my lifelong passion and the majority of my creative energy has been spent creating worlds for my own amusement. And when I invest my creative energy in a project, it’s difficult for me to divide my attention too much. This blog has occupied such a significant percentage of my creative energy and time that it’s been difficult to work on anything else.
So when I really listen to my heart, when I think about what I want to do, I’ve been more and more excited by the prospect of writing a novel for my daughters. In fact, about a week ago I read them the first chapter and I’m happy to report they enjoyed it.
I’m also starting a smaller blog that will be less labor intensive and less of a commitment. In fact, the week after I re-upped the domain for Fierce Fatties, I was playing around with available URLs when I found one that I really liked AND found a coupon that gave me a huge discount for a two-year subscription.
So, I’m now the proud owner of Divine Ground.
I’ve always loved theology and I’d like to do some exploring of different faith traditions and talk about my own belief in the Divine Ground (a term Aldous Huxley used to describe the higher power that most religions are trying to connect to). I don’t know if I’ll write weekly, but I will write when the mood strikes me.
[Side note: Ironically, I recently learned that our blog has an entry in the thoroughly-enlightening Conservapedia which reads: “Fierce, Freethinking Fatties is an atheist fat acceptance movement website.” For the record, we have no official stance on God … but we are comprised of at least one lapsed Roman Catholic, a pagan or two, and the rest I don’t know off-hand because it’s not really a topic we discuss at length here.]
Anyway, that’s the long and short of it. After five years of searching and probing and questioning and doubting and deconstructing and rabble-rousing, my entire philosophy on weight and health can be summed up as follows:
If you want to be healthy, know thyself: who you are, what you need and what you can achieve. Also, know what the science says. Use that knowledge as a kind of guidepost for your journey. Perfection is not the goal, self-actualization is. And if you’re as encouraging and compassionate with yourself as you are with your friends and family, then you’ll have no problem building and sustaining good metabolic health. You got this.
Filed under: DT, FH, Metamorphosis Monday, WL
Trigger warning: Discussion of fat health and weight loss.
For nearly five months, I’ve tried to keep a relatively positive public stance on the discussions I’ve had behind the scenes about Health at Every Size® (HAES). My resolve hasn’t been perfect and I’ve lashed out at perceived hypocrisy, but I’ve tried to maintain a measured posture on what I have seen as a seismic shift in the HAES philosophy concerning the social determinants of health (SDH).
Today, I am ready to speak openly about my views, having finally published the HAES expert roundtable (Part 1 and Part 2), my interviews with SDH experts Dennis Raphael and Stephen Bezruchka, and the SDH impact roundtable (Part 1 and Part 2). What follows is what I consider to be my definitive treatise on HAES, the SDH, health and weight.
I first learned about HAES in 2009, when I began writing on my piddling Blogger site. Back then, the entire concept revolved around personal lifestyle choices and how a healthy behaviors can yield long-term, sustainable benefits regardless of whether it makes you thin or not.
That revolutionary concept — health regardless of weight — completely upended my belief system and sent me on a quest to find out whether the science supported this approach or if HAES was junk science. Along the way, I’ve read a shitload of research and talked to a number of non-HAES experts on health and fitness whose viewpoints may not have been identical to those of Linda Bacon et. al., but whose research reinforced the lifestyle components of HAES.
For example, from my interview with Dr. Steven Blair:
You can’t tell by looking if someone is fit or not. In fact, in our research if we look at adult men and women body mass index of 30 or greater, about half of them are fit by the cardiorespiratory fitness standards that we’ve used in our research and health outcomes … Bottom line, what we’ve found, is that low cardio-respiratory fitness, those who are unfit, is really one of the strongest predictors of morbidity and mortality of anything we’ve measured in this data set. For example, over 50,000 men and women followed for on average more than 10 years and about 4,000 of them died. Sixteen to seventeen percent of those deaths can be said to be caused by low fitness; two or three percent of the deaths were caused by obesity; I think four or five or six percent to diabetes. The only thing that was even close to low fitness in terms of the number of deaths it caused in the population was hypertension in men.
As my understanding of the evidence grew, my personal behaviors began to change and, consequently, my health markers began to improve. You know what didn’t change? My weight.
These concepts were already demonstrated in Bacon’s 2005 research paper which pitted a traditional weight-centric approach to HAES. After a two-year followup, the dieters had regained the weight and lost their metabolic improvements, while the HAES group remained weight stable and maintained their metabolic improvements.
For years, Bacon’s study was the cornerstone of HAES and the foundation of a lifestyle philosophy I felt compelled to research exhaustively and promote vigorously.
Then, back in September, things changed.
I read and reviewed Body Respect by Linda Bacon and Lucy Aphramor, which seemed to reinforce this earlier approach to HAES as lifestyle choice, but introduced a new emphasis on the social determinants of health.
From the beginning, I have been whole-heartedly supportive of promoting the SDH as a vital key to improving health on a population level. Address socioeconomic inequity and you put marginalized people on a level playing field in terms of chronic stress and baseline health needs.
My biggest question, though, was what affect does this new emphasis on the SDH have on HAES? Body Respect does promotes the idea of the importance of healthy behaviors, but there are caveats throughout the book like this one: “Blaming illness on behaviors stops us from addressing the policies and systems that shape our lives in unequal and unhealthy ways.”
And when I asked Linda Bacon these questions, she told me that the effects of personal health behaviors were “blown out of proportion in terms of how they affect health.” Elsewhere, I’ve seen Bacon emphasize the fact that stigma is the cause of so-called “weight-related illnesses.” For example, from her post on the American Medical Association’s decision to label obesity a disease:
The AMA decision also leads to more prejudice and discrimination, which unfortunately, also increases disease. Extensive evidence shows the chronic stress of stigma plays a role in almost every disease currently blamed on obesity.
While stigma certainly can contribute to disease (as I learned from my interview with Dr. Rebecca Puhl), I find this new framing problematic.
First, there’s the issue of how personal health behaviors fit into the context of the SDH. The implication is that the effects of the SDH are so overwhelming that you can’t blame behaviors for illness. For example, there’s this quote from Body Respect:
[I]t is wrong to assume that diet, or even diet and exercise, are the main determinants of health. In fact, according to the U.S. Centers for Disease Control and Prevention and others, health behaviors account for less than a quarter of the differences in health outcomes between groups.
This is absolutely true. In the first HAES roundtable, I was stunned to find the following graphic on the CDC’s website regarding the SDH:
Likewise, Dennis Raphael said that two individuals on the same socioeconomic level who engaged in opposing ends of health behaviors would have about a 15% variance in health.
In my view, the question then becomes does that limited variance make a significant difference in the lives of those able to make those personal lifestyle choices?
Just four years ago, Bacon and Aphramor published a paper in the Nutrition Journal that made a compelling case that they do. So what has changed?
What I see changing is that we have left out of our discussions of HAES a significant segment of the population who begin life in poverty and oppression, which contributes to a lifetime of inequality, chronic stress and limited self-care options.
Focusing on marginalized communities is vital, and addressing the negative impact of the SDH will have a profoundly positive public health impact. But it feels as though the emphasis from HAES experts is swinging hard to the other side of the pendulum. We’ve gone from emphasizing personal health behaviors as the most important health factor to emphasizing poverty and inequality as the most important health factor.
And yet, both emphases are true and both are important.
The SDH is a diabolical factor destroying the health of far too many people across the globe. But not everybody is negatively affected by the SDH. In fact, HAES rose to popularity as a countercultural response to a weight-centric culture that drove privileged people to pursue diet and exercise as tools of health management. More likely than not, the people who adopted HAES were in a position where their biggest concerns were over lifestyle choices, not whether they could feed their family or who is going to care for their children or how they’re going to get to work.
As Dr. Raphael said, “Once you’re living in a poor neighborhood, it doesn’t matter what your weight or physical activity is in terms of your likelihood of getting cardiovascular disease.”
So the negative effects of the SDH, and therefore the public policy responses that HAES could support in response, rest on a gradient. The more wealth, power and privilege you have, the less the SDH will contribute to your negative health.
For those privileged HAES supporters who don’t have to worry about the SDH personally (myself included), they want to know what else they can do to improve and maintain good health for as much of their life as possible.
This was certainly my aim. I’ve written about my family history of cardiovascular disease, and how my interest in HAES is framed by the reality of that genetic inheritance. I want to know how to stave off a heart attack for as long as possible.
For me, the personal lifestyle emphasis of HAES led to behavioral changes that yielded demonstrable metabolic benefits in terms of my blood pressure, blood sugar and blood lipids. When I lapsed in those healthy behaviors, I watched those metabolic benefits erode and the indicators of metabolic disorder creep up.
The SDH has given me the privilege to focus solely on that 15-25% of my health that I can affect through my behavior. And given the evidence of Bacon and Blair’s work, I see that, all things being equal, exercise and fitness can help me reduce my risk of morbidity and mortality. To me, that’s enough to justify a continued emphasis on personal behaviors.
And yet, at the exact same time, I can look at the reality of the SDH and its impact on those with less privilege and feel equally compelled to fight for greater socioeconomic justice for all. The impact of personal behavior does not need to be diminished to make room for the impact of the SDH. What it needs is context.
Again, Dennis Raphael provided some great context to consider:
There’s this guy, David Seedhouse, who wrote a book called The Foundations of Health, and he made the argument, philosophically, that unless you provide people with the basics, you can’t go after them on these other issues. What I suggest to people is that all things considered, you want to do what you can. You do what you can no matter what level. If you’re an anti-smoking person, you do anti-smoking, but you don’t do it like “You guys are just stupid, stop smoking.” You do it in terms of empowering them.
Any time somebody comes along and says “We gotta stop Latinos from smoking,” although they don’t smoke that much, you come out and say, “Yes, of course we do, but don’t you think we should be spending some time on the kinds of employment opportunities and educational opportunities that kids have?” So you just try to shift that 99% of attention to 95% or 90%, or just work its way down.
To me, this is how HAES should balance the dual emphasis of personal lifestyle behaviors and the SDH:
If you look at your own life and your own situation in relation to Maslow’s hierarchy of needs, you can get a rough idea of which HAES emphasis will have a greater impact on you as an individual.
If you’re struggling with those basic needs at the bottom of the pyramid, personal behaviors are largely irrelevant. You have more pressing health concerns affecting your day-to-day health, so adding exercise or improving your diet are low priorities.
If you have aren’t struggling to satisfy your physiological needs, safety and security, and love and belonging, then, if you wish to improve your health, you are in a far better position to start working on self-acceptance, intuitive eating and joyful movement.
Then there’s an additional layer to this: if you’re at the top of Maslow’s hierarchy, if you have the kind of economic security that affords you the time and resources to engage in healthy lifestyle behaviors, then you can find additional eudaimonic (my new favorite word) well-being by fighting for equity in this incredibly unjust world.
And if you’re at the bottom of that hierarchy and want to reduce the health risks caused by the SDH, then Raphael and Bezruchka recommend civic engagement and community involvement. Bezruchka pointed out that although Latinos are frequently at the low end of the socioeconomic scale, they have some of the best health outcomes. He and other researchers believe the mitigating factor is the cultural emphasis on family and community and social support that is virtually absent in the more privileged, social media culture that many of us live in.
But what we should not do, as HAES activists, is treat the effects of the SDH as universally equal or the benefits of personal behavior universally futile. Likewise, this new attempt to paint metabolic disorders as largely caused by stigma is problematic.
Stigma certainly affects health, but if weight stigma is the driving factor of the metabolic disorders associated with obesity, then Steven Blair would not have found such radical differences in metabolic health between sedentary and active people. If stigma was the driving factor, then thin, sedentary people would have better health and fat, active people would have worse health because stigma would still be absent and present, respectively.
Likewise, Bacon’s 2005 study found metabolic benefits despite weight stability in the HAES group. Bacon’s current emphasis on stigma makes little sense if she was able to help subjects improve their metabolic indicators without affecting their stigmatization status.
What I have learned most over the past five years of studying HAES is that the relationship between weight and health is incredibly complicated and individualized. The worst thing we can do as HAES advocates is to issue blanket statements that oversimplify the issues. Not all fat is metabolically dangerous, but not all fat is completely benign; not all “healthy behaviors” lead to noticeable weight loss, but not all weight loss leads to improved health; not all fat people suffer the ill effects of weight stigma, but not all weight stigma is harmless.
HAES should educate people about EVERY aspect of weight and health, then allow individuals to process all that knowledge and all that truth through the lens of their individual life experiences. Only then will HAES be capable of improving lives across the broad spectrum of humanity.
Filed under: DT, EX, FH, FP, Frank Friday, FS, MBL, WL
Trigger warning: Discussion of weight, eating disorders, health and weight loss.
Yesterday, we heard from seven women who shared their experiences with the social determinants of health (SDH) and how it has affected their self-care. For the final three questions, I ask them to describe their relationship to Health at Every Size® (HAES) and for their suggestions on how we, as a community, can address the social determinants of health. What’s awesome is that their answers sound a lot like the suggestions made by Dr. Dennis Raphael and Dr. Stephen Bezruchka, the two SDH experts with decades of research in this field.
Question 4: Do you consider yourself to be “practicing HAES”? If so, what does that look like in your life? If not, how has HAES been insufficient at meeting your needs?
I used to think I was practicing HAES, but I am not so sure anymore. I find that I am not necessarily at my healthiest. I know that my weight is taking a toll on my body. I am still curvy, but I am finding that when my own weight goes down my joints and polycystic ovary syndrome (PCOS) symptoms go down. So I am really conflicted.
I consider myself to be practicing HAES. I find that with me, balance is key — everything in moderation. I don’t drive, so I walk and take public transportation everywhere. Still, I wish I had more enjoyable movement in my life. I used to go clubbing a lot, but at over 40 I feel like it’s time for something new.
I do my best to practice HAES. There are times when I have to let go of it, though. I’m gluten free to help with joint pain/inflammation, and when I get really broke, I end up eating cheap, processed wheat products to get by. And when I get really busy with work, or I have to travel long distances for art fairs, my activity level plummets.
I think that doing the best you can with the resources available to you at any given time is part of HAES. Seeing health and healthy choices as a continuum, rather than a right or wrong situation, is what differentiates HAES from the weight-loss paradigm. I’m reminding myself of that a lot lately, like when I seek out healthy behaviors and treatment for health conditions that my body weight might change as a side effect. I’m currently examining ways to control my PCOS better, and it’s looking like all of the options that I haven’t tried yet typically lead to weight loss, often significant weight loss. I’m struggling to integrate that with my HAES mindset.
Yes, I have been practicing HAES since 2010. I’m not saying it has been easy or that I got it perfectly. I’ve been working on different aspects of myself ever since.
Since I have struggled with eating disorders before. It’s been a long way. So far I have manged my self-image and understood my hunger signals. Still, I struggle with diet mentality and with joyful movement mainly because exercise was my way of purging.
I do, however, enjoy exercise. I don’t have a problem with motivation, but with obsession on performance. I tend to overdo stuff and I burn out. It has been more difficult ever since I got Hodgkins last year. I’ve lost a good deal of physical fitness since then. I can’t seem to take it easy and I overdo my routines. I’m giving myself a break on that. Also, I’m focusing on learning how to nurture myself without concerning to excess about the “perfect” meal. Which rationally I know its bullshit, but from time to time I tend to get engage in a diet mentality, I know I eventually will get it, but I think I need professional support to achieve it. And that is where money gets in the way.
I would say yes. I have made an effort to eat food that makes me feel good, to add in more fruits and vegetables, to try new things. I can’t exercise like I used to due to a knee injury, but I do the best I can. I think that HAES should incorporate doing the best you can with what you have while trying to enjoy yourself. I’m not going to participate in movement that I don’t like and I’m not going to eat food that I don’t like for the sake of “health.”
For me, it’s a mixed bag. Oftentimes, I’ll eat plenty of good fruits and vegetables and other food that makes me feel good, and I’ll be fairly active and get a good amount of exercise, but other times, not so much. When my depression flares up, though, I don’t do as well, and I’m less active and less mindful about the foods that I eat.
Question Five: The SDH have both social and economic origins. If you could direct a group of activists to fight the SDH in a way that would have a positive impact on yourself and/or others you know who struggle with the SDH, what would you recommend? If you have multiple suggestions, please give some indication as to priority or “bang for the buck” in your view.
The most important thing for me is something many activists are already focusing on: being treated fairly, by medical and fitness professionals, would really make a huge difference.
My answer would take too long. The short version would be to make healthy habits more affordable and sustainable. I budget myself well enough to get by, but I work like a dog to do it and forego certain things like owning a vehicle, etc. Things I want to partake in either aren’t available in my area or are too expensive to maintain long term. Plus, who has time?
Here in Massachusetts, the Governor installed a program that allows doctors to write a prescription that would give obese patients at high risk a considerable discount to use the local bike share program, called New Balance Hubway, to get around. However, the Hubway bikes are only rated to 260 pounds and you must sign a legal contract that you won’t put more weight than that on the bikes — anything happens to you on that bike and you’re on your own. My current focus of ire are the carnival barkers who talk over fat people and oversimplify the issues while stealthily being backed by industries set to profit off public fears.
I agree with Lisa, the first thing would be to pressure the healthcare system to educate about weight prejudice. Second, I would urge them to pressure the government to stop the new legislation in my country that will penalize the patient for their illness.
To add to what the others have said, I’d encourage more work toward changing the way our food production system is currently incentivized. The agricultural subsidies are just a start (to be clear, I don’t want to take those subsidies away from farmers completely, just shift the focus and perhaps make those subsidies only available to individual farmers and not corporations). At a more local level, I love the programs that allow SNAP recipients to purchase produce at farmer’s markets. Let’s use those agriculture subsidy dollars to pay farmers to set up markets in food deserts. Let’s make fresh foods and whole foods cheaper than processed foods. I’d love to see more options for quick meals for people who spend a lot of time working or using public transit or in school or whatever. Let’s put home economics back in schools so that people have the opportunity to learn the skills they need to cook from scratch. I could go on and on, but there’s a start. Oh, and finally, involve the people you’re trying to help in the planning and implementation of the solutions. Not in a patronizing, “you’re here as the token poor person on the committee” way, either.
Final question: If you were Benevolent Dictator of your nation for an hour, what changes would you make to improve the SDH situation for yourself and others?
Education! And pay equality. lol
I agree, if I had an army on my side I would dismantle the corruption in the Mexican government, confiscate their assets gained with dirty money, and see that those assets covered some of the main financial problems in Mexico, so we can have better social and economic conditions that would make it easier to achieve a better health.
- Better social and economic conditions for Mexicans
- A food and agricultural policy that provides support to local farmers, and better exportation and importation policies
- A truly universal public health system that provided people full health coverage.
- Involvement of the private sector, but not just as “promoters of health”; rigorous regulations on toxic wastes, and true ecological engagement, along with better working conditions for employees
Public transit. It benefits people’s economic situation in that they can get to and from their jobs without the expense of a car. It reduces stress from commuting, it helps the environment, and when using public transit people typically are more active by walking/wheeling to the transit stop. What we did for roads with the interstate system in the US we now need to do with public transit. And by making public transit cleaner, more efficient, and more accessible, we reduce the stigma of utilizing that service. When it’s not just a service for the poor but a service for everyone, we’re doing something right.
More time. We spend so much time working and commuting. I really don’t blame anyone who doesn’t want to leave work to start chopping vegetables for cooking or to go to the gym for two hours.
I would also say pay a parent to stay at home for at least the first four to five years of a child’s life. And three to four weeks of paid vacation per year.
I can’t think of anything that hasn’t already been said in these comments. I definitely second improving public transit, and less time working. I know Europeans think the American work week is barbaric.
Filed under: DT, ED, EX, FH, FP, Frank Friday, MBL, WL
Trigger warning: Discussion of diet and exercise as healthy lifestyle approaches.
Yesterday, we heard from Dr. Dennis Raphael, an expert on the social determinants of health (SDH). Today’s interview is with Dr. Raphael’s collaborator and colleague, Dr. Stephen Bezruchka, Senior Lecturer at the University of Washington School of Public Health. You might expect these two gentlemen to have similar approaches to the SDH, but I noticed a slight difference in their messages (although I’m sure they would agree with the ideas of the other). While Dr. Raphael emphasized civic involvement, Dr. Bezruchka promotes investment in early childhood development as the best bang for the buck. As for what each of us can do to fight back against socioeconomic inequity, it’s so simple you just need half an hour and an unwitting telemarketer.
Where does obesity, diabetes, cardiovascular disease fit into the SDH worldview?
There’s something called the thrifty phenotype hypothesis and what that says is that as a species we try to economize our physiology in order to survive to reproduction. All sorts of factors in our physiology are programmed early in life through epigentic means, which are factors in the environment, broadly considered, that dictate levels of gene expression.
The human genome project found we have somewhere between 10 and 20,000 genes and we’re not all that different from a pufferfish or earthworm, though we appear to be much more complex. So how do we address this complexity? The current thinking is by differential expression of that genetic material. So, what produces these differences in expression?
If you consider obesity, rewind back two or three generations. If we think back to the 40s and 50s after the Second World War and think about food; food was relatively expensive compared to today, it was time consuming to prepare, you tended to eat it at traditional meal times, and it was relatively low caloric density. We ate a lot of food, we consumed a lot of calories, because we had a lot of physical work to do. Through epigenetics, this has been programmed into our physiology. Namely, eat a lot of food because you’ve got a lot of work to do.
Fast forward to the present: food is incredibly cheap, it is high caloric density, it is eaten almost continuously throughout the day, takes seconds to prepare. So here we are, surrounded by this food and we’re programmed to eat as much as we can because we were supposed to have a lot of work to do.
But what kind of work do we do now? We’ve lost manufacturing jobs; mechanization has made it difficult to do physical work. Some of us who are privileged can pay money to do physical work — that is, we can join gyms, have a personal trainer, take adventure vacations, have exercise machines at home. So, the more privileged of us [who are] programmed to eat have ways of working off that energy. Some people don’t.
If you look at the demographics of obesity, the poor are by and large the more obese. That’s one way of looking at today’s obesity epidemic. Not the only way, but one that I think is actually pretty important. Relating this to the social determinants of the health, that depends on what you mean by the social determinants of the health. I think of the determinants of the health as the factors that produce health in populations. You might consider the social determinants of the health the nonmedical factors that produce health in society.
If you look at pretty much any mortality indicator of health, we’re behind pretty well all of the other rich countries. Cuba does better than we do. Slovenia, Costa Rica, Chile. Forget all the other rich countries, we’re far behind.
This is not something that most of us want to look at. The stress in our society is a major factor in the health issues and why we’re not doing so well. International surveys show we report some of the highest stress of all countries. This is a subjective measure, but nevertheless, this is what people report.
It’s not that hard to observe how stressful American society is now. Stress is hurry, worry and eat too much. What does that mean? We try to cope with this society by engaging in behaviors that make it easier. I worked as an ER doc for 35 years and I’ve worked in innercity situations and I’ve worked in hospitals where some of the richest people in the world live. And in innercity situations, your bread and butter is heroin overdoses and cocaine chest pain and injection abscesses, among other things. It’s poor people who do all this stuff and I used to blame them for making me work so hard. But I came to see that their behavior are a response to the stress in society and their inability to cope.
This is programmed early in life. Eating is a way of relieving stress and you see this constantly now with people on the streets. When I teach a class, people are eating during the class now. Thirty years ago, nobody brought food to class. If you want to have some kind of function at school, like I make my students organize a community event, they always have to serve food or nobody will come. Obesity is a response to programming that happened generations ago and the stress of modern life.
In the chapter that you wrote, you mentioned Elizabeth Warren’s book The Two Income Trap and how in 1970 a median two parent, two child family with one parent working outside the home had more disposable income than a similar family in 2000 where both parents work outside the home. Haven’t we engineered cooking and fitness out of our society entirely, rather than just a function of the response to stress? Haven’t we made it more difficult for people to cook meals from scratch or even just go for a walk because they don’t have as much time or money?
Yeah, but how did that come about? How could the 1970 family be situated economically better than the 2000 family with both parents working? If you look at productivity historically from the 1800s to the present — productivity is the amount of stuff produced per unit input — what seemed to be the case from 1820, when we first started having this data in the United States, productivity rose and hourly wage rose. And they more or less paralleled. You worked harder, you get paid more.
The curves diverged, a lot of things diverged, in the early 1970s. Productivity kept increasing, but the average wage has remained stable in inflation-adjusted dollars. We are no longer making more money for working harder as a nation. So what was the response? We consume much, much more than we did in 1970, and how did we do that? We put more family members to work outside the home, we put children to work, we borrowed against home equity, we borrowed against credit cards that led to the crash in 2008.
Things were better in 1970 on a lot of indicators, not just hourly wage. We were happier as a society then. Everything sort of fits together if you’re willing to look at indicators reflecting progress or its lack in large societies.
Given our current political environment in the US, austerity is a huge buzzword and there’s so much obstruction, and attempts to deconstruct our existing social safety net. Do you see a future for turning this around in politics or has the US too far gone?
Everything goes in cycles. Things get better, things get worse; the economy grows, it contracts. I think we’re in the midst of a social movement. And as somebody who was in a social movement in the 1960s, we were not aware of it then. We had this utopian vision, there was opposition to the invasion of Vietnam, inner cities were burning, there was the Civil Rights Movement, the Democracy trials in Chicago, and our voting rates were the highest that they’ve ever been in society for Presidential elections.
As a result of that popular force, a whole bunch of things happened that were actually beneficial, and people often don’t recognize the political tendencies of both parties to produce legislation that benefited the public. Medicare in 1966, the social welfare system.
In 1969, Richard Nixon proposed a guaranteed income for all American families. That was his Family Assistance Act that was announced in August 1969. The newspaper and TV and editorial comment was 94% in favor. Imagine a Republican President proposing a tranche of income for every American family. And we thought it was a great idea. Today, if anybody proposed that they’d be a laughing stock. I just can’t imagine that.
So, our values were different then. Having been around then, I think that was pretty true. We cared for one another. There was a sense of the power of people, a sense of people massing together, pushing for their ideas. These days, that’s beginning again, but it’s really struggling. Somewhere in the last four or five years, we’ve had an awareness.
The Occupy Movement gave us recognition of what the numbers 1% and 99% mean. There was an immigrant march that was not reported much in this country, but it was huge. The million people in Paris demonstrating against terrorism. It’s not just happening in the United States, I think it’s happening in a lot of places.
What did the highest paid person make in 2013 in the United States? The answer is $400,000 an hour and most of us find that hard to believe, but it’s true. That’s gotta come down. We’re going to see the maximum wage fall in the next decade or so.
They just released a study that the top 1% will own the top half of the wealth. It seems like the momentum is on the side of the 1%.
I can wear two hats: one hat I wear, it was crafted by Thomas Piketty and Capital in the 21st Century. I use his material all the time. r is greater than g, so equality is going to grow. At the same time, something is happening in this country and elsewhere in the world that wants to do something about it. Piketty’s solutions are global transparency for income wealth and inheritance. He calls them utopian solutions, but I think that’s what we should be debating or discussing.
People are uncomfortable with the inequality in this country. On the one hand and on the other hand, the poor seem to think that someday before they die they’re going to strike the big one. You just have to go into a 7-11 and watch who buys lottery tickets: poor people are just betting on winning the big one.
I agree that inequality is bound to increase. I’m kind of a doomsday person, but I’m impressed with the fact that inequality is declining in Latin America. It’s the only place in the world where it is. And the capacity of people to mobilize mostly outside of the United States is hopeful.
Do you have any thoughts on President Obama’s recent proposals that seemed aimed at addressing social injustice?
There’s only two countries without a paid maternity leave and we’re one and Papua New Guinea is the other. He has at least stated that the basic problem in this country is inequality.
We need to do what’s necessary in early life when all this stuff is programmed or we pay the price later: obesity or heart attacks or horrible cancers, all that stuff. Back in October in the New York Times was an article on birth weight and standardized test scores.
The study took all the births in Florida over about 15 years where they recorded their birth weight and they followed these kids on grades three to eight and looked at standardized test scores. What they found was a striking socioeconomic gradient, always poorer people do more poorly. In this case, it was birth weight and standardized test scores. The birth weights went from 2 to 12 pounds, but [America has] the most low birth weights of pretty much all rich countries and preterm deliveries, that’s another issue. The higher your birth weight, the better you did on standardized test scores, peaking at around 9.5, 10 pounds.
If we think of what’s happening to early life in this country, there’s a segment of the population that does very well, but we have so much low birth weight, so many preterm deliveries, so many kids — 23% of kids in this country growing up in poverty, it’s not good. School boards are struggling with No Child Left Behind and Race for the Top and all these ways of trying to get money to improve the quality of their education and, by and large, most of it’s not working.
So we’re focusing on firing teachers who don’t produce good test scores, but a lot of kids in this country can’t learn in the school system that we have. That may not be a bad thing because we focus so much on education, but we spent most of our history as hunter gatherers and we had no schools then and people were remarkably adapted to surviving in that environment. But with today’s environment, we tend to think that education of poor people will be the way for them to succeed. But I don’t think that they have the capacity to function in our school environment without changing a lot of things.
So what do we need to change? We could have Nixon’s guaranteed income. We could try and support parenting instead of outsourcing it. Kids are no longer raised by parents, they’re raised in a haphazard mix of environments that are not good for their health. We have to change the circumstances that impact early life and given the innergenerational programming that occurs, we have to wait a few generations to see results. We’re not that patient as a society.
Are there things that individuals who may not have access to all the determinants of health that they can do to reduce or mitigate or counteract the effects of those health issues that arise from inequality?
Yes, but it’s not the usual advice.
[Editor’s note: at this point in the interview, Dr. Bezruchka mentions Dr. Raphael’s “10 Tips for Better Health,” which immediately rang a bell because it was once on the Wikipedia page for the social determinants of health. It’s not any more. But the inimitable Michelle Allison captured the entry, plus I related the list in the post I wrote about the SDH back in 2012. So it wasn’t until this moment in the interview when I realized that the guy I just interviewed an hour before was the author of this great list. It’s well worth revisiting in its entirety:
The traditional 10 Tips for Better Health
- Don’t smoke. If you can, stop. If you can’t, cut down.
- Follow a balanced diet with plenty of fruit and vegetables.
- Keep physically active.
- Manage stress by, for example, talking things through and making time to relax.
- If you drink alcohol, do so in moderation.
- Cover up in the sun, and protect children from sunburn.
- Practice safer sex.
- Take up cancer-screening opportunities.
- Be safe on the roads: follow the Highway Code.
- Learn the First Aid ABCs: airways, breathing, circulation.
The social determinants 10 Tips for Better Health
- Don’t be poor. If you can, stop. If you can’t, try not to be poor for long.
- Don’t have poor parents.
- Own a car.
- Don’t work in a stressful, low-paid manual job.
- Don’t live in damp, low-quality housing.
- Be able to afford to go on a foreign holiday and sunbathe.
- Practice not losing your job and don’t become unemployed.
- Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.
- Don’t live next to a busy major road or near a polluting factory.
- Learn how to fill in the complex housing benefit/asylum application forms before you become homeless and destitute.
We now return to Dr. Bezruchka.]
So what can an individual do? Let me give you an example based on my own personal experience. I think the way I do because I have a background as a mathematician and everything has to make logical sense. If I want to prove a theorem, I have an axiom and deductions and I work logically. As an ER doc, I never saw a Latino patient in the ER. I saw a whole bunch of people standing around a stretcher and one of them was the Latino patient and the rest were their family and friends there to support them.
Meanwhile, next to them is a White guy moaning alone. Latinos in the United States have better health outcomes than non-Latino Whites. Whenever I talked about the social economic gradients, poor people tend to have poorer health (when I say better health, I mean as measured by mortality indicators: life expectancy, mortality and that kind of stuff). Yet they’re poor, by and large. Latinos tend to be poor.
So there’s something that I just described about the social nature of Latino society that buffers the adverse effects of being poor. Having friends’ support is stronger than not smoking or exercising or eating the usual kind of things that we think are bad for you, but not having friends is worse. What individuals can do is seek out friendship and social support in whatever ways they can.
This year I had about five groups looking at things like CrossFit, Pure Barre, swing dancing. LARPing, a whole host of these groups that are near the university that they’re observing, participating, and interviewing people in. A common thing that they found was that people are attracted to these various activities because of the sense of community and social togetherness that they found there.
The way that I interpret this, because I think this has changed so much, social media has individualized us tremendously. You walk down the street and most people have a handheld device and they’re constantly interacting with it. This is a real problem. Mothers aren’t mothering their infants. They’re checking Facebook or so on. This is changing the nature of parenting to what extent it’s already been eroded and it’s too soon to tell what effect it’s having. Certain kinds of people (not the poor because they’re working too hard, too many jobs, no time), those of means, are seeking out community because they recognize some benefit from that.
Given the gravity and impact of the SDH, how should we view individual health behaviors in the context of the SDH?
I think they’re a good idea. I exercise, I don’t eat too much, I’ve tried being in environments where I’m forced to work naturally. If I can’t, that’s harder and harder. I’ve had some health issues, so I’ve lost some capacity, but on Saturday I’m going up and making a 2,000 foot ascent with a former student of mine and I tend to do that on a weekly basis.
It used to be that my office hours were undertaking this hike with students. And we would talk mostly on the way down. I’m fortunate living in Seattle because I can drive a half an hour and have this 2,000 foot ascent. There’s no way I’d tell somebody to just give up the individual factors that we know are good for health, it’s just that they’re not as important as working together to try and change society.
I try to arrange for people to do that in whatever way they can. In my course, the students have to take the ideas out of the class and present them to an audience that they organize. And that gives them some confidence that they have ideas that others don’t know about and they can inform and have discussions on them.
Trying to talk about these ideas is the most important — the most important thing we need to do at this point. The Institute of Medicine came out with its report in 2013: “US Health In International Perspective: Shorter Lives, Poorer Health.” The most important document they’ve ever come out with. They had 500 pages of basically the same stuff I’ve been talking about for 20 years. It just legitimizes it with their imprimatur.
When [the IoM document] came to what to do, the first thing was “Inform the public.” Inform the public that our health status is that of a middle-income country at best; that we’re good at dying young … not a thing that most Americans want to even consider.
The second thing was look at what healthier countries are doing that might be of use here. We have to see that Sweden, for example, spends more government money in the first year of life than in any subsequent year. If you look at where we spend our government money, it’s on people my age and older, Social Security and all that stuff.
If we look at early life, it’s once they get into school, age 5 or 6. That’s where we start to spend money, when you get your real bang for the buck in your first or two of life. I make this statement that roughly half of our health as adults are programmed in the first thousand days after conception.
What sort of investments would you recommend making in that first year of life?
I would have paid maternity leave on very generous standards. If we want people to parent, give them time to do that. Sweden mandates a year’s maternity leave with full pay. The mothers take the whole year, the fathers take 12 weeks. In the second year, it’s optional, but at 80%. Now, who pays your salary while you’re off work? It’s not the business you work for, it’s the government. Te percent of the [gross domestic product] that the Swedish government spends is about 50%. Ours is about 30%. So they have a lot of money because they have high tax rates and people accept that to spend it on early life.
Antenatal leave: life is stressful and a pregnant mother being stressed is not good for the health of her children. Lots of studies demonstrate that. Pretty well all other rich countries give you paid time off work if you’re pregnant up to about 18 weeks. We have five states in this country that give you four weeks paid maternity leave and they all show better health outcomes.
Spending money on early life, both in terms of supporting parents by giving them paid time off, by raising the minimum wage, by having a generous welfare system. The word welfare is a putdown here, but in Sweden it’s not. It’s what people are owed because it’s good for them. When Bill Clinton said we’re ending welfare as we know it and Reagan spoke of welfare queens, that was a real disservice to the 20-plus percent of people who are poor. And there’s a lot of poor people who don’t avail themselves in this country of what welfare there is because it’s shameful.
One thing you said earlier that caught my ear, but did you say that if you had to pick one, personal behaviors versus advocating for social equality, you would recommend social equality?
Absolutely. There’s evidence on eudaimonic well-being, which is a form of well-being or happiness in which you look for your own self-actualization and focus on helping others. They looked at biomarkers of people with eudaimonic well-being in contrast to hedonic well-being. Biomarkers are better in those who seem to have this sense of purpose in life is to help others.
I’ve heard this proposal before, that focusing on reducing inequality is a better bang-for-your-buck than individual health behaviors, which seems so counter-intuitive to what we’re taught.
The way the world is organized right now with corporations having most of the power, for climate change and sustainability and a whole host of issues, the political structure of the world has to change for human survivorship. How that will happen and what it will be like, if you look back 200 years ago, there’s no way you could predict that we’d end up in this neo-liberal nirvana of corporate greed being glorified.
But the European social democracies seem to be capitalist in many ways, and yet the people feel like the government should be there to support them. When you speak of health, there’s a whole bunch of factors you could look at. I look mostly at mortality because it’s hard to fake a death. There’s a study on dental health. Your mouth is really a mirror of the rest of your body, and a study looking at political organization in countries and their dental health, and they show that the Scandinavian social democracies produced healthy teeth.
Is that a function of access to dental services or education on dental health? What is it attributable to?
We all want to say “Oh you brush your teeth twice a day, you see a dentist and you paint fluorides on and all that stuff.” I think it’s the psychosocial feeling you get living in a society where you feel less exploited.In Japan, they have twice the rate of men smoking that we do and yet their health status is phenomenally better than ours. And there are studies showing that the adverse health effects of smoking in Japan are less than you would predict by looking at a country like the United States.
So what is it that makes Japan be able to smoke and get away with it? Yes, smokers in Japan have worse health than non-smokers, but the difference isn’t as big. The life expectancy hit is not as big. Social factors, I think, can mitigate the adverse affects of bad behaviors. I illustrate that when I speak by asking the question: “Do you ever see a lone Japanese tourist here?” I then say “Do you ever see a lone American tourist” and everybody nods. Yeah, all the time.
They do things together. They have this concept in Japanese society called social harmony or Wa. That togetherness can make up for an awful lot of bad behaviors or factors like that. I think the dental health thing in social democracies relates to the sense of being that people feel there that they don’t here. We can see this actually in studies of stress responses.
In other words, you physiologically stress people experimentally in Lithuania and Sweden, separated by a not very big body of water. The Swedish people can mount a real high stress response with a rapid decay to this experimental procedure. The people in Lithuania have a much slower rise in the stress response, smaller peak, takes a long time to decay. It’s emblematic of the idea that the society you live in has a huge impact on your health and well-being. It’s not what you do that matters as much.
Is it fair to say that the #BlackLivesMatter movement that’s happening around Michael Brown and Eric Garner, is that a health movement as well?
Yes. Race compounds the effects of inequality and social status. It’s programmed in early life.
The first studies were done in the 1930s and they’ve been repeated many times and they all find the same thing: black children are programmed from an early life to feel bad about themselves. Society reinforces that every step of the way. The awareness that this is creating and the discussion in the media is very healthy, but I think trying to change most people’s attitudes toward races is like the epigenetic program: it’s going to take a long time. I think the racial prejudices are programmed in early life and they are reinforced by society and so they have to start with the right programming in early childhood and reinforce that. That’s a real tough one.
How does a person look at the SDH, the effects of income disparity and social inequality, how do you look at the enormity of the institutions that uphold that inequality and not succumb to feelings of futility and immutable fate in terms of your own personal health or long-term objectives in trying to achieve greater equality? How do you recommend someone interested in fighting that not feeling so overwhelmed by what they’re up against?
My advice to people is to understand what’s going on. That’s not easy. What can you do? I think it’s hard to do stuff you don’t have skills at, so do something you have some skills for. It’s hard to do something you don’t enjoy, so do something you enjoy that uses your skills. And don’t expect to be paid for it — that is, if we’re going to do something about improving our health status, about decreasing inequality, it’s hard to get a job with that in mind.
And so, as a doctor I was privileged to be able to have another source of income. I eventually got out of doing clinical medicine because this was much more satisfying. I got into a situation where I could try and influence others on more than an individual basis with a patient. If they understand these non-individual medical factors are really what matter, they have to find ways of engaging others in using their skills.
In my courses, I try to give [students] ways of doing that. You’ve got to get comfortable talking about these ideas. You can practice around dinner time when you get a marketing call from some company trying to sell you something, especially the ones that say this call is being recorded for quality assurance purposes because they won’t hang up.
So you can practice what you’re trying to say. That’s what I do sometimes. That’s kind of cheap, but still, we have to gain the facilities to talk about this. You find it different in other societies. At the benefit of being in other countries where you can talk about these ideas. So develop some skills at doing stuff that you enjoy doing.
Filed under: DT, EX, Fatual Friday, FH, FP, FS
Serious trigger warning: Frank discussion of health, weight loss, weight loss surgery and eating disorders.
When I first began putting together a roundtable of Health at Every Size® (HAES) experts to discuss the social determinants of health (SDH), several people recommended that it would be valuable to have a similar roundtable with people who have felt the negative impact of the SDH.
It took me months to find the seven participants who volunteered their time to answer a few questions about their experience with HAES and the SDH. My hope is that their input will help HAES experts and advocates to approach the problem of the SDH with help and input from the grassroots level.
I would like to thank all of our participants for being so open and honest about their experiences. Tomorrow, I will share the second part of the roundtable, where they discuss how they would address the SDH and how HAES can be more effective in their lives.
Question 1: What are some of the barriers that you have faced over the course of your life in your efforts at self-care?
I have an aggressive clotting disorder and take blood thinners to keep it under control. Vitamin K counteracts the effects, so I have to be wary of green veggies and fruits. It has been difficult for me to create a balanced diet for myself in which I am getting all the vitamins and nutrients I need to stay healthy. I’ve sought assistance from nutritionists, who I’ve learned are simply glorified diet doctors more concerned with me losing weight than me losing my eyesight or other faculties. It’s very difficult being taken seriously, as my weight looms large in the minds of every professional I’ve met so far.
I grew up poor in a fairly rural community. So as a kid, despite my desire to participate in certain sports, the few things that were offered were not things that I wanted to do, nor was my family able to financially handle the cost of my participation. For example, in middle school I desperately wanted to join the dance team. I was able to scrape together enough money to pay for my costume/uniform and required gear (shoes mostly), but the daily before-school practices meant that my mom had to drive me to school. I know it was difficult for her to afford, and I think she breathed a sigh of relief when I didn’t make the team in high school.
So from an early age, I associated group or team fitness activities with not-belonging on two levels: as a fat kid and as a poor kid. Those kinds of experiences make it difficult for me to seek out fitness opportunities, something I know is essential to my self-care. Being involved in movement that I enjoy helps to alleviate depression, and just makes me feel better all around.
I must say that the first barrier is the culture we live in, where being thin is one of the most important things you “must” do as a women, and for some, as it was for me, it’s even more important than health itself.
I grew up as a fat kid, I wore an adult size 5 at age 9. My father is a doctor, so he took concern at how this was affecting my life, and he took me to a nutritionist.
I know he did this out of love, and my nutritionist always had the best interest in my health. Even so, I began my first diet at 9, and this left a big impression in my mind. I learned that certain foods where bad and that, for me, being a good kid meant sticking to the diet. So every time I failed and came back to the nutritionist office after I gained the weight back, it made me feel like I was a bad kid and a failure. It didn’t matter that I was smart or a great martial artist or talented, I always distrusted all my abilities and felt that if I wasn’t thin I was still a failure.
I went on and off diets ever since, until I turned 25. At 23, I said to myself that I didn’t need the humiliation of going through another appointment with my nutritionist, so I decided to take the matter on my hands and that is when my eating disorder started.
I didn’t think I was doing anything out of the norm until last year. When I really analyzed what I did, I discovered that my behavior was not normal. I was eating very little and I restricted my diet to a certain amount of calories, and I was exercising for two hours a day, six days a week as a way of purging. I skipped meals and in 2010 I ended up binging, until I learned that I needed to stop. So with help I did, I’ve been diet-free since 2010. Still, I get obsessive over exercise and I tend to overdo it. I’m trying to figure out how to keep moving without obsessing over it.
This idea that being thin was the most important thing in my life led me to do things that weren’t healthy at all, I would say that my first barrier is in the culture itself, and our standards of beauty.
My second barrier, perhaps, is the work ethic that I was brought up in.
We live in a world where we value working over resting, so I was the kind of person who would much rather not sleep than fail on my obligations in school. I ended up not sleeping at all, or sleeping just about four hours each day.
And this, I think, had something to do with my weakened immune system. I think that sort of thing keeps a lot of us from resting properly and, of course, keeping us from trying healthy habits.
Third, I must say it’s economic status. Ever since I was diagnosed with Hodgkin’s lymphoma, I’ve said to myself that I have to make my heath a priority. I’m not in poverty; I’m middle class and so far I have insurance, and my family manages to pay a psychologist for me. I’m truly grateful for this.
But ever since I finished my master’s degree, well, I ran out of funds since I’m also unemployed because I still have a weak immune system.
So I live of what my father can give me at the time. I know I need help with my eating habits, since I still have issues with food and movement; I still tend to skip meals and binge sometimes, and I know that I can’t overcome this alone. Where I live, all except one nutritionist focus on weight management. There is just one nutritionist specialized in eating disorders in my town; even so, I can’t afford it, nor I can afford to travel to the USA to San Diego to meet with a nutritionist who manages HAES.
Also, accessing healthy foods is kind of difficult because of the lack of money. Mexico is having an economic crisis, so even when I want to eat better quality foods and avoid chemicals in my personal hygiene products, I can’t afford it all; I have to eat whatever we have around, when we have it available. My dad is retired, my mom, my brother and I are unemployed.
Last year I had my scholarship and I earned around $700 a month, which was a big economic help in my house, but I have no scholarship anymore because I finished my degree.
One barrier for me has been anxiety and depression tied into my being transgender. For most of my life (and still sometimes today) I have avoided going out with friends or doing things in public that I enjoy doing because I’m afraid of the negative reaction I’ll get as a trans woman. Also, being a fat trans woman who lives in a smaller city, I’m not able to find very many clothes that fit me locally, and expressing myself through fashion is definitely one way that I practice self-care. At first I loved going shopping with my friends, trying to find cute outfits, but that soon turned south. Trying to go shopping for new clothes I like here where I live got to be so fruitless and depressing that I haven’t done it in over six months.
Lack of workout wear available/affordable in my size. Lack of affordable natural and organic foods. I’ve had people not take me seriously when talking about nutrition or exercise, thinking I wouldn’t know about nutrition because of my size. Assumptions that my attempts to better my health meant, often exclusively, that I was trying to lose weight. I’ve also worried about weight limits on things like workout equipment, and when I was shopping for a new bicycle, I had to keep reminding the store clerk of my needs with regard to weight limit.
My own beliefs of my worth have kept me from a lot of self-care. I felt like I wasn’t worth anything because I didn’t fit the typical society standards.
Time is the biggest barrier to self-care. I would give anything to be able to arrange my work schedule so that I could have more time to myself.
The older I get, the less I care about what people think, but I still have that nagging voice in the back of my mind. What if I go somewhere or try a new activity and I am the biggest person? What if I don’t physically fit? Are people going to laugh? What if I am actually not capable of doing said activity? I’m sad that I haven’t been able to completely shake these thoughts.
Question 2: What kinds of self-care would you like to engage in or adopt if there weren’t barriers to access or ability?
Honestly, I’d like access to an aqua-aerobics class. Unfortunately, most of them cater to seniors and retired people and won’t fit around a full-time working person’s schedule. Also, clubs with pools tend to be more expensive and are not handicap accessible (narrow ladder entry, etc.)
I’d like to get back my gym membership, but I can’t afford it right now. Gyms tend to be super-expensive. The gym I used to go to was nice, but I would have to take the stairs two floors down to get to the change room, then two floors up to get to the pool. I’m currently walking with a cane due to a knee injury, so that’s not going to work.
I’d like to take the fat-positive yoga classes offered in my city, but as a public transit user, as well as being a student and working half-time, I just can’t make it to any of the scheduled classes, all of which are at a studio on the other side of the metro area. Even if I could fit it into my schedule and have transportation, the cost would be a barrier.
I’d like to be able to chose movement options that I enjoy, but instead I currently only have time to do the walking needed to supplement my use of public transit in going about my normal, everyday life. I like walking, and I would otherwise walk for pleasure, but with the current state of things, I’m walking routes that aren’t very fun or interesting.
I’d like to cook all of my food from scratch, gardening and raising most of it myself. Again, the time limitations of a long-transit commute on top of working and going to school. Plus, with space limitations of being an apartment dweller, there’s only so much you can grow in planters on your patio, assuming you’ve got enough sunlight each day for growing things.
I’d also like to have dedicated time for my hobbies, as a way to relax. Time and space are major factors right now; my sewing table has been taken over by my fiance’s computer because we only have room for one desk in our bedroom. We’ll be moving soon, and I’ll have the space for my sewing things again, but the decision to pay more for an apartment that has a second bedroom we can use as an office was tough. It’s $200 over the budget we were comfortable with, which probably doesn’t sound like that much to most people, but to us it nearly broke the budget.
I would say that I would like to have the help from a HAES-trained nutritionist who would help me to learn to eat normally, and make better choices without obsessing about eating the perfect meal. I think that that, along with the help of my psychologist, would help me overcome my issues with eating and food, and would contribute to a better general health after cancer.
I would also buy a lot of more healthy food more often, and I would like to go to yoga classes, since I am the kind of person who needs instruction.
There is a great fat yoga place that I would love to go to, but every class conflicts with my work schedule.
I’d love to be able to experiment with my wardrobe and be able to wear whatever clothes I want, but I can’t afford to and I can’t find many clothes I like that are my size. I’d also like to learn to dance, but again, there’s the money problem, and I don’t know how fat-friendly any local dance classes are.
Gym workouts, dance, naked yoga. Shopping for clothes somewhere other than online stores. Nutrition advice that doesn’t revolve around weight loss. Eating organic.
Question 3: Have you faced any forms of discrimination by healthcare professionals? If so, what was your experience? How did it affect your view of the healthcare industry?
Personally I have not.
I’m able-bodied, and I’m Mestiza (mixed race), middle class, and a “small” fat women.
The persons who experience the most discrimination in my country are the persons who belong to Mexico’s different ethnic groups. Things are so bad for these persons that even public hospitals have denied their service to people who belong to ethnic groups.
Because my BMI is just 30 (I’m officially considered by my doctors obese, but a barely obese women), and because I have a very curvy body, I have not experienced discrimination in my doctor’s office. Just a bit of biased treatment when one of my doctors send me to test for diabetes. Still, it didn’t bother me because I have diabetic relatives, and I’m not sure if this was routine.
I have also noticed that the distribution of fat plays a role in how people treat you. When you tend to carry your fat over the abdomen, you get more social rejection than when, as a women, you carry it at the hips and breasts.
I used to think that weight discrimination didn’t happen in Mexican doctors’ offices, but I was wrong, since several of my friends have faced this kind of discrimination in a doctor’s office. It enrages me.
Also, the government is planning to change the health laws by modifying the Mexican Constitution. In short (among a lot of other awful policies), they are planning that we, the fat and the chronically ill, will have to pay extra to compensate the State, along with complementary insurance that would cover the illness that are not included in the basic service.
Lots of us in Mexico are hoping that these laws never come to reality.
I went to see a new doctor. Things went well. We talked about my weight, my health goals, my obstacles, etc. He bid me farewell and made a follow-up appointment for two weeks later. I went and he must have been busy. He merely gave me a cursory once-over and was trying to rush me out. Whatever, I didn’t really want to be there anyway.
A little while after that I became very sick. I had pain in my joints, swollen glands and a high fever. I went to see him and when he finally came in after the nurse’s initial exam he insisted that I be weighed — would not proceed any further unless I got on the scale. I was sick and had no fight in me so I obliged. Turned out, I had lost weight (alarming since I wasn’t trying). He was ecstatic and congratulated me — talked about my diet, what exercises I was doing, what more I could add on to my efforts, recommended a nutritionist.
My time was near up before I got to talk to him about the roaring fever I had that the nurse discovered before he came in. Suddenly, he couldn’t be bothered. Told me it was probably a problem with my teeth, gave me a script for a mild dose antibiotic and told me to see my dentist. I went to the dentist who, after an exam, became quietly alarmed. After an X-ray, that I had to pay for out of pocket because I had already had one at my last appointment, he found nothing at all wrong with my teeth. He called in a script for a higher dosage of the antibiotic and told me to get to the emergency room right away if I suddenly found it difficult to swallow.
I was furious and decided to do something about it. I wrote a nasty letter to the clinic abut how unimpressed I was with the new doctor and how he ignored my initial reason for coming in to the clinic. He replied to the other doctor but accidentally hit ‘Reply All’ and I saw him blatantly lying about what occurred during the appointment. I called him out, which made me feel better, but nothing really became of it. A year later and he is no longer practicing there, but I felt good about calling him to task, something I would not have done several years ago.
I think the clearest memory of discrimination I have in a healthcare setting was when I went in regarding menorrhagia (excessive menstrual bleeding). At the time I wasn’t making more than about $12,000/year, so my only healthcare was through the local health department’s sliding fee scale clinic. I could receive routine care through the clinic at very little or no cost.
The practitioner I had been assigned was a male Physician’s Assistant who seemed to be very unenthusiastic about being there. We had several interactions where I just felt like he wasn’t hearing me, and I got the usual “stop drinking soda and you’ll lose weight!” sort of crap. When I went in about my periods, as I’m asking the question he’s getting up and doing the whole hand-on-the-door-knob-I’m-done-will-you-shut-up-already thing.
His response? He shrugged and said “Well, you’re probably just built that way” and leaves. He asked zero questions about the frequency and regularity of my cycles. He asked zero questions about volume or flow rate. He didn’t ask about my risk factors for sexually transmitted infections. He didn’t ask me to keep records and check back in after a couple of months.
Five years later, I’ve finally pinned down that it’s likely a symptom of polycystic ovary syndrome (PCOS) for me, but I’ve still yet to find a treatment that doesn’t involve birth control, because I’ve already experimented with multiple forms of that with poor results.
I’m at a point where I don’t go into the doctor’s office until I’ve researched my symptoms and come to a preliminary idea of what might be going on. Whenever possible, I even have a method of treatment in mind, which leaves me in a position where I’m only seeing the doctor for confirmation and to write the prescription. I’ve had doctors treat me even more poorly for being so well-informed. One said outright that I couldn’t possibly know how to read medical research appropriately, and then dismissed my suggestion of what might be wrong out of hand, insisting that it must be something else.
Because I’m poor and don’t have a college degree, plus I’m fat, I must be lazy, stupid, and deluded. I hate that healthcare is an industry, and I think that’s one of the biggest problems we face. We’ve put our survival and well-being as a race in the hands of a for-profit industry, from health insurers to pharmaceutical manufacturers to doctors who pick specialties based on potential annual income. It’s completely messed up, when you step back and think about it.
In my early 20s, I decided I wanted to be thin. I threw out all the food in my apartment and started from scratch, joined a gym, started going three days a week, started riding my bike to work and being active on the weekends. I never managed to lose weight, but I started having irregular periods — was spotting in between. I went to a gynecologist who railed at me about my weight, and wanted to prescribe the diet drug Fen-Phen and weight loss surgery for me.
I refused those, but she convinced me to take birth control pills to prevent ovarian cancer. I started them and by the end of the month I had a blood clot in my calf. I thought I’d pulled a muscle hiking in the mountains, so I worked it out and kept going — had a new blood clot by morning. Over the course of several months, I had more episodes of calf discomfort and shortness of breath that I didn’t realize were related to each other.
Trips to the ER resulted in doctors telling me I was out of shape and needed to get more exercise to lose weight. They had cognitive dissonance in what I was actually saying to them against their own beliefs. Knowing something was terribly wrong, I stopped going to the gym and schlepping around on my bike.
Long story short, I went to a new doctor who, by the time I got to him, discovered I had legions of blood clots in my lungs. I could not walk from the chair to the desk without panting like I’d run a marathon. Doctors from other hospitals came to my bedside astounded that I had survived pulmonary emboli of this severity.
This experience and many others I have had give me a cautiously cynical view of the medical profession as a whole. I know that the help one needs often comes filtered though a medical professional’s personal beliefs. I will often seek another opinion when I feel it’s necessary and will do my own research.
Yes, and often. I had a doctor who wouldn’t give me contraceptives because I couldn’t possibly need them, as a fat woman (mid-1980s). Another would pick fights with me, then take my blood pressure, and when it was high (from fighting, duh!) he’d prescribe me medications that had terrible side effects. When I said I couldn’t handle the side effects, the doctor told me that those were not the side effects of that drug (FWIW, my blood pressure has been on the high side of normal pretty much forever — not medication-worthy).
When I changed doctors, the new one would all but ignore anything I went in for, in favor of lecturing me on my weight. The worst was telling me to go on a diet as treatment for a knee injury (I fell… not a stress fracture), and prescribing diuretics for what I thought was a bone spur on my heel (as a weight loss surgery survivor, diuretics can put me in the hospital).
I haven’t seen a general practitioner in over three years. I know I’ll get nowhere with anything that is actually afflicting me. Fortunately, I’ve had a great gynecologist. I’ve never had a single issue in her office. They have large gowns, and large blood pressure cuffs, and we discuss real medical issues there.
That’s just a small sampling of what I’ve experienced.
The only thing I can think of is that I’ve had doctors spend a lot of time talking to me about how I should lose weight when I’m at the hospital for completely unrelated things. Like when I broke my foot, when I broke my finger and when I’m getting check-ups for my epilepsy. Still, the doctors tell me that I should lose weight.
My Mom and I share the same doctor. My mother was suffering for over a year with a nonstop period. She was cramping and uncomfortable. He told her it was because she was fat and smoked. My sister got really frustrated and made her a doctor’s appointment with someone else since my Mom’s doctor refused to refer her. Turns out she had uterine cancer. Luckily they caught it in time.
Personally I am afraid to go to a doctor for two reasons: 1) I have depression and anxiety, and 2) I am overweight. All of my symptoms have been blamed on one or the other or both. I am due for a check-up and have been putting it off. I have a new doctor now, but I am still afraid.
I’d like to share something I witnessed within my own family. My grandmother knew for a long time that she had sleep apnea, but she didn’t want to seek treatment because she didn’t want to wear a restrictive face mask. When we finally convinced her to be officially tested, she was already unable to transfer from her wheelchair to the bed on her own, and we were using a Hoyer lift for transfers.
The sleep clinic was aware of her mobility limitations and size well in advance. When she arrived, there was only one staffer there for the night, and my mom (her caregiver) had been told she wasn’t allowed to stay the night to assist. They had a lift for transfers, but upon getting her out of the wheelchair and over the bed, they discovered that the lift was broken and they weren’t able to lower her to the bed or back to her wheelchair.
The staffer left her dangling in the broken lift, no longer over the bed or the wheelchair, and left the room to get a different lift. The next one wouldn’t function either. Finally, the third lift worked and they got her wired up for the sleep study. Unsurprisingly, by this time she was so upset and humiliated by the treatment that she was unable to sleep.
This was no rinky-dink, backwater doctor’s office. This was at a major regional hospital that otherwise has an amazing standard of care. She went on to refuse to be tested again, and almost a year later sleep apnea, along with congestive heart failure, contributed significantly to her death.
Her experience was so horrific, that others who work in the same healthcare system heard the story (without her name of course), in some cases working in different towns! Who knows what might have happened had she been tested and treated appropriately.
She had plenty of health issues, but there’s an ache every time I think about seeing her in intensive care on a respirator. There’s anger every time I think of her trapped in faulty equipment. There’s fear that I could be in that position myself.
I’ve been quite lucky in that regard; I haven’t had too many bad medical experiences. My general practitioner will mention my weight, but she has also said that she doesn’t think that everybody is meant to be thin, and she has heard of HAES before. My major problem with her is that she doesn’t have extra-large blood pressure cuffs.
When I was younger, she would put me on diets or give me diet pills, but that was before I knew better. The doctor that I had before her put me on this meal replacement cookie diet when I was around 12. I look at pictures of myself back then and I want to give him a shake. Sure, I was bigger than my classmates, but I was not fat.
I had surgery a few years ago and not one of the doctors mentioned my weight. I’m currently dealing with torn cartilage in my knee and, again, nobody has mentioned weight. Either they are afraid of me, heh, or here in Canada doctors aren’t as obesity-obsessed as other places. Who knows. I hope that my luck continues to hold out. Reading other people’s stories has my guard up, so I’m ready to have this discussion with doctors.
Filed under: DT, DW, ED, EX, FH, FP, MBL, Themeless Thursday, WL, WLS
This week is the five year anniversary of Fierce, Freethinking Fatties. I’m pretty proud of all we’ve accomplished over the years, but what I’m most proud of are the interviews I’ve been able to conduct with some of the most influential and knowledgeable experts on a great number of subjects affecting weight and health.
Recently, I published the roundtable (Part 1 and Part 2) I put together with Health at Every Size® (HAES) experts about its invigorated emphasis on the social determinants of health (SDH). Some of the conversations I had about the SDH with some experts seemed fairly hesitant about suggesting solutions or actions that could be taken to address the problem of the SDH, even something as modest as increasing the minimum wage.
Yet I had read papers from a number of (primarily Canadian) scientists and researchers who have been studying the problem of the SDH for decades and had a long list of ideas on how to dig up the roots of the SDH.
Next to Sir Michael Marmot, the second most frequent name I saw associated with the SDH was Dennis Raphael, a professor of Health Policy and Management at York University in Toronto with a staggering list of publications on the SDH.
I contacted Dr. Raphael and he agreed to an interview. I think you’ll see some of the challenges of a HAES movement in the United States (in particular) promoting solutions to the SDH. We live in a hyperpartisan nation and many of the public policy recommendations that Dr. Raphael suggests would be a nonstarter for more than half of the nation, considering that “socialism” is treated as a four-letter word these days. To put this interview in perspective, at one point Dr. Raphael says that President Barack Obama is too far to the Right. And this is the point in our interview where what few Conservative readers we have will start screaming at the screen.
I hope you find the interview as fascinating and illuminating as I did.
Note: My questions are in green bold.
Dr. Raphael sent me numerous papers that he and his colleague, Stephen Bezruchka, had written on the SDH, as well as a fascinating interview from Unnatural Causes (PDF). I began the interview by pointing out something that surprised me.
The interesting thing that I noticed is that you don’t seem too impressed with Canada’s response to the SDH.
Let me put it this way, Stephen Bezruchka at the University of Washington always says, “You’re too hard on Canada. You’re light years ahead of us.” Here’s the difference: basically, if you look at the range of OECD [Organisation for Economic Co-operation and Development] countries, in wealthy, developed countries in terms of their general approach to public policy, what you see is that Canada’s much closer to the United States than we are to all of the European countries. In terms of general, actual public policy; in terms of inequality, poverty, lack of support for people across the lifespan, provision of childcare, provision of home care — on those kinds of important public policy issues, we’re much closer to the United States. So that’s nothing to brag about.
But we’re profoundly different from the United States. But if you look at it from a big, broad perspective, every country provides affordable child care. In Canada and the United States, we don’t. Labor legislation, in terms of providing people with security, ability to unionize, the kinds of things that make work more rewarding, we’re much, much closer to the United States.
In one sense, it’s a lot better up here. The union movement’s much more open, we have the ability to write and publish [about the SDH], and we basically have room to talk about this stuff with the potential that our more progressive political parties could take us up and actually do something. In terms of our ability for intellectual interaction, our ability to be published, our ability to be heard in the media, we’re light years ahead of the United States. But in terms of actual public policy, in terms of what we do, our poverty rates, our inequality, when you plot it out on a line from 0 to 10 where the United States is 10 and the Scandinavian countries are 0, we’re about 7 or 7.5.
Is the US the worst country in terms of the SDH?
Let’s limit ourselves to OECD countries. Turkey and Mexico are the worst, and then the United States. In terms of poverty and equality and developed welfare state, Turkey and Mexico are the last places you want to be. However, the United States is a profound outlier. In fact, when people published studies where they’re doing correlations between inequality and crime, or provision of childcare and child development, they always run two analyses: they run an analysis with the United States and they produce a correlation coefficient, then they remove the United States because it’s such an outlier that it dishonestly inflates the correlation.
One of the things I always like to show, because I grew up in the States in the ’50s and ’60s, is from 1945 to 1975, if you break the American population into quintiles, each quintile increased in real income significantly. The people in the bottom 20% doubled their income in real dollars, the people at the top doubled their income, so growth in income and wealth was evenly distributed across the population.
How much of that is attributable to FDR’s New Deal?
Certainly I think it was the attitude and the mentality of the New Deal. For example, one of the things I remember, being in grade six, this was the case in Canada as well, the highest marginal tax rate in the United States was 90%. And then going back to those charts, from 1975 to the present, beginning with the Reagan era, you now have growth more or less being limited to the top 20%.
When you look at the history of the United States, you have these spikes, but that’s the anomaly. The progressive era in the 1880s/1890s, those were anomalies because the way the Constitution was set up, you have a country that’s kind of frozen in time. The progressive era, the 1930s, the New Deal, the 1960s — those were always the deviation from the path. And the path is primarily similar to Canada and the UK — it’s an absolute celebration of free enterprise and, in theory, the individual.
But the way it plays out is that it ends up, when business and corporate interests dominate the operation of the economy and of the political culture, you end up with the kinds of inequality and disparities that lead to poor health. Because free enterprise doesn’t do a great job on things like universal education, universal healthcare, housing.
In the European countries, there’s two traditions that emerged to oppose this so-called liberal approach, and that, of course, was the Bismark and the conservative approach of the 1870s, where basically Bismark found that you couldn’t just let the market dominate the society. The so-called conservative approach (not to be confused with Conservatives in the United States) is one of promoting solidarity, watching out for each other, and basic provisions.
Those countries, of course, are France, Germany, Belgium, Holland, Switzerland. The other alternative was the social democratic. The social democratic approach, which is of course in the Nordic countries, was one of managing or controlling the economy in the public interest.
The United States is the extreme opposite: government is bad, get government out of the way. And it’s so pervasive that the average businessman in Europe is more likely to believe that government has a role providing people with jobs, providing people with education, providing people with enough to live, than most people in the United States. It’s really quite remarkable.
It’s an exaggeration of what has always been the American case with significant anomalies, like when I grew up in the ’50s and ’60s. For whatever reason, they were willing to put a 90% tax on the super-rich. But over time, beginning with the Reagan era, that gradually became watered down.
[This] is being driven by three things: one is any semblance of managing the economy is gone and the most obvious manifestations was, of course, Clinton and the derivatives. And Obama basically hasn’t really outlined any alternative to that. In fact, we were struck by the fact that once he got elected he took all the Bush guys into government. So, you have even less of a willingness on the part of society to manage the economy, so any kind of pressures by business have absolutely dominated civil society and any attempt to manage the economy. So that’s pretty bad.
It’s been reinforced by the American exceptionalism, such that Robert Woods Foundation actually does research where they try to point out to Americans that we’re not doing to well in terms of health outcomes. And what they find is really unbelievable when they come out and say America is really good at a lot of stuff, but, you know, compared to countries like France and Germany and England, our health isn’t that good.
What you find is in most European countries, a progressive vision is put forth by the labor movement and the labor movement is virtually nonexistent in the United States now. The New York Times had a story about how membership is down to 7%.
I’m literally 23 minutes away from Cleveland across the lake and I had this period a couple of years ago where I went down there literally four times in a year-and-a-half, and I would get up there and put up a chart and would compare life expectancy between 12 OECD countries and people just tuned out. I was on a panel and I say one of the things we have to do is strengthen the labor movement. The guy who followed me would say “Yeah, that’s certainly true, but that’s not going to work here so let’s forget about it.”
Whether it’s possible or not is another question. But in terms of this issue of health and inequalities and introducing these broader concepts, I think somehow it has to be communicated. In the 1970s the United States was number one, or near the top, in terms of life expectancy. And somehow, a movement has to somehow break people’s mindsets that [the United States] can do no wrong; that in the 1930s, America did this, America did that, but since then something’s happened.
In terms of values and thinking, somehow it has to be communicated that not only are we not doing that well, we’re doing very badly. In the 1970s, when I was just finishing university, that’s when the SAT scores began to plummet and people were making the argument, oh it’s because so many Black kids are now taking the test, when, actually, the effects of inequality were beginning to show.
The second thing, the labor movement here has a whole bunch of public ads that says the labor movement is here for all of us and it talks about education, healthcare. Somehow, a lot of research indicates that a good driver of equity and health is a strong labor movement. Of course, the United States has a long way to go.
I think an attitudinal thing is somehow trying to educate people that we’re not doing a great job for most Americans: the healthcare, of course, is the most egregious, but stagnating wages of 80%, the concentration of wealth. The problem is that ties into the American exceptionalism that 80% of kids think they’re going to be rich some day.
So it’s really hard. What we’re doing up here, we’ve been able to get the Canadian Medical Association, the Canadian Nurses Association, pretty well all the institutional players have bought into [the SDH]. The problem is that none of it has moved up to the political level. So even the new Democrats will have something on their website about the SDH, but they haven’t come to the realization that this will be a way to get people to vote for them. There are also Americans who would be receptive to this. In Maine, you’ve got Bernie Sanders.
Well, there is Elizabeth Warren.
Yes, yes, we know about her. We certainly know about her attempt to manage Wall Street. The fact is, she comes from a working class background. So, yeah, if she could be brought on to it, it has to resonate, but the problem, again, is they can’t make everybody happy. Maybe you’ll never get people from Nebraska won over.
There are certain things here that I’ve got to celebrate because we forget about them. For example, funding for education of elementary schools in the province of Ontario is not based on local taxes.
The United States is notorious for that.
What happens here is not only is it equal no matter where you are in the province, but the poorest areas get more money. I’m still in a neighborhood that’s considered to be lower-middle income and we get more money per kid on the basis of need.
There are some things that are built into the [American] system that are just atrocious. The funding for education, the weakening of labor laws in the South. It’s not just the South any more, it’s Wisconsin. In Wisconsin they banned unions. I find it really helpful to put up the slide that says the minimum wage in France is double what it is in Canada. People look at that and say “Why can’t we be more like France?” Or we show childcare in the Scandinavian countries or we try to show public transportation. Actually, in public transportation, the United States is now moving ahead of Canada.
What would need to be done is organizations like the American Public Health Association, somehow joining together with other civil societies: the NAACP, Urban League, all of these NGOs [non-governmental organizations] that have a modicum of respect for the American people. In Australia, they’ve created what they’ve called the Social Determinants of Health Alliance.
Somehow, there has to be some recognition that things have gone awry, which I think most Americans feel at least intuitively, and that we can begin to make sense out of this. Maybe the same way that people around the world learned from America about Microsoft and Google and Hollywood; maybe there’s something we can be learning from these other countries.
What do you make of the proposals President Obama made recently: free community college, free preschool for all?
The average kid up here is completely disengaged and I think Obama’s a really good guy. One of the things I say to my students is, forgetting about what these guys would like to do or what they would say to you over a few beers, when you look at Obama’s political positions on the role of the market, on healthcare, on a whole bunch of things, he’s actually to the right of Stephen Harper.
What!?! I find that hard to believe.
Well, Medicare, healthcare, in terms of managing the markets. I mean, basically, the Canadian banking system, we didn’t have that much of a problem in 2008 because it’s really well regulated. You don’t see Stephen Harper coming out and calling for right-to-work laws, certainly not gun control, and certainly even in public policy, as bad as we’ve become, we’ve had relationships with Cuba and Venezuela for a very long time. But I guess I’m saying that the politics in the United States has shifted so far to the right…
… that you kind of have to be to the right of the Left.
That’s right. Or else people will just ignore you and think you’re insane.
You’re too radical.
Yeah. So, in terms of Obama, he can come out and say these things, like increasing the taxes on the super-rich or the free community college, in the State of the Union message. I think that he feels he can come out and say that, but there’s not a chance in hell that it’s going to be accepted.
He’s got nothing to lose now.
That’s right. If he did it earlier when he still had control of the House, then he would have these conservative Senators and Congressmen knocking on his door.
Yeah, but he spent all that capital on healthcare.
And all he’s done is, Obamacare is simply forcing people to buy into private insurance. Ted Rall is a pretty radical cartoonist in the United States and he said it’s hard to believe, but every President since FDR has been worse than the one before.
Isn’t there a case to be made that, like you said, from ’45 until ’75, we were fairly progressive and Reagan kind of broke that fever and took us the other way to deregulation and all that. Couldn’t Obama serve as a kind of left-wing Reagan where it’s the turning point where the conversation starts to shift to the left?
Absolutely, if he did this consistently and it wasn’t just a one-off, you’re right. You’re absolutely right. Because things were going fairly well until Reagan convinced everybody they weren’t. So Obama could come along, but I don’t think he has it in him. I think he’s young, I think he has to worry about income, although he’s done well from his books, but you’re absolutely right. If he went out to Gary, Indiana to these decaying factories, any person in authority could become that kind of person. That’s good. He could.
I have a hunch that’s what the next two years are going to be: focused on income inequality.
And him up there somehow trying to build a groundswell for the next Congressional election.
I personally would love Elizabeth Warren for President.
It’s so different that even in the literature on poverty, poverty looks different in the United States.
The SDH is completely off the radar here. It’s almost unheard of here.
It’s been really big. The World Health Organization, the European Union — health inequalities has been on its agenda since 1992. They identified reducing health inequalities. Until the Bush era, the Centers for Disease Control used to report on it. It used to be called “Health United States 1998,” and they produced the same kind of charts that we produce here. Then it was off for eight years during the Bush era; they weren’t allowed to do anything about it, and now the CDC is starting to report. They use the term “health disparities.” So there is some attempt out there.
Claudia Chaufan is with us for six months as a Fulbright Scholar. Claudia is the only person in the United States, literally the only person in the United States, who says that an awful lot of what’s causing and driving diabetes is inequality, poverty and insecure living conditions. [Editor’s note: after this interview, I discovered the work of David Spero, who has written a book with a similar message]
Where do weight-related issues fit into the SDH?
The 1970s, when they did all the Whitehall Studies, the assumption was that you could explain the differences in heart disease on the basis of weight — they did BMI, they did smoking, they did cholesterol, they did glucose intolerance and they found that once you were lower on the socioeconomic ladder, these things didn’t make a difference.
What we found in all our diabetes studies — and these were both cross-sectional studies and longitudinal studies — is once you were low-income, that was a really good predictor of you getting adult diabetes and it didn’t matter if you were fat or not.
There’s a researcher in Michigan who does cardiovascular disease, and she finds that once you’re living in a poor neighborhood, it doesn’t matter what your weight or physical activity is in terms of your likelihood of getting cardiovascular disease.
What you have with obesity, I think it’s the same way as income: income has direct effects on health. And those direct effects, of course, are crowding, infections, poor diet, danger, all that kind of stuff. But income inequality is not the end all and be all, that’s simply an indicator of a whole bunch of other processes.
Obesity, at its extremes, is not good for health. However, being overweight is a protective factor, especially for the elderly. So, obesity in the United States, I think for some people can be a direct cause of poor health. I think it’s more of an indicator of all the other things that aren’t working.
I guess what I’m saying is that if you identified all the people in the United States that had decent, secure jobs and happen to be fat, you’d find no effect of fatness. I think obesity is one of these things that politicians and everybody latched onto to show that they’re concerned about health without having to deal with all of this other stuff. Plus there’s this whole big literature in Western thought demonizing fat people and all that kind of stuff. So there’s a whole anti-obesity literature.
My approach is, yeah, of course you don’t want people to weigh 500 pounds, of course you don’t want them to smoke, but in terms of the major health issues facing us, they’re pretty well low on the scale compared to whether it’s poverty or precarious work or food bank use or poor housing or that kind of stuff. I think it’s something that, to me, is generally the attention being paid to it is divisive in terms of diverting people from things that are a lot more important.
Going back to the Whitehall Studies, something I’ve wondered is that it shows two people can have the same lifestyle behaviors but if they’re in different socioeconomic classes then they’ll have different health outcomes.
Absolutely. What this means is that if you’re a wealthy person at the top of the hierarchy who smokes that will have less of a health effect than if you’re someone lower on the hierarchy who smokes
What if you compare two people on the same level who have different behaviors? Is it a muted impact?
Maybe it will count for 15% of variance. What will happen is, if you take, let’s say, a hundred people that are wealthy and you separate them into smokers and nonsmokers, you’ll find a difference. But it won’t be at the magnitude that you have between wealthy people and not-so-wealthy people. So it’s pretty consistent. If you have to bet who’s going to get heart disease, ask them what mom and dad did for a living and ask them what they do for a living. Once you know that, then you place your bet. If they smoke, you’re a little more sure. But it really is remarkable, it’s pretty striking.
Tthe problem is, even up here we couldn’t get this stuff published. We get a lot of this stuff published in international journals. They’re more receptive to all of this stuff than even Canadian journals are. And the American journals we don’t even bother with anymore.
On that individual level, speaking of someone on the low economic side of the scale, are there things that an individual can do to personally reduce or mitigate or counteract the effects of the SDH?
Clearly at an individual level, the most obvious ones are don’t smoke, don’t drink yourself into a stupor. But I would argue, I say to my students that it’s probably healthier, probably more important whether you vote or not, or become engaged. And there’s this whole literature that came out of the [Alameda County Study]. I’m not a big fan of it because it avoids broader issues, but they found that people that were socially isolated were much more likely to die as they got older.
If I was a community developer and I went into a poor neighborhood, I’d say to people, “You know, you hear a lot about not smoking and exercising and, of course, these things are all really important. But another important thing you can do is try to get engaged in order to improve living conditions around here.” What you do is take people who really don’t understand what’s going on, they see their friends getting sick, and somehow you engage them in some kind of activity that gives them some hope and connections and, at the very minimum, builds relationships with other people.
For example we have something called the Good Food Box. The idea is that you go up and down the street and you say “For $20 a week, we can get this stuff directly from farmers.” It started out as being really for poor people. It’s not so much that you get them fruits and vegetables, but that you get people connected and engaged. Because when you go to a food bank, you’re not engaged, you’re not connected.
What could people do? I think people need to begin to understand the roots of this, but also that as difficult as it may be, we can do things like they’ve done in Seattle, we can do things like they’ve done in New Westminster, British Columbia, where you get involved with the local public health unit and you try to get some immediate gains, but you also recognize that we’ve got a long way to go.
Along those lines, I have another question: how do you look at the effects of the SDH, especially if you are working with other NGOs trying to make a difference, how do you not look at the enormity of the institutions that ensure the ongoing existence of the SDH and not succumb to feelings of futility or immutable fate?
No matter what I do, it’s still going to make it easier for the people that come after me. Now, in terms of the average person, I say this to myself when I get disgusted with the so-called new Democratic party here. We have no choice. We literally have no choice, we have to stay with it, we have to become engaged because the alternative is for things to get even worse. So, what do you do? You look for examples. There’s a lot of good stuff that happens in the United States, but it’s localized and it’s not publicized. The problem is they’re tremendously isolated and they’re very small.
But it’s what you’re up against here. It’s pretty bad. And the people that are tuned into it have really decided to keep their heads down. In some places in the Midwest or maybe in the South, if you’re too outspoken then they go after you. We heard about people being unable to use university emails or stuff like that for something that’s perceived as being anti-American. So I don’t envy anybody down there. I really don’t. It’s really a difficult situation to be in. But, again, there are pockets across the country and one way to do that is to publicize it and bring it together and give people a little bit of hope.
Knowing everything that you know about the SDH, the gravity, the impact, how does it affect your understanding of individual health behaviors? Are they just not that important when you look at the grand scale or are they still vital on an individual level? How do you put that in perspective?
There’s this guy, David Seedhouse, who wrote a book called The Foundations of Health, and he made the argument, philosophically, that unless you provide people with the basics, you can’t go after them on these other issues. What I suggest to people is that all things considered, you want to do what you can. You do what you can no matter what level. If you’re an anti-smoking person, you do anti-smoking, but you don’t do it like “You guys are just stupid, stop smoking.” You do it in terms of empowering them.
Any time somebody comes along and says “We gotta stop Latinos from smoking,” although they don’t smoke that much, you come out and say, “Yes, of course we do, but don’t you think we should be spending some time on the kinds of employment opportunities and educational opportunities that kids have?” So you just try to shift that 99% of attention to 95% or 90%, or just work its way down.
Do you think the United States has crossed the tipping point? Are we too far gone?
Well, you know, we were too far gone until the New Deal came along, right? And who would have thought that Vietnam War stuff would have happened? So, yeah, you never know. It seems to me when you see something like Seattle and it happens and it works, or you see a guy like Bernie Sanders gets elected in Vermont, then anything is possible.
Filed under: DT, EX, FH, FP, FS, Themeless Thursday
Trigger warning: Discussion of diets and weight loss.
I’ve been seeing quite a few comments on my Facebook feed about “clean” eating — how it’s so much healthier for one’s body and how easily it leads to weight loss are the two main recommendations that people give as the reason for eating a “clean” diet. So I decided to do a little research to find out just what all the fuss was about. Believe me, there is a lot of fuss about it going on too; advocates of “clean” eating are vehement about their choice to eat “clean” and some of them are very judgmental of anyone who doesn’t drop their “dirty” food habit immediately and jump on the bandwagon.
The best article I could find that explains what “clean eating” is was fairly clear about it all, but there are a few assumptions in here that need to be challenged.
Where did the “clean” eating movement come from?
Clean eating is mostly a new-age concept that began when we had enough cultural advancements to create excess. Books such as Michael Pollan’s “The Omnivore’s Dilemma” and popular documentaries like “Food, Inc.” have helped bring ingredient awareness to the forefront of people’s minds. Michelle Obama’s healthy-eating campaign has also played a major role in this awareness.
More significantly is the need for clean eating as a necessity for health. ”Heart disease, cancer, stroke and diabetes are in almost every household in the country. Those are lifestyle related conditions. We’re all affected by it. The problem is so urgent at this point we can’t just keep on keeping on.”
It looks, to me anyway, like people who have the time, money, and energy to devote to this type of diet are the ones who created it. But what I take exception with in the above quote is the “Heart disease, cancer, stroke and diabetes are in almost every household in the country. Those are lifestyle related conditions.” Lifestyle-related conditions? Really? Genetics don’t have any part to play in them at all?
While I may agree that some of the ingredients in our food supply may contribute to heart disease, cancer, stroke, and diabetes, I don’t think that eating “clean” is going to eradicate or lessen the impact of any of those diseases. Way to add fuel to the fire — the fire of blaming people for the diseases they get. Blame them because what they ate wasn’t up to some “standard” of “clean.” If they had just eaten “clean”, they wouldn’t have gotten whatever disease or it wouldn’t have been as bad.
As for how urgent the problem is, I think lowering the diagnostic standards for what constitutes the start of hypertension or diabetes has more to do with that. Every time the standards are lowered, previously healthy people are added to the list of those who need “treatment” (which is something I’ve written, and ranted, about before).
Let’s take a look at what “clean” eating is. According to the linked article, it’s eating foods that have as few ingredients as possible — in other words, unprocessed.
The clean eating rule of thumb: The shorter the ingredient list, the better. No specific food is off-limits as long as it’s a real, honest-to-goodness food. In other words, this isn’t a “diet” that bans bread or sacrifices sugar.
It doesn’t ban bread outright, but if you don’t have the time or the money to buy the ingredients to bake your own bread, bread would not be on the list of “clean” foods. Ever read the ingredient list on a loaf of bread? Even the “whole grain,” supposedly “healthy-for-you” breads have ingredients in them that we can’t pronounce and we would have to look up to see exactly what they are and what purpose they serve.
“This is a way of eating that you can eat until you’re full and satisfied, and the side benefit is the weight loss,” said Ivy Larson, co-author of “Clean Cuisine.” Larson’s multiple sclerosis symptoms were lessened when she started eating a “clean” diet.
Although Larson and her clients have a more strict interpretation of clean eating, the core principles of the plan are the same: Eat whole foods and less packaged items.
Larson recommends starting by adding one “clean” meal a day to your diet, adding more week by week. She suggests that buying frozen vegetables or fruits is a quick way to add nutrients to your diet with less work.
A common belief is that clean eating — or healthy eating in general — is more expensive than fast-food choices. “To eat this way is actually cheaper than processed food. You just have to put in the labor,” said Orlando, “We take more energy making our car nice than taking care of our bodies,” he said.
There always has to be a side benefit, and that side benefit just has to be weight loss. Why can’t we just stop at improved health? Why does it always have to have “weight loss” thrown in there too? I noticed that nowhere is it stated, as a number of pounds or a percentage of beginning body weight, what that “weight loss” looks like. Why is there this obsession with weight, and with blaming weight for all of our ills? Even people who aren’t fat get these diseases. Even people who aren’t fat can end up disabled, for whatever reason. So why is the focus always on weight loss?
“Clean” eating may be right for you, if you have the money, time, and energy (spoons) to devote to shopping for “clean” foods and then preparing them. Not to mention you also need to have a place to store all those “clean” foods/ingredients — refrigerator/freezer, cupboards, containers, etc., as well as a stove (and the wherewithal to pay for the gas/electricity it takes), and enough pots/pans to cook those foods.
Sorry, but there are some of us who just don’t have enough spoons to do the grocery shopping for “clean” food, let alone have enough spoons left over to put it all away properly, and then actually prepare meals from scratch. There are a lot of illnesses and disabilities that “clean” eating isn’t going to resolve, and those of us who can’t jump on this bandwagon don’t need to be judged for our choices (and I’ve seen a lot of that judgment issued against people online).
In the end, it all boils down to everyone eating as best they can in the circumstances with which they’re dealing. And that is a very personal issue for each and every one of us, which is not the business of anyone else. Whoever wants to eat “clean” has the right to do so without judgment. But I reserve the right to not eat “clean,” for whatever reasons, and not be judged for that. My body, my choice — your body, your choice.
Filed under: DT, FH, FN, Weighty Wednesday, WL
I grew up in a fairly conservative and religious household. Sexuality was something to be repressed and ashamed of. My aunt used to slut shame before we were even thinking of sex. As I grew up and into feminism, I began reclaiming my sexuality. I came out as bisexual and poly, began dating, exploring, having fun, and all that good stuff that comes with being an independent adult (much to my mother’s dismay I might add).
Despite the fact that fat women are often either fetishized or desexualized, as a feminist I was picky about who I slept with, and overall it’s been empowering and a plain ol’ good time for everyone involved. In fact, I have a date this week that I’m looking forward to.
But what do I do when someone asks me to be sexy?
I am coming up on class number three of a burlesque class that I’m taking. Once a week, I drive about an hour to another town to take this class. I’ve picked a stage name, learned to “peel” (and done so in front of a class while wearing thigh highs and a garter belt). But I feel absolutely ridiculous. I feel goofy and awkward and I want to laugh. Look, I can’t make sexy faces and have them be serious, I just can’t!
This has left me feeling inadequate and ashamed of myself. I’ve never had to be sexy before, just sexual. Never had to entice or seduce, it just … happened! I’ve been with men and women and never once did I try to be sexy. If I had, I’m fairly certain I would have failed.
This isn’t to say that fat women (or anyone else!) can’t be sexy. I’ve seen some fat women pull over a seductive look that would stop you in your tracks. It just isn’t for me. And yet I have to put together a performance centered around stripping on a stage and being sexy.
You know, Valentine’s Day is coming up and I’m going to be sending body love cards to friends. Maybe I should make one for myself because I need a serious reminder that I deserve to be sexy and, more so, my sexy doesn’t have to be someone else’s sexy.
I’ll admit that being a fat woman in a class of mostly thin women is getting to me. All the more reason that I need to tell my body what’s what and that it’s amazing and precious and wonderful.
Hey body, yeah you, did you know that I love you? Now, more than ever.
Filed under: FX, MBL, TMI Tuesday
Trigger warning: Discussion of weight loss, weight and health.
The following is the next part in my series asking Health at Every Size® (HAES) questions about how the social determinants of health (SDH) fits into the HAES model. You can read the first part here.
My apologies for not having this out “tomorrow” as I said at the end of the previous piece, but last Wednesday night I was hit with a fever that was the start of a bout with strep throat that left me unconscious and shivering for two straight days.
What follows is a single question followed by a series of answers from many HAES experts, including Lucy Aphramor and Linda Bacon, whose interview cancellation led to this roundtable in the first place.
Because of the reaction I got to this question from the initial roundtable I assembled, I decided to put the question into a specific context, which resulted in a long setup prior to the actual question. I’m not sure if it was the setup or the question itself, but something triggered a robust response from a number of people who see this issue from different sides.
Although I had intended to ask six questions, but after this question the holidays were right in the thick of when I would have asked the last two. Also, the response to this question was so overwhelming I felt as though it was effective on its own.
And so, without further ado, the final question in the HAES expert roundtable. (Note: I have Americanized the spelling of terms to make this roundtable consistent … sorry non-Americans!)
When I first learned about HAES five years ago, the focus was on evidence-based methods of improving one’s metabolic health by focusing on behaviors rather than weight loss. Lately, I’ve heard from several HAES thought leaders who seem to be distancing HAES from personal lifestyle as the central component. Instead, it seems as if the ubiquitous effects of the social determinants of health have become the heaviest object in the HAES universe.
In Body Respect, there’s reference to the results found in the Whitehall studies, whereby class and status in work environment is directly correlated with the health outcomes of employees. The most shocking detail is that two people can have the exact same healthy lifestyle and the “highest grade” employee will have far better health than the “lowest grade” employee.
And yet, the two-year HAES study clearly showed that a weight-neutral approach to health yielded significantly better long-term outcomes than traditional weight loss approaches. The message was obviously that if you wanted to improve your metabolic health, there were effective weight-neutral ways to do that. So it seems like two low-grade employees at opposite ends of the spectrum in terms of health behaviors would have different long-term health outcomes.
HAES has also very clearly said from the beginning that individual mileage may vary. Those two low-grade employees would have very different reasons for their current lifestyle, healthy or not. The HAES model told both employees that if they wanted to be healthier, then they could do what they were capable of doing and what they were comfortable doing to improve their health. Central to HAES is the idea that we each know what’s best for our mental and physical well-being. This seemed like a natural response to the social determinants of health as well. They’re the macro and micro approaches to health and wellness.
But it feels like something has changed in the emphasis on personal lifestyle choices since the discussion of the SDH has begun in earnest. I just can’t put my finger on it. So here’s the next question:
Question 4: How does the gravity and impact of the social determinants of health affect our understanding of the earlier HAES emphasis on individual health behaviors?
Nutritionist and HAES Health Coach
These discussions are good for reflection and consideration. For me, it feels like HAES is changing due to continued research, more awareness of other factors, new people, new ideas. Like any system, the change will differ in rate and uptake based on who, where and what is involved. Personally, I feel that we first need to appreciate what HAES is for us and what it means to us, how it applies to us and, most importantly, how does it help us. Because if we don’t believe it’s helpful and useful then all these discussions become rather pointless.
For sure when I was first stumbled across HAES 7 years ago, it was a revelation and I couldn’t understand why it wasn’t being adopted everywhere. Throughout this journey I have come across many people from many backgrounds and learned new ideas, such as social justice, social determinants of health, intersectionality; I have read (most of my HAES connections are online) about the struggles, the discrimination, the marginalization of the lived experience and learned to understand privilege, especially my own. My capacity to understand these issues has expanded, but it was a journey. So for me the question becomes “How willing are we to keep looking and keep asking questions in order to have a movement that has space for everyone?”
Perhaps I’m less of a philosopher and more of a practical person that my answer is not as in-depth as is needed.
Biomedical scientist and PhD candidate
To me, Health At Every Size, by its very name, is about countering the weight-based paradigm and the double standards of healthcare for fat and thin people, and to use a health-centred approach for all people no matter what their body size.
Like many others, when I first discovered HAES, it was a revelation. It was liberating. It gave me agency to do what I could for my own health, within the constraints that still existed within society, my own life, and my own body. The principles told me that no matter what hand I had been dealt, if I wanted to improve my health, I could optimize my outcomes by choosing controllable behaviors — the principles at that time were about accepting size diversity/size acceptance, listening to internal body cues and eating intuitively, and moving for pleasure rather than punishment.
All this was framed within the context of individuality — trusting my body, working with my body, finding what worked for me, which might not be the same as what worked for any given person. This approach gave me hope for the first time and left me feeling liberated rather than defeated.
Separate to that, I became involved in Size Acceptance and anti-weight stigma work. It was always clear to me that fighting for equal rights for people of all sizes was separate from HAES. HAES was about optimizing individual health, and nobody was obliged to do so. Further, whether a person chose to improve their health or not, or was healthy or not, should have no impact on how society treats them. This was a human rights issue, and I separated the social justice aspect of this fight from the individual health concerns. I think both are needed, but that they are not the same. By coupling the weight stigma issue with the “weight is not the be all and end all and health metrics are more meaningful and achievable,” risks moving into a healthist approach to fat people — they’re OK so long as they’re healthy, or trying to be healthy. And for that reason, individual health was always separated from stigma and discrimination work, despite the impact that stigma and discrimination have on health, both directly and indirectly.
I am also aware that for people who are marginalized daily and whose lives are fraught with physical and emotional trauma, intuitive eating is not a high priority. And I know that no matter how much health behavior an individual engages in, social determinants of health (and genetics), will still play a significantly larger part in their well-being and future health outcomes. To me, this does not detract from what I saw as the HAES message — that there are things you can do for yourself that are nurturing rather than destructive, and that these, at least, are within your control.
I think there really do need to be two separate focuses — what individuals can do for themselves and what all of us can do to improve the world we live in.
Lucy Aphramor, PhD, RD
Dietitian and co-author of Body Respect
I wonder if some of the confusion may arise from what gets described as HAES. So, when the trademark holder ASDAH states that HAES must “ground itself in a social justice framework,” then it follows (to me) that something not grounded in this framework isn’t HAES. With this in mind, I know I’ve used the term “HAES” erroneously in the past to describe studies that I now describe as “wellness-centred approaches.” These studies used a weight-equitable approach and taught mindful eating and joyful movement — all the studies had positive outcomes, but they weren’t grounded in social justice, so according to (my reading of) the definition they’re not in fact HAES.
I think it’s quite common for HAES to be (mis)understood as a wellness approach to lifestyle change, one that embraces compassion and acceptance and that addresses internal and external size stigma. Undoubtedly many people have benefited personally from this message of size awareness and compassionate self-care; it changes lives as people heal from body shame and experience real shifts in their relationship with food, and its impact should not be underestimated … but if it doesn’t also embrace a social justice agenda then it leaves unchanged the thinking that leads to inequality, which unwittingly serves the status quo, and it’s not HAES. Serving the status quo means that the deep structures that lead to stereotype, including size stigma, are reinforced even if we get to moderate the impact in our own lives.
(As an aside while discussing definitions, many of the studies I’m referring to described their approach as HAES as weight-neutral. To me “weight-equitable” better reflects the fact that people of different sizes may well require different treatment for the same outcomes, so being weight-neutral isn’t the most effective framing, in the same way that being gender blind, or race neutral, works against social justice. Deb and Sigrun et. al. used “weight inclusive” in their recent paper … it’s interesting to see how important attention to language is in HAES, and how terms and concepts are evolving all the time.)
Advancing social justice requires more than using a weight-equitable approach to promote health-gain. And if we don’t have social justice we can’t have weight equity; there are no single issues. One way a HAES approach advances social justice is by challenging the narratives that reinforce privilege such as when we offer an accurate, socio-politically aware perspective on the role of lifestyle and non-lifestyle factors in health outcomes. This questions the more common view where health is seen to reside in individuals and metabolic fitness is viewed as within individual control and primarily due to behaviors or access to healthcare. By including social justice, the HAES framework finds room for data and conversation about oppression and privilege, issues often overlooked in critical appraisal of weight science in a wellness approach that isn’t also HAES.
A weight-equitable personal wellness approach can end up bolstering existing power imbalances. When it is blind to the metabolic impact of racism, classism, homophobia, sexism, etc., we can assume it is also unaware of the way that knowledge gets constructed and so inevitably reinforces the unequal power dynamics it is ignorant of. The fact that there is so little awareness of social determinants of health, including among highly-educated practitioners committed to equality, shows how effective dominant discourse is at teaching us both to not see and to believe we are experts at the same time. Moving dialogue forward will take more than adding in biomedical data on social justice to an existing evidence base; it requires us to fix the systems of thought and silencing and abdication to experts that brought us here in the first place. The systems that fuel social injustice are the same systems that fuel weight stigma.
In other words, even with a wellness approach, if we ignore the science on social justice we implicitly uphold (masculinist) ideologies that support the status quo, teach individualism, exclude marginalized voices, and lead to size stereotype. These ideologies don’t get seen as such and the approach is treated as good science, valuable and value-free. This happens at the expense of feminist science, and other ways of knowing that do include marginalized voices and routinely get dismissed as “not valuable” and too biased. “Doing social justice” in HAES is part and parcel of the criticality inherent in unpacking size stigma, not an optional extra. And if we don’t include SDH in health talk we’re using silo-science, it’s not ethical and it infringes practitioner codes of conduct on veracity and best practice in informed consent.
None of this talk of SDH is to detract from the fact that HAES does enhance personal wellness — but by adding in criticality and connectedness to compassion it moves us away from constructing health as a lifestyle commodity to constructing health as something that circulates in relationships along with self-worth, power, resources, privilege, respect and so on in fair societies. The difference is HAES works to enhance personal and collective well-being and recognizes these are always interlinked and influenced by structural factors. Anyone who stands to benefit from self-acceptance, intuitive eating and joyful movement will do so, and those who stand to benefit from the consciousness raising that helps us build a fairer world will also do so.
These days, I think of HAES as a way of helping people “heal the disconnect,” leaving out the social and political realities of our lives and relationships works against this.
In the past I have spent a lot of time defending HAES against charges of being healthist. And it’s true, when I first came across HAES it didn’t seem to offer a socio-politically aware framing and was commonly presented as Size Acceptance/intuitive eating/joyful movement. Like I said earlier, I knew this was really helpful for loads of people, and represents a significant shift in traditional thinking, but to my mind that wasn’t enough to recommend it as it stood. If something is non-relational and ignores inequalities it’s a no-go because it reinscribes privilege and the mindset that creates oppression.
For a time I called my approach “health in every respect” which was HAES + SDH/ relationality, to get away from the emphasis on health behaviors. Of course, I’ve also learnt heaps from what I’ve read in HAES and am hugely grateful to be part of community for support and discussion. Plus, as I’ve read more I’ve come across many HAES advocates and activists who have always challenged the emphasis on individual health behaviours as healthist.
As you’ll have gathered, these days I’d say if it’s healthist (i.e., ignores SDH) then it isn’t HAES, though I know there’s plenty of people doing great work who would disagree with this position.
How does the gravity and impact of the social determinants of health affect our understanding of the earlier HAES emphasis on individual health behaviors?
Here’s the short version — IMO:
If a health program adopts a mechanistic paradigm approach and/or ignores equality issues other than weight equity, then it isn’t HAES, or scientific. If instead it challenges the idea that health outcomes are primarily a result of individual health behaviors by relying on a critical reading of the science and teaching compassionate self-care and relationality, then it’s probably HAES. Many HAES advocates already emphasize this “integrative health” paradigm.
If the question is “Is HAES an approach to wellness (for people to use themselves or professionals to use with clients) or is HAES a social movement?” my gut response is that that is too much territory for one concept to hold.
As someone who lives in both the healthcare and social justice worlds, I’m pretty sure health workers can be won to HAES as a wellness approach, though it won’t be at all easy to move them against the weight-centric tide. That would make a huge difference in the lives of millions of fat people.
Getting health workers to embrace a social justice approach to health is a much harder proposition. So combining the two at the level of core principles will slow HAES down in healthcare.
For people outside of healthcare, it seems that whether we include social issues in HAES or don’t include them, we will be excluding a large group. It can’t be helped. My health-promoting self says to put the social issues on a different level. Inform people of them, but don’t require activism as a part of personal health or empowerment. It’s a useful addition but people don’t have to start there. My social activist side says whatever we can do to raise awareness about the social determinants of health is a good thing, so HAES should do that.
There is no right or wrong to this. Both sides are right but seeing things from different points of view. If I got a vote, I’d say keep HAES as primarily a wellness-centered approach. That will continue to bring more people in and help them immediately. Educate people about social issues while they are helping themselves.
Meanwhile, bring HAES science into groups who are already fighting for social approaches to health. Those groups tend to be almost as weight-biased as mainstream public health because they are subject to the same propaganda, but they are the ones experienced and skilled in moving society in a healthier, more just direction.
It’s a difficult question for sure.
I am welcoming the discussion, thank you all.
I just want to notice that we are all white people.
Show Me the Data is mostly white people. ASDAH is mostly white people. The Facebook HAES group is mostly white people.
The views presented here debating including the social determinants of health in the model are white people’s views.
The concerns about excluding/distressing/upsetting the people who don’t see the social justice issues as relevant to health are concerns about white people. These issues are not abstractions in the lives of people living with oppression. “Weight stigma” is not a stand-alone concept for bodies that are fat AND Black, fat AND poor, fat AND disabled.
I get it that the HAES-White model works for white people and is the most frictionless set of ideas — for white people.
I just ask us to consider, what about everyone else? We have been given the gift of feedback from people who are not White about the casual racism in our communities, the hypocrisy of saying we want to support health and then contributing to the burden of regular and frequent microaggressions, ignorance of people’s experiences, cluelessness about the impracticality of the model’s emphasis on certain practices that require privilege.
And if that argument isn’t compelling to you, I am sad, but I will appeal to an additional argument: the HAES model has ALWAYS been about the best evidence science can give us. There is no getting around the facts that social support, enough financial resources, and how we are treated by others are the most important determinants of our health. To continue to ignore these scientific facts — as the reductionistic medical model does — is to turn away from addressing the most powerful factors in human well-being.
To me, the challenge is to create communities that give each others lots of support and appreciation (social support!) even as we are trying to learn how to be aware of our privilege and casually-cruel and exclusionary points of view. This is the growing edge.
I have no doubt that the broader population of white people will continue to find the elements of the HAES model they need. Why is this a worry? White people are very good at ignoring what they have the privilege of not caring about. They will do HAES-White. But there needs to be a strong community of people who are making sure that this tool, for what it is worth, is available and relevant to everyone else also.
So you are clear that the term HAES should mean a social movement aimed at ending or reducing many forms of oppression and discrimination, forms that have an impact on health. That movement would be a wonderful thing to have. But why is it called HAES? Wouldn’t there be a lot more to the goals of such a movement than just health?
Wouldn’t improved health be a secondary outcome of the social changes the movement would seek to make, most of which have little to do with health or healthcare?
Maybe we should go over all HAES documents, including Linda’s book, to identify passages and practices that might privilege some and exclude others, and change them. And call the movement something else. HAES is the revolutionary concept that any body can be healthy and that all should be treated equally (which might not mean exactly the same, because bodies are different). A movement to tear down racism, sexism, heterosexism, and most of capitalism would be a wonderful thing, and would be good for health. But is it HAES?
As one white person to another, I’m afraid we are not the right ones to answer these questions. Hopefully others will join in.
Linda Bacon, PhD
Nutrition professor, researcher and co-author of Body Respect and Health at Every Size
I think this is an important discussion, and that if we don’t do a better job of integrating the personal with the political, this is the kind of stuff that can make or break our movement. I feel a bit scared for our future, and at times feel disenfranchised from some of the dominant messages I hear in the community (and I include in that a re-reading of some of my own historical work, so I take responsibility here too).
And this is a rarity — I’m so typically on the same page as you Deb, but you lost me here. You suggest that the HAES-White model works for some people, and what I’d like to suggest is that an inclusive model will work even better, not just for POC, but for White people too. I don’t think those of us who are White and/or otherwise privileged need to adopt a social justice model of health just because we’re altruistic caring people and it’s the right thing to do.
The HAES-White model doesn’t work nearly as effectively as a social justice model could for us either. Who among us has 100% privilege (meaning unearned advantages)? And what are the costs to having privilege? I’m pretty high up there on that lucky scale and even I find ways I deviate from the privileged expectations – and can trace the ways they played a role in my developing an eating disorder and other challenges with self-care – and the ways in which that privilege I have is also a burden/challenge. Integrating a social justice perspective allowed me to improve self-care and recover from my eating disorder; without it I would have been mired in self-blame and stuck for so many other reasons. I didn’t make all those steps explicit in my first book – I didn’t even understand it back then — and really regret that now.
People’s stories matter (love this phrasing, which comes from Lucy Aphramor) – and our experience as social beings in an inequitable world needs to be part of healing for ALL of us.
I do hope that people will seriously grapple with these issues. Lucy and I have written about them much more extensively in our book Body Respect. In it, we explicitly show the connections between social justice and health, and how that integration can happen in healthcare/self-care. And I like to think we did it in a very readable and engaging style.
I totally understand the significance of SDH — part of my own research and my activism focuses on one aspect of that exactly. I am also aware of the limited impact of personal behavior in the face of the effects of SDH, but I don’t believe this means that individuals cannot act to improve their circumstances.
Yes, I think we need to let people know that their health is massively influenced by the interaction of forces beyond their control, and move away from the personal responsibility argument that people get sick because of their own poor choice. However, a s I noted in my original post, I do believe, and the scientific evidence supports, that within one’s current situation, individual choices are an individual’s best shot at maximizing their outcomes.
I think one of the greatest gifts that HAES has given to so many people is returning their agency, with a concomitant massive increase in well-being. This in turn then often raises awareness of issues of social justice and many people move from that point into activism.I do not believe many of us disagree on the existence of or need to address structural inequalities, or the impact of these on individual and population health. Where there seem to be differences are in what we consider the appropriate FOCUS of HAES. I believe that this should be led by the name itself — Health, Size.
The “more restricted” (if you will) conceptualization of HAES as a non-weight-focused approach to health is simple and can be sold to the people who need to buy it in order to make a difference to the immediate care of millions of individuals. I believe that saying HAES is not HAES unless we address every single social inequality as part of it at this time risks making the message too diffuse to be immediately relevant to almost anybody, derailing ongoing efforts and possibly wiping out what has been achieved so far. By reworking the entire concept of HAES as a social movement seeking to overthrow the kyriarchy, as much as this may need doing, risks HAES disappearing almost entirely from public consciousness, sad though that may be, and make it inaccessible to all but a small group of highly-educated academics and professionals with the energy to pursue it.
I am glad to have read posts on this issue, thank you all. I’m not sure this adds anything of substance to what has already been posted and I’ve written it mainly for clarification including to acknowledge Angela’s post and respond to my mention in it.
It’s not good enough to leave someone thinking that getting “5 a day” is the best thing they can do for their health when we know health behaviors count for so little of health outcomes.
I’m not exactly sure why this is cited, but yes, absolutely. Which is not the same as saying that self-care is redundant: I have worked with many adults with difficult lives who attended the HAES course “Well Now.” I don’t know if attendance touched local figures on health inequalities or longevity, but I do know it made a huge difference to people’s well-being whether measured in HbA1C or number of Christmas cards given and received.
Putting health behaviors in perspective doesn’t mean throwing the baby out with the bathwater. In fact, I’d say that self-care makes a disproportionate difference to quality of life for disadvantaged groups, and being introduced to the bigger picture of health helps reduce self-blame, increase sense of coherence and sense of agency. I want my work to be rooted in a politics of justice, and this means using a paradigm approach that insists on context and in so doing bridges self-care and social justice. (In saying this I’m not suggesting anything about other people’s work or intent). That’s why I choose to challenge ways of thinking that erroneously conflate health and health behaviors. These reductionist ways of thinking decontextualize lives and silence marginalized voices. A partial reading of the data is also flawed in terms of ethics and scientific quality.
A growing trans-disciplinary movement called Health at Every Size (HAES) shifts the focus from weight management to health promotion. The primary intent of HAES is to support improved health behaviors for people of all sizes without using weight as a mediator; weight loss may or may not be a side effect.
This is from the article I was referring to in my earlier post. These days, I explain that the six randomized controlled trials (RCTs) we referred to as HAES are more accurately described as a wellness approach using intuitive eating/joyful movement and Size Acceptance, and not as HAES RCTs where the ASDAH definition of HAES is “grounded in social justice.” I haven’t reread the article for ages and wasn’t aware we gave this definition of HAES. Speaking for myself, we got this wrong. I think the article is really useful in many ways, but I’ll critique this too now when I refer to it in my own teaching. If I was to rewrite it I’d say something like “the primary intent is to build a society where every body (and explicitly including people of all sizes) is respected and to promote well-being for all by advancing social justice and fostering compassionate self-care.” It will also be useful to reflect on why we didn’t use a definition like this in the first place, particularly as the definition doesn’t reflect the work I was doing at the time.
Challenging size bias per se was a trigger for me to change practice because of the stories I heard as a dietitian in clinic. At the same time, researching links with oppression and health, I realized that Health at Every Size had to start with respect at every size, ethnicity, class, etc.
Generally, the health professionals I speak to have a sense that what they are doing in weight management could be improved; they’re concerned about body dissatisfaction, food preoccupation, the “obesity epidemic,” the implication of high failure rates for patients and their own jobs, and wider factors impacting health. These experiences set the scene for discussing the benefits of HAES as a paradigm shift to health-gain for all sizes etc., within which respect, self-care and equity are understood as integral to health. It’s not been difficult for health professionals to get the revolutionary potential of HAES; and a model of HAES grounded in social justice has been adopted by NHS Highland as integral to their healthy weight policy.
On a personal note, I dislike the way that any disagreement on this issue is deemed to be due to total misunderstanding of what HAES is, possibly due to only reading about it in a book (as per Lucy’s response above),
I’m not sure where this has come from. I get a daily bulletin from Show Me the Data so wrote my response before I had read Angela’s or any of the later posts, that’s why it’s addressed to Shannon. I have reread my post and can’t find anything where I mention books or devalue particular avenues of learning. The question about validity and credibility attached to different forms of knowledge (here the lay vs. academic canon) seems very pertinent to this discussion though. To me, this strongly relates to issues of who/what counts in knowledge creation in the community and very much speaks to the metanarrative of what we’re grappling with at the moment.
For the record, poetry and polemic changed the course of my professional (and personal) life. Having been taught a prescribed form of critical appraisal in formal education, I learnt to interrogate and look beyond this to the criticality that informs my practice — to unlearn to not see/feel — from reading Adrienne Rich, Audre Lorde, ecofeminism, etc. In fact, an integral part of my HAES work is to find different and creative ways to learn, listen and teach so non-scientific contributions are not trivialized as “only” art/experience/lay reading etc.
My understanding of HAES then is as a deep movement that engages with situated knowers and can accommodate the particularity and troublesome knowledge of our lives rather than something beholden to conceptual frameworks that seek universal truths and settle for the dualism of reason and emotion. (Regardless of which, outside of the HAES community, most people still come to me looking for solutions to weight management.)
A deep movement travels some distance from the presenting problem to look for solutions. The presenting problem is often struggles with eating and weight, tied up with personal, professional and political frameworks of judgement rooted in a logic of domination, leading to shame and disconnect. I want to initiate narratives of compassion, criticality and connectedness to foster healing from shame and disconnect, a relational stance which, to my understanding, impacts individual and collective wellbeing.
I am at a loss to grasp how it can be anything other than this (i.e., a social movement), according to the ASDAH definition and notwithstanding points highlighted about health and size in the name.
Having said this, I clearly hear that others, also dedicated to justice and well-being, disagree with me, may see my position as a misunderstanding and/or believe that it is well meant but misguided and even counterproductive with regard to timeliness and effectiveness of message and potential outcomes.
Lucy, maybe it would help to give an example of how you use the social justice framework with a client who comes to you for weight management. What do you do? How does it help? Has it been your experience that learning about the health effects of disempowerment or discrimination or poverty helps people be healthier or happier?
Because in my experience, it often doesn’t work that way. Even if they are helped to cut down on self-blame, people wind up feeling more helpless than they were before. I’ve had people with diabetes tell me, “I’ve already got this terrible disease, and now you’re telling me society is out to get me. What chance do I have?” If you have found good ways to integrate social justice with health on an individual level, that would be great information for HAES and many other social movements and health workers to have.
I think your question is best addressed in more detail than I could do in a listserv post. Addressing this question was part of our intent in writing Body Respect. While the whole book is peppered with this info, the last chapter (“Building Body Respect: The Professional Journey”) describes an interaction between a nurse and a client who comes in for diabetes treatment and how it looks different between the two paradigms, noting that “The [HAES] model spans and dovetails the concerns of both self-care and social justice.” The opening paragraph: “For everyone looking to incorporate Body Respect into clinical or social care, let’s return to where we started — contrasting the health impact of personal behaviors like nutrition and lifestyle habits — through the old and new paradigms, Weight Focus and HAES. Consider a hypothetical patient, Janet, newly diagnosed with diabetes.”
Angela – Forgot to mention this earlier, but I remember that one of your concerns was how to frame the incorporation of the social determinants of health in a way that’s palatable and understandable. Know that there’s a long history of people doing this. The Robert Wood Johnson Foundation came out with a good analysis of what works, and made a “messaging guide,” suggestions for framing here.
It does seems that learning about the impact of circumstance and context on health behavior and outcomes has been helpful to people. Here’s an extract from an article I’ve got under review that sums it up: someone described having an “aha moment” when they were able to make the link between life experiences and poor health (supported by Laura McKibbin’s Food for Thought Pyramid, 2009), circumstances that did not make sense to them within the narrower reductionist lifestyle paradigm they had erstwhile been exposed to.
My experience has been that putting things in context helps people towards a sense of coherence. This might be as simple as saying there’s more to heart disease than diet and activity, to explaining about lifeworld. In practice, the fuller discussions would typically take place in group setting. Certainly there is always the risk of overwhelm, and this is also a very immediate fear for us as practitioners as we come to terms with the limits of lifestyle change and what this means for our own practice too. I find talking about SDH has similarities to helping people manage a whole mix of difficult feelings when first they learn that yo-yo dieting can have health implications. I wonder if it’s the fact we’re working in a philosophy that encourages acceptance/mindfulness which helps people feel they have some choice in their response to reality and that this is significant in moving from despair to resilience. We could also tie the process in to consciousness raising as in other social movements that link the personal and the political.
Linda pointed to a story in Body Respect comparing a consultation with a HAES and non-HAES professional, and there’s a second one in the conclusion that follows “Josie’s” journey and speaks to similar themes.
Filed under: Uncategorized
Trigger warning: This post touches on issues of health and wellness, weight loss and eating disorders.
Perhaps you aren’t aware, but there’s a seismic shift happening within the Health at Every Size® (HAES) community. It all started with the book Body Respect by Lucy Aphramor and Linda Bacon.
As most of you know, Bacon wrote the groundbreaking book Health at Every Size, which tackled the way in which personal health behaviors can have a profoundly positive effect on metabolic health even if weight loss is not a consequence of those behaviors.
Bacon’s book was a seismic shift in itself, directly challenging the orthodox view that weight loss is the end all, be all goal for overall health and well-being. When I began blogging back in 2009, my goal was to explore the science of HAES and to find out for myself whether weight loss was necessary for health. I’m pretty sure you all know where I stand now.
The seismic shift caused by Body Respect adds a depth of understanding to HAES that had previously been lacking. Namely, that the social determinants of health (SDH) have a broad-ranging effect on the health choices of both the privileged and unprivileged classes of every culture.
If you’re White, middle class, cis, heterosexual, able-bodied and male, then odds are in your favor that you’ll have better access to healthcare, quality education, a variety of nutrition and exercise options, economic security and overall stability than someone who is a PoC, poor, transgender, homosexual, physically or mentally disabled, and/or female.
There is broad global agreement (starting with the World Health Organization) that the SDH affects health across the spectrum and has an enormous impact on the health and well-being of everyone, but a particularly nasty impact on marginalized communities. The stress of economic insecurity alone has been indicted as a primary driver of poor health.
In my review of Body Respect, I praised Aphramor and Bacon for incorporating the SDH into HAES as long overdue. I strongly believe that socioeconomic inequality is the biggest issue of our generation, and HAES can play a pivotal role in drawing attention to and addressing the SDH.
But in that review I raised some questions as to where this new focus on the SDH leaves the promotion of individual health behaviors. As the authors said in Body Respect, “Health behaviors account for less than a quarter of the differences in health outcomes between groups.” If that’s the case, then how should we frame personal behaviors within HAES? Does this signal a decreased emphasis on the health effects of diet and exercise? And if the SDH is the number one issue for HAES, then how can we, as HAES activists, fight against their toxic effects?
These are some of the questions I planned to ask Lucy Aphramor in my interview that she cancelled. So my first stop on my search for answers was the Association for Size Diversity and Health (ASDAH) blog, where Fall Ferguson wrote this post on health inequities. So I posted this comment and got no response.
After some consideration, I decided that maybe I could put together a panel of HAES experts to discuss the SDH. At first, I approached six HAES experts and arranged a sort of weekly email roundtable. But due to conflicting schedules and the impending holidays, it fell apart shortly after it began.
Still hungry for answers, I approached the Show Me the Data group, a private email list which includes most of the prominent HAES experts we know and love. I sent a message to everyone explaining the roundtable and how I would like to ask six questions and publish their answers here. Finally, I got a response and I was able to begin.
The First Three
The questions I chose were complicated, there’s no doubt. Asking “What do we do about the SDH?” is like asking “What do we do about that meteor heading for Earth?” We might have some suggestions, but the scope of the problem is so broad, so enormous, so all-encompassing that any answer will be, by definition, inadequate.
The SDH is woven into our systems, our culture, our heritage, where we equate success with hard work and poverty with laziness. And interweaving those economic issues are issues of racism, sexism, homophobia, transphobia, ableism and the inherent bias directed at marginalized groups. So, I came to the table knowing that we weren’t going to resolve the issue on a listserv.
However, I am optimistic that if we organize our thoughts, our knowledge, our understanding, perhaps we can construct a framework for advocacy so that we, as HAES advocates, can all push in the same direction. For example, a small, but (relatively) simple proposal that could have a net positive impact on millions of Americans is to raise the minimum wage. Hell, if I were King, I’d push for a living wage pegged to inflation. As they say, a rising tide lifts all boats.
If ASDAH and HAES advocates were to rally behind this economic issue, we could join the countless other social movements pushing for economic justice.
And so, it is with all of this context in mind that I asked my first three questions. I hope that this dialogue will provide insight into how HAES can play an effective role in addressing the SDH.
Question 1: If HAES is focusing more on the social determinants of health, what can individuals do to either reduce, mitigate or counteract the effects of the social determinants of health? What can/should we expect from the future of HAES advocacy in terms of addressing the root causes of the SDH (e.g., economic inequality, social injustice, institutionalized discrimination)?
David Spero, R.N.
A registered nurse with 35 years experience focusing on diabetes and the SDH
This is a very difficult question — what can individuals do about social causes of illness? It’s why my diabetes book was never popular with people with diabetes — learning about the social causes only made people feel more disempowered than they already felt. I usually suggest:
- Use knowledge of the pathways from economic and social inequalities to illness to stop blaming yourself.
- Be more open with others in your community about SDH to provide mutual support.
- Use knowledge of the health effects of oppression to make plans to reduce those effects in the limited, but still useful ways, that are available to you (e.g., relaxation, exercise, social support).
- If willing and able, get involved in trying to change some of the SDH that are affecting your community directly, which could be stigma, environmental pollution, poverty, lack of access to care or to food, etc. … there are a lot of them. The act of fighting back reduces the feeling of hopelessness, which is a major stressor, maybe the worst. Remember that stress is the number one way that oppression damages health in most cases.
Hope this helps. I am in no way saying that these are the only measures or the best measures. They are just the ones I know and use. People seem to like the sound of them, but I have no data on people putting them into practice.
Laurie Klipfel, MSN, RN, BC-ANP,WCC,CDE
Nurse Practitioner and Diabetes Educator
Well said David. I also am not sure we have the power to change socioeconomic status, but we can stop placing blame that only adds to the oppression and makes the effect much worse.
Lisa Du Breuil, LICSW
Clinical Social Worker who treats people dealing with addictions, eating disorders and problems post-weight-loss surgery at an outpatient psychiatry clinic in Boston
I really like David’s response to your question, Shannon.
In addition: Right now when I think of what HAES-oriented people can do to address root causes of the SDH, I think of working to get different voices heard by the people who currently have power in our health care system. I think about helping people actually see the systemic discrimination — what people used to call (still call?) “raising consciousness” — happening around these issues.
Question 2: How does one look at the effects of the social determinants of health, and the enormity of the institutions that ensure its ongoing existence, and not succumb to feelings of futility and immutable fate regarding one’s health and wellness?
Shannon, you are asking the questions that politically-minded public health people have been wondering for years. A health approach to oppression, inequality, and environmental degradation gives the same picture that a social or political approach gives — the same problems and the same alignment of forces on different sides. If the 0.1% remain unwilling to share and willing to use all their power to maintain and exacerbate the status quo, it will be very hard to change conditions. Appealing to their sense of fairness or compassion sounds like a total waste of time to me. They don’t have such concepts about us.
So, to change SDH in a positive direction would require a very strong class-based movement, like in the US in the 30s or 60s, and in Europe until recently. On an individual, community, and family basis, we pull together to take the best care of ourselves and of each other that we can, we fight on issues where we have a chance, and we don’t give up. Beyond that, I don’t know.
Your questions aren’t new Shannon. Many activists have written books about how to keep strong in the face of the powers we are up against. Check out Joanna Macy for one, or Nelson Mandela.
Deb Burgard, PhD
Eating Disorder Psychologist and Past President of ASDAH
I guess I fall back on the skills that I use in the face of almost anything that seems overwhelming to me: I think, OK, this isn’t going to get fixed right away, but what can I do today to chip away at it? What can I do every day to chip away at it? How do I think about this so that I integrate it into my life as a part of my daily self-care? Care of the world = self care.
Practically speaking, I start with the low-hanging fruit and then build from there. What is right in front of me to do? Just start. And then just repeat. And then, just return (after I — inevitably — get interrupted).
Part of the problem is the dealing with the confusion about what is enough to do. It will never be enough, so how do we figure out whether doing anything is worth it? How do we figure out how much is worth doing?
I guess I am proposing Intuitive Activism — that there is something that is possible and worth it, and we need to free ourselves up to do it, and manage the sense of overwhelm/guilt/despair that lurks constantly over our efforts.
I think people underestimate the power of small, consistent, irritations on the status quo. I may not be able to change it all in my lifetime but that doesn’t mean I can’t use the opportunities that I have for being an obstacle to the Death Machine. If everyone did that there would probably be enough lack of cooperation that many of these big forces would lose at least some of their momentum. And because the big forces come down to money, if it becomes too expensive to fuel the big forces, then they stop getting fed.
The other thing that really helps me is to understand that the world I inherited was made better by those kinds of efforts that people before me made. I feel like I am part of a long chain, a long tradition that is the best human company there is. I want to be part of it. So I don’t want to do nothing, because I want those efforts that other people made to come to some fruition eventually. It is not just numbers of people who get momentum going, it is persistence over time and generations, and that is something that we do through institutions, traditions, oral history, activism. We are a team, it is my turn with the ball.
Jon Robison, PhD, MS
Researcher, assistant professor at Michigan State University and co-editor of the Health at Every Size journal
Love the sentiment — and for me it is always about the music — chippin’ away.
Beautiful, Deb. It’s harder for me to maintain belief in the long-term when the long-term seems to be disappearing, but as long as we can hope for a future, I guess, we can keep trying to make it better.
Yes, David, many times before humans have had to face the worry that they will not be here much longer, even in my lifetime. I think our work is directly impacting the available energy for people to face those pressing and urgent problems and stop frittering away time and energy on fruitless weight loss projects.
I heard somewhere that pilots learn and practice to keep flying the plane no matter how close to crashing they are (I guess as long as they don’t have the option to parachute out!). I can see that being quite useful since you never know for sure.
Beautifully said Deb. Even after you are long dead, your chipping lives on. You really have no idea what your impact will be, or how big the small changes will grow. Watching It’s a Wonderful Life shows how little impacts can make a big difference.
Psychotherapist with a focus on eating disorders
I am so grateful for this discussion — thank you everyone! I am totally in love with the idea of “intuitive activism”!
One of my favorite authors is Margaret (Meg) Wheatley. One of her most recent books, So Far From Home, was a tough but important read for me because she takes on this issue of “feeling exhausted, overwhelmed, and sometimes despairing even as you paradoxically experience moments of joy, belonging, and greater resolve to do your work.”
This is the text of one of her posters, made from the book, and I was reminded of it while catching up on these wonderful emails!
A Path for Warriors
We are grateful to discover our right work and happy to be engaged in it.
We embody values and practices that offer us meaningful lives now.
We let go of needing to impact the future.
We refrain from adding to the aggression, fear and confusion of this time.
We welcome every opportunity to practice our skills of compassion and insight, even very challenging ones.
We resist seeking the illusory comfort of certainty and stability.
We delight when our work achieves good results yet let go of needing others to adopt our successes.
We know that all problems have complex causes.
We do not place blame on any one person or cause, including ourselves and colleagues.
We are vigilant with our relationships, mindful to counteract the polarizing dynamics of this time.
Our actions embody our confidence that humans can get through anything as long as we’re together.
We stay present to the world as it is with open minds and hearts, knowing this nourishes our gentleness, decency and bravery.
We care for ourselves as tenderly as we care for others, taking time for rest, reflection and renewal.
We are richly blessed with moments of delight, humor, grace and joy. We are grateful for these.
Question 3: How has HAES been supportive of and successful for marginalized communities? How has HAES fallen short? What are some specific ways in which we can support and reach out to those most affected by the social determinants of health?
I received no response to this question.
Tomorrow, I shall post the second part of this roundtable, which is a single question that got an overwhelming amount of response. Many thanks to all the HAES experts who participated.
Filed under: DT, ED, EX, FH, FP, FS, Weighty Wednesday, WL, WLS