Fierce Freethinking Fatties

I get so tired of ranting about how I’m treated at the doctor’s office, or how scared I am whenever I meet a new doctor.

So, today, I’ll rant about how my husband was recently treated at the doctor’s office.

A week ago, Conall had a … well, we’re not sure. He had symptoms of a heart attack: extreme chest pain, shoulder pain, shortness of breath. I took him to the urgent care that is right across the street from our apartment. They were great, took care of him as best they could, then had him transferred to the emergency room via ambulance.

They ran all sorts of tests on him and determined that he didn’t have, and wasn’t having, a heart attack, so they released him with instructions to follow up with a primary care physician. They didn’t do anything for his pain, but that’s a different issue. The pain went away on it’s own by Saturday.

So, of course, on Sunday he decided to participate in archery for two hours. Of course.

But I digress.

On Monday, he had an appointment with a new doctor. As much as I didn’t want to have him see a new doctor for whatever this is, he needed a “you may return to work” note, and he hasn’t been to a doctor for three years. This was a doctor that was a “preferred provider” from our insurance. Maybe that should have warned me. She was able to get him in fast though, and so I made the appointment.

When we arrived at the office, we weren’t in the waiting room five minutes when we were called into the office. We didn’t even have a chance to finish all the paperwork. The nurse came into the examination room and asked all the usual questions, including questions like “how active are you?”

Now, I’ve written previously about the “health initiative” his work is engaged in. We know for a fact that Conall walks 35 miles a week because he wears a pedometer, and some weeks he walks even more than that. That’s only the walking part of his job. He also does a lot of lifting, pulling and pushing heavy items, bending, stretching, and so on. In fact, he has a very active job.

Besides that, he is active in his hobbies. I mentioned the archery he did on Sunday because he wasn’t hurting any longer. He shoots both cross bow and long bow (the cross bow has a 75 pound pull, which means it takes 75 pounds to pull the string to full extension, cock the bow and put the arrow in; the long bow has a 35 pound pull). For about two and a half hours, he shot arrows on a range that had staggered targets from twenty yards to forty yards. After he shot six arrows, he’d walk down to the target to retrieve them and do it again.

He also fences regularly. Every Thursday night that he’s not working, he fences for three or more hours.

So, he’s very active.

Oh, did I mention he’s fat? Y’all kind of guessed that, right?

Up until last year, he was “only” overweight (at a BMI of 29). But then, he broke his knee at work near the beginning of the year, and our karate dojo imploded. The lack of activity for three months from not being allowed to work or doing any of his hobbies, as well as not being able to get back into karate since then has meant he has really packed on the pounds — all 20 of them.

Those 20 pounds were enough to bring his BMI up three points and put him into “OMG YOU’RE GOING TO DIE TOMORROW!” range.

The doctor came in and, right off the bat, told him that he was “obese,” and needed to lose weight, first and foremost. If he didn’t, dire things would happen, like more events that put him into the ER last Thursday. Then she started talking about the tests that were done on him at the urgent care and hospital. Everything looked okay, except his blood sugar — but she wasn’t too concerned about that, because he had an IV in, and that could cause a false high reading.

His “high reading”? 109 for a NON-fasting test. He’d had milk, a protein shake, and some raisin bran in the four hours preceding the test. According to ABC News, the normal range for a non-fasting blood sugar test is between 100 and 130. But this doctor wasn’t too concerned about how “high” his result was because having an IV is known to mess with the values.

The only reason I didn’t say anything to her was because we needed that all-important piece of paper saying he could go back to work.

And Conall, even though he has read the studies about losing weight, heard my commentary on the UCLA meta-analysis of diets (and how they don’t work for anybody), and even sent me links to studies that were either completely ludicrous (study shows you can catch obesity from your fat friends!) or showed how the obesity epipanic is so overblown …

Even after all that, he told the doctor, “Yes. You’re right and I’ll work harder to lose weight.”

Up until then, losing weight had NEVER been a priority for him. He knew he was healthy because of normal blood pressure, normal readings on all tests (granted, that was three years ago), not eating much fast food or restaurant food, and living a very active life. But now, because this doctor told him to lose weight, it became a priority.

I had to bite my tongue to keep from telling her off. When we got out of the office, I went off about her. She either didn’t read the notes the nurse took about how active his life was, or she took one look at him (and even though he’s tall, big boned, and has a LOT of muscle, he also has some fat on him) and decided he was lying. Either way, she made a decision about his health — that he was in her office after a very terrifying and painful episode that we still don’t know the cause of — because he is fat.

At the end of the visit, she gave him a paper that stated his next steps (as well as the work release). The paper told him that because a heart incident hasn’t been completely ruled out, he needs to not exercise or do anything strenuous until after he gets a stress test. The very next bullet point pointed out that he has a BMI of 32 and therefore needs to change his eating habits, increase his exercise, and lose weight.

Did I mention she never asked what his eating habits are?

This is the first time Conall’s been diagnosed “fat.” Because of his height and muscles, and because his BMI has never officially been “OMG YOU’RE GOING TO DIE!” he’s been able to bypass that part of an examination. At the most, a doctor would tell him, “You might want to think about losing weight at some point, or at least not gaining any more.” But he was never told “if you don’t lose weight you will die.”

It took him a day and a half before common sense kicked in. Until he realized that she just treated him like I’ve usually been treated. Until he realized that he was allowing her to do the same things to him that he’s seen me do to myself after doctor’s visits (before I found Size Acceptance/Fat Acceptance and Health at Every Size^®). I also helped by making fun of all the stupid things she said (the “high” blood sugar level, the “don’t exercise, but eat better and increase activity so you lose weight”). At one point, I also said, “If you are going to die tomorrow because your BMI is 32, then at BMI 44 (close enough, I’ve not been weighed in forever but all my clothes fit the same) I should have died yesterday! Oh, wait! I probably am already dead, my body just hasn’t figured out it’s supposed to lay down yet!”

And he agrees with me. We’re only staying with this doctor until the results of the stress test come back. Once that happens — whatever the results are of it — we will be finding a new doctor for him who won’t fat shame him, who won’t diagnose him as fat and tell him all his issues will be fixed if he just eats better and exercises more so he’ll lose weight.

Humans like simple, categorized things, even when they say they don’t. That’s just their biology at play, since that is how their brains work. Sure, you can actively work against it, but realize that it happens regardless.

What the hell am I talking about? Well, oversimplification silly! Rarely are there cut and dried answers in this life, with the majority typically falling within some state of gray.

A great example of pigeon-holing is saying all fat people are lazy and if they would just get off their gluteus maximus and exercise for a change, we would all be thin or at least thinner than we are now. Another great example is when a politician says if we just do X, then the economy/country will be better. Just like the biology of a fat person isn’t a “calories in, calories out” machine, so too is a nation not a “one fix will solve all our problems” experiment.

But I still seem to see the same kind of one-size-fixes-all solutions for both. “Our country would be so much better off if we would just…” should be just as much of a trigger phrase as “You would be so much better off if you would just…” Our nations are like a hive of bees that collectively support each other in various endeavors and have the ability to accomplish great feats when put to the task. Our nations are a compilation of millions of individuals, each with different a culture, religion, viewpoint, opinion, and background. But I digress.

Let me count the ways on how exactly things work in the body and WHY it is so complicated. Our bodies are an amazing piece of machinery designed for survival on this planet. Because of this, we have thrived for hundreds of thousands of years. Every single one of you reading this is the byproduct of evolution, of our ancestors fighting for survival coupled with successful breeding. As a result, our body is an incredibly delicate specimen and very much a perfectionist. You wouldn’t believe me if I told you that reproducing is extremely difficult biology-wise. Everything has to go a specific way or else the body will reject the cells and shed the uterine lining.

Like other tissue in the body, adipose tissue has different, but important roles. Nothing in the body has just one role; even the heart that pumps your blood also has secondary roles, like producing hormones for certain things (when you have a heart attack, doctors check for these hormones of distress which leave you with the sense that something is wrong). As far as adipose tissue goes:

“In humans, adipose tissue is located beneath the skin (subcutaneous fat), around internal organs (visceral fat), in bone marrow (yellow bone marrow) and in breast tissue. Adipose tissue is found in specific locations, which are referred to as adipose depots. Apart from adipocytes, which comprise the highest percentage of cells within adipose tissue, other cell types are present collectively termed stromal vascular fraction (SVF) of cells. SVF includes preadipocytes, fibroblasts, adipose tissue macrophages, and endothelial cells. Adipose tissue contains many small blood vessels. In the integumentary system, which includes the skin, it accumulates in the deepest level, the subcutaneous layer, providing insulation from heat and cold. Around organs, it provides protective padding. However, its main function is to be a reserve of lipids, which can be burned to meet the energy needs of the body and to protect it from excess glucose by storing triglycerides produced by the liver from sugars, although some evidence suggests that most lipids synthesized from carbohydrates occurs in the adipose tissue itself. Adipose depots in different parts of the body have different biochemical profiles. Under normal conditions, it provides feedback for hunger and diet to the brain. …

Free fatty acids are liberated from lipoproteins by lipoprotein lipase (LPL) and enter the adipocyte, where they are reassembled into triglycerides by esterifying it onto glycerol. Human fat tissue contains about 87% lipids. There is a constant flux of FFA (Free Fatty Acids) entering and leaving adipose tissue. The net direction of this flux is controlled by insulin and leptin — if insulin is elevated there is a net inward flux of FFA and only when insulin is low can FFA leave adipose tissue. Insulin secretion is stimulated by high blood sugar which results from consuming carbohydrates. In humans, lipolysis (hydrolysis of triglycerides into free fatty acids) is controlled through the balanced control of lipolytic B-adrenergic receptors and a2A-adrenergic receptor-mediated antilipolysis.” [Emphasis mine]

Adipose tissue is more than just fat reserves and plays an important role in “intuitive eating.” And if that last paragraph didn’t astound you into thanking your body, you should go back and look closely at those terms. Basically, your body takes one form of substance, disassembles it, takes some parts and reassembles it into something totally different and with an amazing amount of energy. Every one of those triglycerides that are produced can be cleaved for energy equaling about 1,134 calories (or 1,134,000 “physics” calories). Plus, the body is incredibly efficient with these stores of energy.

I think it was posted somewhere, but if we used gas instead of food, our bodies would get roughly 1,300 mpg on a bicycle. Holy crap.

And I am sure you have seen the video of Dr. Friedman about how the body is 99.6% efficient in calibrating its energy balance. No other human-made machine is that efficient.

If you are interested in the exact breakdown of all the biological things your body can do, I recommend buying or renting Campbell’s Biology, 9th edition. It not only thoroughly dissects every possible biological system including cells and chemical pathways, but it gives all this information in a fascinating manner.

The following are studies referenced or useful to the discussion we are having tonight on Huffington Post about physician shaming.

Barriers to routine gynecological cancer screening for White and African-American obese women

Physician Respect for Patients with Obesity

40 physicians and 238 patients

Negative bias towards persons with obesity has been well documented in health-care providers, including physicians, for the last 40 years. In a survey of physicians, obesity was identified as a characteristic that elicited negative feelings, and other studies have found that physicians associate negative terms, such as ignorant, lazy and incompetent, with obesity. In addition, physicians have reported ambivalence towards the treatment of obesity. However, none of these studies have documented physician attitudes towards specific patients with obesity. Several studies have documented health-care avoidance in patients with obesity, and in some studies, participants cited individual and institutional biases as the reason for avoidance. There is also evidence that obesity is associated with decreased preventive services, especially cancer screenings.

The primary outcome was physician-reported respect. Physicians were asked to rank their level of respect for the patient on a 5-point Likert scale after the patient visit.

A ten-unit higher BMI was associated with a 14% higher prevalence of low physician respect.

We found that higher patient BMI was associated with lower physician respect. Further research is needed to understand if lower physician respect for patients with higher BMI adversely affects the quality of care.

Exploring the association between body weight, stigma of obesity, and health care avoidance. (PDF)

The findings show an increase in BMI is associated with an increase in the delay/avoidance of health care. Weight-related reasons for delaying/avoiding health care included having “gained weight since last health care visit,” not wanting to “get weighted on the provider’s scale,” and knowing they would be told to “lose weight.”

Approximately 34% (n=25) of the obese women (n=73) were shown to delay/avoid health care “ever” due to “weight gain since the last health care visit” (Table 3). Of the obese respondents, 26% (n=19) had delayed/avoided health care due to “not wanting to be weighed on the provider’s scale”. Being “told to lose weight” was a deterring factor to utilizing health care for almost one-third (n=22) of the obese subjects. Among the morbidly obese (BMI > 40; n=11) more than one-fourth of the respondents (n=3) reported that “undressing in the provider’s office” was a reason to delay/avoid seeking health care. More than 60% (n=7) of the morbidly obese cited being “told to lose weight” as a deterrent to seeking medical care.

Studies have shown that health care providers will readily attribute many physical maladies to a client’s obesity and perform limited examinations (Young & Powell, 1985; Packer, 1990). Obesity does not preclude the need for a careful and thorough health history and physical examination. It should not be assumed that an obese person’s pathology is due to excessive adiposity.

Overweight women delay medical care.

All female nurses, nursing assistants, health unit coordinators, and general psychiatric assistants who were employed full- or part-time at the community hospital in July 1992. We received 310 (76%) responses from 409 potential respondents.

Overall, 12.7% of respondents reported delaying or canceling a physician appointment because of weight concerns. Another 2.6% kept their appointments but refused to be weighed. Only body mass index was significantly associated with appointment cancellation. The odds ratio of an obese woman (body mass index in excess of 27) delaying medical care was 3.885 (95% confidence interval, 1.509 to 10.274).

Barriers to routine gynecological cancer screening for White and African-American obese women.

Women with BMI > 55 kg/m(2) had a significantly lower rate (68%) of Papanicolaou (Pap) tests compared to others (86%). The lower screening rate was not a result of lack of available health care since more than 90% of the women had health insurance. Women report that barriers related to their weight contribute to delay of health care. These barriers include disrespectful treatment, embarrassment at being weighed, negative attitudes of providers, unsolicited advice to lose weight, and medical equipment that was too small to be functional. The percentage of women who reported these barriers increased as the women’s BMI increased. Women who delay were significantly less likely to have timely pelvic examinations, Pap tests, and mammograms than the comparison group, even though they reported that they were ‘moderately’ or ‘very concerned’ about cancer symptoms. The women who delay care were also more likely to have been on weight-loss programs five or more times

Women with BMI over 55 were less likely to have pap smears, breast exams and mammograms.

Approximately 16% of respondents included specific examples of barriers or listed additional barriers for the ‘other (please specify)’ option of this question. Examples of disrespectful treatment included disparaging comments by providers or office staff, as well as women’s perceptions that their treatment was influenced by their weight, for example, women asked ‘Would you treat me this way if I were thin?’ Women cited examples of health screenings and treatments that were not provided because the women were told they were too large, ‘my doctor told me he was unable to perform a Pap smear on me because of my size’ or that their health concerns were attributed to being overweight, ‘doctors blame all my symptoms on my obesity’. Embarrassment about being weighed was made worse if the woman was weighed in a public place in view of other patients and staff. Some women questioned whether routine weighing was necessary for treatment of routine medical needs. Women commented on the irony of health care providers who were themselves obese giving weight-loss lectures. Women did not appreciate unsolicited advice to have gastric surgery or what they perceived as scare tactics. Medical equipment that was noted to be too small to be functional included blood pressure cuffs, scales, examination tables, examination rooms that could not accommodate a friend or helper, hospital gowns that did not fit, and waiting rooms with only small chairs with arms.

Physicians’ attitudes about obesity and their associations with competency and specialty: A cross-sectional study

400 physicians

More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm.

In one study, physicians rated obesity treatment as less effective than therapies for 9 out of 10 chronic conditions, and only 14% agreed that they were usually successful in helping obese patients lose weight. In another study, 31% of internal medicine residents believed that treating obesity is futile and only 44% felt qualified to treat obese patients.

Most obese patients could reach a normal weight (for height) if motivated (38% agree, 61% disagree)

Obesity is primarily caused by behavioral factors (33% agree, 67% disagree)

Obesity is a treatable condition (92% agree, 8% disagree)

Discussing Weight with Obese Primary Care Patients: Physician and Patient Perceptions

Long-term weight loss maintenance in the United States

When the Doctor Is Overweight

Dr. George Fielding, a pioneer of weight loss surgery in Australia, remembers how patients treated him in the late 1990s, when his weight reached 330 pounds on his six-foot frame. He would meet new patients, dressed in Armani suits and feeling on top of the world, and then be abruptly upended.

Despite being an internationally recognized expert on lap band and gastric bypass surgeries, Dr. Fielding knew that his appearance was dissuading some patients from using his services. And years of yo-yo dieting and extreme exercise hadn’t helped him keep the weight off.

overweight doctors are seen as less credible than “normal weight” doctors, and patients are less likely to follow their medical advice, the study found.

Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006.

The prevalence of weight/height discrimination increased from 7% in 1995-1996 to 12% in 2004-2006, affecting all population groups but the elderly. This growth is unlikely to be explained by changes in obesity rates.

Bias, discrimination, and obesity.

24% of nurses said that they are “repulsed” by obese persons;

The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice

[R]espondents report more mistrust of physicians who are overweight or obese, are less inclined to follow their medical advice and are more likely to change providers if their physician appeared overweight or obese, compared to normal-weight physicians who elicit more favorable opinions from respondents. These biases remained present regardless of participants’ own body weight, and were more pronounced among individuals who demonstrated stronger weight bias toward obese persons in general.

Yale Rudd List of studies (PDF)

Weight Stigma Among Providers Decreases the Quality of Care Received by obese Patients (PDF)

Two very different types of women have dominated my life.

One faction was the warm, matriarchal housewife type who loved to cook, eat and enjoyed providing nourishment and a loving home for others.

The flip side of that coin was the set who made sure to dole out the icy, but subtle, disapproving glares that let you know you just weren’t cutting it on a number of fronts.

Your hair was a mess, your clothes were too wrinkled to go out in public, your face (devoid of makeup) shouldn’t be viewed by strangers. Were you even wearing clean underwear?

I bounced between these polar opposites while growing up, and I’m happy to report that they had at least one thing in common; they were all mothers.

No, not motherfuckers. Somebody’s mother.

I’d be a millionaire if I had a dime for every strange, passive aggressive story retold around a campfire about how someone’s domineering mother looked disapprovingly at the cannoli they were about to shove into their mouth and blurted out “You’re going to eat that, huh?” Of course, the daughter would retort “Yes, I’m going to eat this freaking cannoli, why?” And, of course, this would be met with a wounded look of surprise and the clever reversal, “Well, I’m just thinking some fruit would be healthier is all.”

[Shoves entire cannoli into mouth all in one shot. Drools the excess onto the floor. Swallows. Drops mic]

The dynamic between mothers and daughters has been an ever-present struggle throughout the ages. While some spend a lifetime preparing to disengage from their mothers, others want to stay close to a woman who, while sometimes their most vicious critic, can also be their most stalwart champion.

It’s a complicated mix.

While growing up, my adolescence was met with mixed signals.

Be your own person, but be mindful of how you act. Take into consideration what others think of you.

Eat healthy, but don’t overeat. Being heavy is a sign of weakness.

Run free in the woods for hours, play sports, sweat all you want, but don’t forget your feminine side. Boys don’t want girls who are too butch.

Make sure you can be of service to others, but don’t be a pushover. Make sure you know the difference.

My mother, is naturally passive aggressive about things like my cooking, cleaning and life skills, but she’s never bothered to hound me too much about my weight. Perhaps it’s because that was something I kept concerned about on my own. But I’ve seen the worry and fear in the eyes of the parents of my kids’ friends when they see their child return from the corner store with a bag of Doritos and two Cokes.

I’ve tried not to become one of those mothers who send all three of their kids into lifelong therapy for parental wrongs so heinous that a Lifetime movie could easily be based on them… but I fear I’m failing. I still criticize, want things for them they don’t want for themselves, and generally have a difficult time with letting go of the control that was only an illusion anyway.

And if all this philosophical rambling and soul searching doesn’t help, I’ve got tickets for eight days in Disney World that might help erase some of the damage!

Please Note: “And Now for Something Completely Different” is a new theme that will be dedicated to posts that are not directly related to fat. Until I develop a forum for posts like this, I’m going to use this forum to get things off my chest. These will not replace the fresh daily posts on fat subjects.

Dying is easy. Comedy is hard. Debating comedy is damn-near impossible.

I’ve tackled the subject of fat jokes on this blog many times, from Kathy Griffin to George Takei to Daniel Tosh, but each time I feel a bit uneasy about the entire process of critiquing comedy because it resides in such an awkward zone of free speech. Contemporary comedy (at least the hackneyed, undisciplined kind) seems to thrive on pushing the envelope and making its audience uncomfortable.

We can thank Lenny Bruce, Mort Sahl, and George Carlin (among so many others) for transitioning comedy from “Take my wife, please!” to constructive social commentary. And the best comedic commentary is the kind that simultaneously makes people squirm and think. The late Bill Hicks remains the gold standard, while Louis CK has taken up the mantle.

So when I criticize people for making fat jokes, I try to gauge intent, which is about the worst way to criticize anything since the go-to rejoinder is “that wasn’t my intent!” But I think there are cases (e.g., Griffin, Takei and Tosh) where the intent is so egregious that it’s hard to draw any other conclusion than the fact that the joke in question was of the malicious hack variety — no intelligent subtext, just cruelty and a quick laugh.

Although I would love to convince the world that malicious fat jokes are a net negative on the culture, I generally look at them as a squishy grey area that’s open to interpretation. Fat jokes can be troubling, but aren’t as harmful as some of the other shit we put up with.

I can’t say the same about rape jokes.

The controversy over rape jokes came to a head last year when Tosh made a tasteless rape joke at the expense of woman in the audience who heckled him for telling a rape joke. Depending on who you ask, Tosh either talked about how hilarious it would be if that woman was gang-raped by five guys or, as the club owner tried to put it, that it sounded like she’d been raped by five guys.

Of course, comedians jumped to his defense because comedians don’t like the idea of their comedy being restricted in any way. But some of the responses only made a stronger case against carte blanche comedy. For instance, the mind-bogglingly overrated Dane Cook tweeted, “If you journey through this life easily offended by other peoples words I think it’s best for everyone if you just kill yourself.” Meanwhile, Anthony Jeselnik, whose painfully unfunny Comedy Central debut is all about offensive bullshit, tweeted, “This Daniel Tosh rape joke controversy really has me second guessing some of my rapes.”

Those comments are par for course from Cook and Jeselnik, who have the comedic sensibilities of an 8-year-old who just learned his first swear word. Without the periodic gasps of shocked audience members, they wouldn’t have a career to speak of.

Where I was surprised was in Patton Oswalt’s response: “Wow, @danieltosh had to apologize to a self-aggrandizing, idiotic blogger. Hope I never have to do that (again).” Oswalt elaborated to Entertainment Weekly, saying “It’s very dangerous to create an atmosphere where people can’t fuck up onstage, and it costs them their life or career.”

I agree with this latter interpretation. People fuck up. People try to tell rape jokes they thought were clever or insightful or precariously provocative, but end up offending everyone in the world. One joke shouldn’t end your career, but you also shouldn’t be surprised if your career evaporates because your go-to material offends too many people. Free speech doesn’t mean zero consequences.

Fast forward to last week, when Molly Knefel wrote a piece for Salon criticizing Patton Oswalt. Knefel took offense at the fact that Oswalt had written a touching and impassioned response to the Boston Marathon bombings, yet essentially defended a comedian’s right to tell rape jokes. Oswalt’s Boston post included this spirit-raising end:

So when you spot violence, or bigotry, or intolerance or fear or just garden-variety misogyny, hatred or ignorance, just look it in the eye and think, “The good outnumber you, and we always will.”

Oswalt’s words reassured us that even though we had just witnessed an unspeakable horror, it was a blip compared to the reality of a compassionate and selfless humanity. But Knefel drew a direct comparison between Oswalt’s response to Boston and his response to Tosh:

As eloquent as Oswalt’s message about Boston was, it is not particularly challenging to side with the victims of a horrible act of violence committed against civilians. Americans are united in their desire to condemn such atrocities. Many comedians, including Oswalt, also condemned the Aurora theater shooting and made an explicit point not to joke about it. None of this is to compare these different types of violence, but to offer an observation on the types of violence that are universally condemned as opposed to culturally sanctioned. The consensus formed by the majority-male comedy population is that sexual violence is not just OK to joke about, but joke about with extraordinary frequency and viciousness, where the targets of the jokes are the victims, not the perpetrators.

On the heels of Knefel’s post, Lindy West wrote a post for Jezebel that was aimed at the general stand-up comedy culture, but sought to answer the typical justifications for rape jokes that comedians make. She also implored comedians to consider the effect that the tone and trajectory of rape jokes can have on a culture:

You can talk about controversial subjects—in fact, you should talk about controversial subjects, because comedy is an incredibly powerful subversive tool—but if you want people like me to stop bitching at you (a dream we share, I promise!), you need to stop using your comedy to make those things worse. You don’t have to make things better—you are under no obligation to save the world—but if you are actively making things worse for people, especially when you are not a member of the group whose existence you are worsening, don’t be surprised when people complain.

These two pieces covered the anti-rape joke side perfectly and there’s nothing to add to that. Then Oswalt tweeted West to tell her that he appreciated her critique (but not Knefel’s). I’ve Storified their back-and-forth because civil discourse kicks ass. But what bothered me was that West asked Oswalt to expand on his beliefs (rather than simply praising civil discourse) and his response was “Rape is absolutely wrong; speech is absolutely free.”

As defenses go, it’s pretty weak tea. Of course rape is absolutely wrong. Nobody claimed that Patton Oswalt is pro-rape. And speech is not absolutely free. If Daniel Tosh wants to, he can walk through Times Square yelling “I LOVE RAPE!” without being arrested (in theory), but he’s also going to have to deal with observers who choose to confront him and tell him that he’s an asshole. Likewise, Tosh can pack his set with rape jokes, but he still has to deal with fans who think he’s no longer funny.

I find comedians who complain about free speech for rape jokes to be just as laughable as homophobic bigots who complain that they’re labeled homophobic bigots for being homophobic bigots. Comedians and homophobic bigots can say whatever the fuck they want, whenever the fuck they want, but they still have to own the consequences.

Just as Lindy West and Molly Knepfel don’t get to censor the set lists of comedians, comedians don’t get to set the terms of what the public gets offended by. And yet, there’s Patton Oswalt talking about how “dangerous” it would be for comedians to experience actual consequences for saying horrible things, even by accident.

Free speech is a two-way street, and for either side to claim the other is being unfair is absurd. And I found it most absurd in a link Oswalt tweeted to a piece by Chez Pazienza reproaching Knefel.

[A]gain, all he did was not use his public forum in a way someone decided for him that he should. Molly Knefel wrote a piece out of the blue and drew Patton Oswalt into a mini-maelstrom over — nothing.

Pazienza goes on to state the obvious:

Here’s where I say something that shouldn’t need to be said because, as with Patton Oswalt, silence shouldn’t be interpreted as a lack of human decency, but these days you have to fill in every blank lest you be misconstrued: Rape is wrong, period. It’s a sickening and contemptible act and there’s never any excuse or justification for it. It’s also a difficult subject to even broach and if you’re going to try to use it in a way that’s darkly humorous you’d better know going into it that you’re walking on very thin ice. There’s almost nothing in this world that can’t be mined for comedy in the hands of someone who’s truly talented, but a joke involving sexual assault of any kind is the sort of thing that’s just about guaranteed to offend somebody. That said, no one gets to decide for me or anyone else what is and isn’t funny and what I or anyone else can and can’t laugh at. That’s the nature of comedy. Likewise, laughing at a well-done crack involving even a sensitive subject like rape doesn’t make somebody a troglodyte or a despicable monster out to oppress women.

The problem is that the “truly talented” is a relatively small pool of comedians and the number of “well-done cracks” is vastly outnumbered by the number of hateful, despicable, flippant jokes made by hack comics who troll for gasps at how funny it is get sexually assaulted. As West wrote previously, funny rape jokes can be done, but it’s not easy.

The difference, Pazienza asserts, is whether the comedian in question exhibits proper deference to feminists, as he claims Louis CK does:

It’s well-established that Louie is beloved by the people who traditionally raise hell over the use of rape jokes; he’s both the go-to defense for those who make audacious jokes that fall flat and the example used by the perpetually offended of how to do a joke “right,” because, yes, he’s just that good. It’s fair to say that not everyone can walk the kind of comedic tightrope Louie does, but it’s also obvious that Louie’s given a hell of a lot of leeway by the Molly Knefels and Lindy Wests of the world because a lot of his jokes defer to the feminist model embraced by them. While he’s hilarious, Louie does openly genuflect before the god of indignant feminism by doing bits like the one in which he says that men are the biggest threat on Earth to women; that’s music to the ears of the Jezebel staff, proof of him “getting it” simply by seeing things their way.

Really, Chad? When Tosh laughed about how funny it would be if five men raped that woman, the real problem was those darned feminists? Who’s your mentor, Rush Limbaugh?

This isn’t about a “feminist model” for comedy, it’s about basic human decency. And the perspective you should consider is not that of the feminist, but of the victims of rape.

Here’s what I want to ask Patton Oswalt, Chad Pazienza, or any other comedian concerned about their First Amendment rights: you wouldn’t go to Boston and make hilarious bombing jokes, would you? You wouldn’t try out your new “pressure cooker” jokes if you knew one of the bombing victims was in the audience, would you? Of course not, that would be cruel. You would restrict yourself voluntarily (I would hope) because you know the subject would do harm to the victim.

And yet, in any given comedy audience, the victims of rape are there. One in five women have been sexually assaulted. Rape is frighteningly common and rape jokes are a sharp stick in the eye to those who came to your show for a good time.

Comedians love to say “Don’t like rape jokes, don’t listen,” but do comedians post warnings outside the club that they’re going to make rape jokes? No? Oh, so, then are we saying that rape victims have to avoid comedy clubs from now on because there’s an ever-present risk of being mocked and dismissed and debased by some oblivious douchebag who thinks controversy = comedy?

I would like to reframe this debate for Oswalt in a way that I think he’ll understand: through Mystery Science Theater 3000.

In Eegah, Joel reflects upon the slick gas station where Arch Hall, Jr. works:

There existed a time when our nation took pride in its service stations. They gleamed like a beacon of hope from coast to coast. Then, one day, KaBlooey! You know, Sky Chief Super Service turned into the Tank and Tummy. I don’t mind telling you guys – The day this country went self-service was the day that Hell began to bubble up and flood the earth.

Crow responds skeptically. “Well, I hate to burst your bubble, Joel, but, um, what about the bubonic plague? World war? Stalin?”

“Well, come on, those are all big things,” Joel says. “You know, Hell works better when it’s a lot more subtle. Here, I’ll give you an example. Okay….  Crow, um, what do you think of Adolf Hitler?”

“Well, I hate him, naturally,” Crow says.

“Right. Now, um, what do you think of the band Styx?”

“Well, you know, they had one or two decent…” Crow begins, then gasps. “Oh my God, you’re right!”

For those unfamiliar, it’s a classic segment:

Patton, when I saw you respond to Lindy by saying that rape is always wrong and speech is absolutely free, I heard the following dialogue in my head:

Lindy: Patton, um, what do you think of the Tsarnaev brothers?

Patton: Well, I hate them, naturally.

Lindy: Right. Now, um, what do you think of rape jokes?

Patton: Well, you know, free speech is absolutely free…

Yeah, free speech is free, but when widely-admired, widely-respected, and widely-emulated comedians make tactless rape jokes that diminish the physical and psychological damage suffered by rape victims who are most likely in their audience, then they are contributing to that subtler form of Hell that we all tend to ignore.

I don’t believe that Patton Oswalt is under any obligation to use his platform to fight the scourge of sexual assault, but he has shown how he can use his platform to encourage and uplift society to embrace their better nature. When he uses that platform to pluck the low-hanging fruit of shaming terrorists, he gets praised for saying what many of us needed to hear. But when he has the opportunity to examine the cultural implications of defending unlimited freedom for trivializing rape, he states the obvious and nothing more.

Personally, I hold Patton Oswalt to a higher standard, for better or worse. His insights can be razor sharp and his influence on fans and comedians alike can be wide-spread. While under no obligation to say anything about rape, he does has to accept that people are going to be disappointed when he deflects a golden opportunity to dissect and discuss how our culture enables the prevalence of sexual assault.

Oswalt has a daughter, and by that simple fact alone (ignoring his status as a “good guy”) I’m willing to guess that he does not want rape culture to flourish any more than Lindy West or Molly Knefel do. The problem is that when engaging on the issue, Oswalt has chosen silence and the status quo for comedians over taking a stand against the cultural tide that Tosh, Cook and Jeselnik benefit from. I hope that he will reconsider.

I know I have one last installment in my Health at Every Size^® eating series, but there’s something else I want to write about. That’s coming soon, I promise.

Today, I want to write about being afraid to go to the doctor. Only, it’s so much more than that. It isn’t just fear of the doctor dismissing my concern and chalking it up to my weight. It’s fighting against my own deeply-ingrained indoctrination that any kind of pain I might experience is my own fault. My own fault because I’m fat.

For the last few months, my back has bothered me. Really bothered me. Right along my hips, at the top of the place where my back meets my ass. When I stand or walk too long, the pain is nearly unbearable. It especially hurts when I’m standing slightly stooped — doing the dishes is the worst. I can’t do the dishes and wipe the counters down because by the time the dishwasher is loaded (we’re talking ten minutes tops here) I have to lay down to relieve the pressure.

I know I need to go to the doctor. I don’t have health insurance, so it’s easy to say, “I’ll go in October if it’s not better by then.” I Google “severe lower back pain” to try to ease my worry, but make it worse because everything that comes up is about multiple sclerosis. I tell myself that I’m just tired, this semester was particularly rough, and I’m stressed. My book comes out in six weeks. Maybe I’m holding anxiety in my lower back?

The truth is, I don’t want to go to my doctor and have her tell me that the problem is my weight. I’ve been as fat as I am now for eight years and never experienced back pain like this. Maybe it is my weight, or my weight is making it worse, but it isn’t only my weight. It’s my sciatic nerve or some kind of pinched disc or something.

What I hate the most, though, is that I have to fight against my own tendency to believe that I deserve the pain because I don’t have the self-discipline to lose weight. Of course supporting 300 pounds can hurt, right? Right? I have to constantly remind myself that I deserve to feel good. There are fat people everywhere who can do the dishes without breaking down into tears.

Here’s the thing: I can accept that my weight might exacerbate my back problem. The problem comes when I internalize my body’s limitations as a moral failing and start to decide that it means that I don’t deserve good health care. I mean, if I was naturally very thin, I wouldn’t decide that having osteoporosis was something I did to myself and hesitate to get treatment.

I feel like I need a manifesto — so damn it, I’m going to write one.

Fat people deserve comprehensive health care that doesn’t stop at the “well, you’re fat” line. Fat people deserve health care that addresses them as whole people and not just a collection of fat cells. Fat people deserve equal treatment by doctors and other medical professionals. No person should believe that they are somehow so “bad” that they don’t deserve to feel good. Every body is a good body, and every body deserves proper care. Fat bodies, thin bodies, broken bodies, whole bodies, tall bodies, short bodies — all bodies.

It’s become a sort of mantra for me: saddened, but not surprised.

This time, it’s in response to Chris Christie getting the Lap-Band.

So long, rotund Republican rabble-rouser.

Predictably, the press went wild with speculation over Christie’s obvious presidential ambitions. Just as predictably, Jon Stewart pushed back against the hyperventilating punditry by simplifying Christie’s justification:

Why else would a 50-year-old man with young children and a loving family take steps to address obesity and extend his life? Why else? It is a classic presidential run tell… Can’t a guy get healthy without the prognosticators? “Oh, what does it mean?” It means he doesn’t feel well and wants to feel better.

Of course, Stewart’s assessment is also speculation. That’s the thing about personal health: you can’t determine the motives behind such a drastic, personal health choice unless you can peek inside the head of the chooser.

The fact is, you can’t divide motivations into mutually exclusive camps of professional ambition versus personal health concerns. It’s far more complicated than that.

Whatever the reason Christie chose the Lap-Band, it’s his choice. He no doubt researched his options and consulted medical professionals to choose a weight loss surgery that he felt comfortable getting. He even spoke with NFL coach Rex Ryan about the Lap-Band Ryan got in March 2010.

My main concern over the media scrutiny is that the actual, complicated story of Lap-Band is being obfuscated by the more sensational question of Christie’s motivation. As with my open letter to Kevin Smith, my primary concern in addressing these issues is that a comprehensive picture is painted for both the people involved, and those who are observing the media’s attempt at explaining the surgery.

In this case, the underlying question is about the efficacy and safety of Lap-Band surgery. As always, the media half-asses the details, duped by surgery-friendly research that is funded by Allergan, the makers of the Lap-Band. You can refresh your memory with this post I wrote about Allergan’s plan for unfat Americans.

In a nutshell, the Food and Drug Administration (FDA) approved the Lap-Band for those with a BMI over 30 who have at least one health issue correlated with obesity (e.g., high blood sugar, blood pressure or cholesterol). The problem is that the FDA relied on just one unpublished study that was funded by Allergan.

Dr. Joseph J. Cullen, professor of surgery at the University of Iowa Hospitals and Clinics in Iowa City, was on the FDA’s device panel and he voted against expanding the eligibility criteria Cullen has criticized the FDA’s handling of the review (PDF):

The FDA did a poor job presenting other data from some European and US studies that showed no benefit. I was really disappointed in the FDA’s review.

It turns out, Cullen isn’t the only one frustrated by the dependence upon Allergan-funded studies to tout the safety and efficacy of the Lap-Band. While researching the Lap-Band, I came across a January 2013 WebMD article titled “Lap-Band Shown Effective for Long-Term Weight Loss”. The article focused on “the largest and longest study yet” which was funded by Allergan. She passes along the Lap-Band-friendly talking points provided by the researcher:

He says gastric banding offers an effective, reversible, long-term solution for weight loss as long as patients get good follow-up care and are willing to carefully control the way they eat.

It’s only on the second page of the story that readers learn about the troubling history of the Lap-Band:

A 2011 study from Belgium found that the bands eroded in 1 in 3 patients, while 60% required additional surgeries… Four years ago, as many as 40% of weight loss surgeries performed at Lenox Hill Hospital in New York involved gastric banding, says Mitchell Roslin, MD, who is chief of obesity surgery. Today, the figure is closer to 3%. “Last year we took out 80 bands and converted them to other procedures,” he says. “Patients do well in the short term, but they tend to have problems later on.”

Also buried on the second page is the fact that Lap-Band sales have fallen from $300 million in 2011 to half that figure, leading Allergan to announce it was “looking to sell its weight loss surgery division.”

And this is supposed to be an article that touts the long-term benefits of the Lap-Band. But the fact is, we already knew that Lap-Band is an overwhelming failure from the vast trove of long-term studies we’ve got from Europe.

For example, there’s the 10-year study that included a headline that said Lap-Band surgery had “High Long-Term Complication and Failure Rates.” The study found that one-third of those who had the Lap-Band suffered major complications and the authors concluded quite emphatically:

Only about 60% of the patients without major complication maintain an acceptable [excess weight loss (EWL)] in the long term. Each year adds 3-4% to the major complication rate, which contributes to the total failure rate. With a nearly 40% 5-year failure rate, and a 43% 7-year success rate (EWL >50%), [laparoscopic gastric banding] should no longer be considered as the procedure of choice for obesity.

Another 14-year study found similar reoperation rates and pathetic long-term weight loss maintenance:

After 14 years, the reoperation rate was 30.5% with a reoperation rate of 2.2% for every year of follow up. Excess weight loss was 40.2% after 1 year, 46.3% after 2 years, 45.9% after 3 years, 41.9% after five years, 33.3% after 8 years, 30.8% after 10 years, 33.3% after 12 years and 15.6% after 14 years of follow up.

There’s even a two-year study where half the subjects had the band removed and the authors concluded that the Lap-Band is “not a recommended method for super-obese patients and we believe that a BMI greater or equal to 50 kg/m(2) is a contra-indication for this procedure.” Chris Christie has a BMI over 50, I guaran-damn-tee it. But did his surgeons advise him on any of these studies that seem to suggest that Lap-Band is a losing proposition?

Not only is the Lap-Band unsafe and ineffective, but there’s a possibility that it does long-term damage to your esophagus as well. Although gastric reflux initially improves in the short term, one of the few long-term studies about the effects of Lap-Band on the esophagus found a disturbing trend. Esophageal dysmotility disorders, which causes difficulty in swallowing, regurgitation of food and a spasm-type pain, were present in over two-thirds of the 167 patients who underwent the procedure.

If you Google “esophageal cancer lap-band” you’ll find those who have had the surgery and those who are considering the surgery discussing a correlation between the two. But as one Lap-Band cheerleader said, “Even if there is a higher risk, just think of all the diseases you are preventing from having the band! To me that outweighs it!”

Having a friend who died four years ago from esophageal cancer at the age of 41, I’m going to say no. No it does not.

And yet, despite all this evidence, there’s Jon Stewart defending Governor Christie for choosing to “get healthy.”

Because in this day and age, doing something, anything to lose weight is considered healthier than not losing weight. The mere fact that Christie chose a surgery that has a well-documented history of doing more harm than good is an indication that he is (a) on the path to health and (b) presidential material.

Both sides of the debate have it wrong. This decision will have serious, long-term health consequences for Governor Christie aside from the weight loss (although, as a popular, fairly famous public figure, he may have access to a more experienced medical team than the average American). But the media has ignored the evidence in favor of praising the fact that he has taken action.

What’s worse, once Governor Christie loses 50, 75, 100 pounds, then he will become a walking, talking advertisement for the Lap-Band, even while Allergan is having a fire sale to offload its struggling product.

The only net positive I can see coming from all this is that if Chris Christie does become the next President of the United States (and God help us all if he does), then we may have the first fat advocate in the White House. Even though he has made this decision, Christie still understands how difficult it is to be a fat person in America. Christie recently talked to Politico about being fat:

It’s really the only still-acceptable form of discrimination in our country is against people who are overweight… Most people are ignorant on the subject. What happens when you get into public life… you just have to learn to deal with it. Anytime you’re trying to educate people about it, if you yourself are overweight, then most people who aren’t informed on the subject just think you’re making excuses for yourself. Most people think it’s just an issue of willpower or that kind of thing and it’s a heck of a lot more complicated than that. Anyone who has had these problems over the years knows that.

While the “still-acceptable form of discrimination” claim is questionable, the rest of his comment is dead on. Chris Christie is swimming in the same toxic environment that pressures us all to do something, anything to lose weight, and the fact that he caved to an ineffective and harmful surgery is evidence that we’re all susceptible the pressure to take drastic measures.

Nobody should have to undergo surgery to prove their qualifications as a politician. Nobody should have to attach medical devices to their stomach to feel like they are a good and loving parent. But this is the world we live in, where fat is a black and white issue and anything is preferable to the stigma of fat.

Hi everyone! Today in Cooking With Kerasi, I’ll be featuring a recipe for another Greek-inspired dish, feta-stuffed chicken. In the name of full disclosure, it’s Martha Stewart’s recipe (you can view the original, along with a demonstration, on her website here), but perhaps obtaining it via your local third-party fativism website will somehow feel less felonious.

Let’s get started!

Feta-Stuffed Chicken

3/4 cup crumbled feta cheese (about 3 oz.)
1 teaspoon dried oregano
4 boneless, skinless breast halves (6-8 oz. each) [I've also used 8 tenderloins]
Coarse salt and ground pepper
2 tablespoons olive oil [I use Filippo Berio’s olive oils; they have ones designed for frying, grilling, sauteing, etc.]
1/2 cup homemade or low-sodium store-bought chicken stock [I always go store-bought]
Juice of 1/2 lemon [I use concentrate]
2 tablespoons unsalted butter

The method to the madness:

1. In a small bowl, combine the feta cheese and oregano. Set aside. Using a paring knife, make a pocket in the chicken breasts. Holding the chicken flat with the palm of one hand, make an incision in the thicker side of each breast. Carefully pivot the knife to create a deep pocket, being careful not to cut through the other side of the breast. Stuff the pockets with the feta mixture, dividing evenly. Season lightly with salt and generously with pepper.
2. Heat olive oil in a large skillet over medium [Martha says med-high... it's too high!] heat. Add chicken [be careful of the popping oil!] and cook until browned on both sides, 6-7 minutes per side.
3. Cover skillet and continue cooking until chicken is opaque throughout and an instant read thermometer inserted into the thickest part of the chicken registers 160 degrees — about 5 minutes more. Remove chicken to a platter and keep warm.
4. To the skillet, add chicken stock and cook, stirring up brown bits with a wooden spoon until reduced slightly. Add lemon juice and butter. Reduce the heat to low, and swirl pan until butter is melted and sauce is slightly thickened. Serve chicken drizzled with sauce.

The party had already devoured half of the chicken before I could get a good shot!!

I don’t usually serve it with the sauce. Instead I like to use the tzatziki-cucumber yogurt dip from my previous foodie post.

I like to have entire Greek-inspired dinner parties, and you can too! To fully round out the menu, you can serve seeded grapes, Greek salad, whole wheat pita bread, and long grain and wild rice.

Happy Eating!

Poor body image and depression feed each other mercilessly. (Depression also makes it incredibly difficult to write, so I hope I can manage to be coherent.) It’s hard to know which came first. For years I spent weeks or months in seemingly endless cycles of self hate and depression — the severe suicidal kind. For me, it’s hard to know which triggered which. It’s easier to figure out now that I’m a Body Acceptance activist as an adult. My bipolar depression leads to self hate, not the other way around. But was it so simple before I found Fat Acceptance? Not so much.

As a kid I was bullied. Abused might be a better word. Bullied sounds so mild and I have friends who refuse to use the word because abuse is so much more appropriate. So I was abused by my family, by my peers, by my supposed friends. I was often told to kill myself, and when I was 10 I decided to go ahead and give it a try. My bipolar started early. The doctor’s I’ve consulted aren’t quite sure how early, but the best guess is around the age of 7 or 8.

Bipolar is often triggered by some sort of trauma or stress in a person’s life (very often that stress is college) and I wonder to this day how much the teasing led to my diagnosis. Bipolar and depression can cause weight gain for a variety of reasons, and for me the weight certainly did come on. I was a super-skinny kid until my symptoms started up, then I suddenly became a size 22 by the 6th grade at 12 years old. The abuse was relentless and it has never stopped.

It wasn’t long until I started developing body image problems. I remember weighing 150 lbs in elementary school (though I don’t know which grade) and thinking “if only I could stay this weight while I grow then I’ll be okay.” But I didn’t stay that weight. My weight went up as my height did, and I’m still a size 22 woman.

I learned soon of the abuse that could come from complete strangers, as well as loved ones, and a single bad body thought could send me spiraling downward into depression. The opposite was also true; a bout of depression would leave me sure that no one loved me because of how I looked. It’s a complicated relationship. Many people without mental illnesses, such as bipolar, can attest to the damage done by poor body image, though. It’s not just those of us who are sick who feel the harsh pressures to be perfect. Many men and women suffer from depression specifically related to their weight or body image and, in fact, once I found Fat Acceptance, my depression became milder and less frequent by quite a lot.

Fat Acceptance had an obviously positive effect on my mental health. I’ve become a stronger person, a happier person, and a more secure person. And as any doctor can tell you, good mental health leads to better physical health, especially if you’re no longer too depressed to get off the couch. I truly don’t understand those who would argue that I would be better off hating myself, stuck in the depths of depressions that left scars on my skin and very well could have taken my life.

I’m not any thinner now, but all that hate certainly wasn’t making me thinner either. The fact is that self-hatred simply doesn’t make people thin. It only makes people miserable and less healthy than they’d be if they were happy and productive. It’s just more proof that these people don’t care about our health. They only care about their own prejudices.

I believe that Body Acceptance can help promote better overall health, even though health isn’t a requirement for respect or dignity. My point, however, is that negative body image and depression feed each other in a vicious cycle that we have the power to overcome simply by promoting loving and accepting yourself.

Sometimes I think that those who work in the Body Acceptance field get so little praise for the hard work they do and they do more great work than they probably even realize. Helping people not only love themselves, but be healthier and happier? That’s truly an amazing gift! Men and women, thanks to your hard work, are finding Body Acceptance sooner and sooner. Saving them literally decades of  time wasted on self-hatred and depression, and allowing them to lead positive lives. So I want to finish my post on a positive note and say thank you to everyone who’s impacted my life.

For a lot of fat people, the fat doesn’t reach down to their feet and they don’t need extended sizing in shoes. Unfortunately, I’m not one of those fatties.

I wear, depending on the width, anywhere from a size 12WW to a 13W. I have “cankles”, which means the area where the calf meets the ankle has no definition. My feet also swell as the day goes on. So it can be pretty disheartening to have trouble finding fashion that fits your top, your bottom AND your feet.

The majority of shoe stores don’t stock extended sizes for women with the exceptions of Payless Shoes and Avenue. So most of my shoe buying is done online, which, as most of us know, can be a crap shoot. Without being able to try shoes in person, it can be costly to purchase and return them if they don’t fit. But they are out there if you know where to look for them.

I’m going to focus this post on summer shoes, since in most areas it’s nice enough to wear open-toes, and sandals are a lot easier to find for those of us with bigger feet.

Summer Sandal with flower cutout, $29.99 – $34.99

It may not look that fashionable, but this sandal from Woman Within is a lot better in person and it’s comfortable. It molds to your foot and is actually pretty supportive. The price is reasonable and it comes in silver, light blue, tan, white and black. I own the silver and black, and these are pretty much my go-to  sandals for work when the weather is warm. The bottoms are slick when you first get them, but rubbing sandpaper on the soles or walking in them on a rough driveway or sidewalk will get rid of the slickness. I plan to get a couple more of these when I have the cash to do it.

Espadrille Sandals, $24.99

Esapdrilles have been a summer footwear staple for decades and in the last few years, there have been a lot of styles and colors to choose from. This particular one from Avenue goes up to a 13W and comes in pink, natural and black. The price is great, the heel isn’t outrageous and the strap appears to have a stretchy band to accommodate wide feet.

“Margie” Sandals, $44.00

If you need something with a little more hold, these sandals from Bass are pretty good. I own two pairs in black and white. These also go up to a size 13. Word of warning: the buckle straps do have a tendency to stretch out over time. You can get these at Zappo’s.

Airwalk flip-flops, $12.99

Sometimes you just want a basic flip-flop for the beach or to run errands. Payless offers this budget-friendly one from Airwalk, a brand that’s been very fat-foot friendly. This comes in brown and tan and goes to size 13.

Sequin flip flop, $19.95

Lane Bryant has these flip-flops if you want them a little more fancier. They come in four more colors and sizes are 7/8, 9/10, and 11/12.

Men’s flip-flops, $43.99

For the men, and women as well, Crocs gives you a flip-flop that promises to provide comfort for lots of walking. This one goes to size 14 and comes in the brown/tan as shown or distressed brown.

If you know of other places to get extended sizes in shoes, online or in-store, list them in the comments!