I am angrier than I have been in a very long time.  I have had enough. We have officially crossed a line. Several readers sent me this article [trigger warning:  I’m still depressed more than 24 hours after reading it.  It’s horrible].  In it 54% of doctors in the UK who took part in a survey said that “the NHS should have the right to withhold non-emergency treatment from patients who do not lose weight or stop smoking.”

My life is not worth less than a thin person’s life. My health is not less important than a thin person’s health.  I do not need to do anything to “deserve” the same healthcare that people with a lower BMI receive.

First the good news:  54% represents 593 of the 1,096 doctors who self-selected to take the survey.  To be clear – that’s in no way a representative sample – according to some reports it represents .2% of doctors.  The Royal College of Physicians, which represents hospital doctors, said “Lifestyle rationing is creeping into the NHS. There are reported examples where treatments have been restricted by PCTs and we wouldn’t agree with that.”  They are calling it “lifestyle rationing.”  So that’s the good news, here comes the rant.

I think that smoking and obesity are not comparable, but I don’t believe in denying healthcare to smokers, still I’ll keep this discussion to obesity since that’s where my expertise lies.  Before I even get into a civil rights discussion, let’s talk about the practical considerations:

First, what is included in the “non-emergency” procedures?  Were I a fat woman in the UK, what should I expect to be denied treatment for?  Strep throat?  Sprained ankle?  Chronic back pain?  Acute back pain? Do I get a pap smear, mammogram or basic blood work? Or do they do the test but refuse to treat any non-emergency issues that the blood work uncovers?

Second – knowing that weight loss fails 95% of the time I am stuck with some really bad choices?  Do I try to crash diet to get treatment and hope that the treatment works before I gain all my weight back?  Studies show that exercise makes me healthier but rarely leads to weight loss.  However, it also leads to injuries – should I stop dancing, doing pilates, lifting weights etc. to avoid getting an injury for which I will be denied treatment?

Finally, we already know that non-emergencies left untreated can become emergencies.  Painful, expensive, unnecessary, deadly emergencies.  How many fat people won’t bother going in to the doctor at all until it’s too late? Why are people comfortable with me dying because of the way that I look? Using BMI as a measurement also means that very tall and very muscular people will be denied care.

Not for nothing, but in the UK the obese people and the smokers pay the same amount into the system as thin people and non-smokers.  So these 54% of doctors are asking people to pay into a system that will then deny them care.

Let’s look at the claims for why this is a “good idea”:

Operating on a very fat person is more dangerous. Anaesthetically it’s harder, the surgery is harder and the rehabilitation takes longer.

Operating on babies is harder.  Operating on the elderly is harder.  Operating on people with certain pre-existing conditions is harder.  If they find out that a specific ethnic group has worse surgery outcomes will they start denying them surgeries?  Does it mean that if enough doctors have a prejudice that the medical establishment will indulge it?  The job of surgeons is not to cherry pick the easy surgeries. It sounds like there is a need to do more work to develop protocols for performing surgery on fat people.  I also happen to know that they don’t use fat corpses in medical schools because it’s too difficult to deal with the weight.  I say deal with it, figure it out – doctors deserve an education that prepares them for the real world, not an education that makes them prejudiced against their future patients.

It’s their own fault that they are fat so they don’t deserve healthcare.

Leaving aside the fact that weight has been suggested to be as heritable as height, and that there are many reasons that people become fat (including some of the non-emergency health problems that we’re planning NOT to treat fat people for), since when do we decide if people deserve healthcare based on whether their issue is their own fault?  I have a friend who has one leg. His other was amputated after he got on his motorcycle drunk and got into an accident.  He receives both excellent medical care and disability payments, even though he injuries are, by his own admission, entirely his fault and the result of his “stupidity”. If we didn’t treat people whose medical problems were their own fault that would really change the face of medicine and not in a good way.  What about thin people who get so-called “fat people” diseases like heart disease or diabetes?  Do we assume that these diseases are the patients fault if the patient is fat but something else’s fault if the patient is thin?

And these doctors, who want to deny me medical care because of statistics – they don’t have a single piece of research to suggest that the weight loss they are demanding of me is possible in the long term.  So they are asking me to engage in the medically dangerous practices of crash dieting and weight cycling.  They are asking me to put my health in danger in order to “deserve” medical care and if my dangerous crash dieting and weight cycling doesn’t work and leads to medical problems THEY WON’T TREAT ME FOR THEM!!!!  What the actual fuck people?

I will say it again: My life is not worth less than a thin person’s life. My health is not less important than a thin person’s health.  I do not need to do anything to “deserve” the same healthcare that people with a lower BMI receive.  Rather than trying to figure out how to get us the hell out of their offices and operating rooms, I think that doctors should be LIVID that they don’t have the proper tools and education to care for their patients of size. I do not believe that healthcare is just for the rich and the thin.  I think that we need the smartest minds in the world working to figure out how to provide good healthcare to everyone, I believe it’s possible if we will apply ourselves as people against a problem rather than doctors against fat people.

I believe that change will happen in my lifetime when it comes to civil rights for people of size.  I am also aware that it may get worse before it gets better.  There will be bad days, after reading this article, yesterday was a bad day for me.  I was on the way home thinking about this article and a song came on the radio that made me feel better so, being an unrepentant Inspiration Junkie, I’ll leave it here in case it helps someone else:

Join the Club – Support the Work!

I do HAES and SA activism, speaking and writing full time, and I don’t believe in putting corporate ads on my blog and making my readers a commodity. So if you find value in my work, want to support it, and you can afford it, please consider a paid subscription (it works like a fan club where you get extras, discounts on stuff, free subscriber meet-ups etc.) or a one-time contribution.  The regular e-mail subscription (available at the top right hand side of this page) is still completely free. If you’re curious about this policy, you might want to check out this post.  Thanks for reading! ~Ragen

I decided to tap the brilliance of the oldbie group in the Fit Fatties Forum for the advice they would give to newbie exercisers.   (If this doesn’t answer all of your questions, you can always e-mail askafitfatty@gmail.com and the answer will be posted on the Ask a Fit Fatty blog.)

I asked the Oldbies:

I have a question for the oldbies (to help the newbies – I’m going to be putting this in a blog post) – what advice would you give a fatty who is just starting out and wants to get more fit?

Here is their advice.  I happen to think it’s awesome and as always just take what you like and leave the rest, feel free to add your own advice in the comments, and I would ask that you not criticize the contributors.  Thanks!

Hi – the best starting-out advice I can give is start by finding beautiful spaces and places to walk in that make you feel good. For me, I started by walking in local arboretums and botanical gardens that I found on Google maps. The pleasure of seeing the beauty of the space really made me enjoy the movement. And they are generally, I find, very ” genteel” places where weight bullying seems unlikely. I am also a huge believer in black workout clothes (forgive me if I sound silly!). I wear black stretchy form fitting yoga pants with a black v-neck tee for the gym and have a bunch of the same in my closet. I don’t know why but it makes me feel a lot more comfy in the gym. I feel more powerful somehow and less self-conscious. ~Ann

The words of wisdom that I would give to someone who is just starting out is to try a variety of different movement activities to discover which one you derive the most pleasure from. Becoming more fit should be fun and should not feel like a mandatory addition to your day.  Additionally, if you would like to explore some activities such as yoga or Zumba but are worried about the cost, you can try searching for DVDs at your local library. Additionally, many community recreation centers and even some public libraries offer free yoga, hooping, Zumba, and other classes.  ~Rebecca

The advice I would give to someone starting out is all stuff I used myself. I hope some of it resonates with others.

1. Go slow. Seriously. Sloooow. The number of times I started at a million miles an hour and hurt myself or became discouraged because I was too sore to work out for a week is, well it’s a lot. Go for small achievable goals and give yourself mad props for doing them. If 5 mins of walking around the apartment is where you’re at right now, that’s where you’re at and you did it and you’re a hero.

2. Only note what you DID, not what you DIDN’T do. At the beginning I had to stop in every track at Zumba and walk on the spot. It would be easy to notice that I didn’t do the entire class but I only noted that I showed up and did half a class. Yay me! Want to eventually walk for 30 mins and start at 10 mins, that’s 10 mins! Yay you!

I’m also a big fan of rewarding yourself when changing a habit. I know this is dorky but I bought myself a stamp which said ‘Good Job!’ and gave myself a stamp when I worked out. I then bought myself a pressie when I reached a number of stamps. The constant positive reinforcement helped to negate the ‘you’re not good enough’ critical internal voice.

3. Do what you love, or at least avoid what you hate. I know that accessibility, time, money, fitness level and mobility are all factors is what exercise is possible. If it IS possible, try and do what you love. I love to dance, I like high stimulation, music, people etc. Zumba is perfect. My friend loves the peace of walking along the beach looking at the waves. Neither of us would work out if we swapped routines.

If there is nothing you love, if you’re not mobile or in pain or you’ve been so infected by the ‘go harder, beach body, feel the burn, it’s got to hurt, burn off those calories’ horror show of what current society seems to think fitness is, I would say link it with something you DO like.

Watch guilty pleasure tv, listen to music or an audiobook, join a group if you like working out with others, work out in a park if you love the outdoors. Note whether you like working out in the morning or at night, inside or outside, with others or not. It may be the way towards finding activity which you enjoy.

4. Reconnect with your body. Begin to notice how your body feels when you move, when it feels better than at other times. Notice how it feels to have a bath or sit in the sun. When I started I was so disconnected from my body and so angry that a chronic condition meant that I was in constant pain and unable to dance anymore. Plus I didn’t look the way I wanted to look and my body got a lot of hate. Getting back inside it through mindfulness meditation helped as did gratitude. On the days when I couldn’t walk and had to be helped to the bathroom I would have to think, hey I can read, I am breathing, I can laugh. I can lift my hand and feed myself. It’s all relative.

5. Try not to mind read. At the beginning I was the one red faced and panting, sweating like crazy, modifying everything, having to stop and because I was around others I worried that they were judging me. Some of them may have been but I didn’t have to do the work for them. I developed my own mantra of positivity inside my head and tried to remind myself that I didn’t know what they were thinking and in any case they didn’t know me. I don’t always succeed but most of the time I don’t notice anyone else and that’s because I’m king inside my own head. They don’t know that when I box I am totally Buffy.

I feel so lucky to be able to be active and anything I can do to encourage or support others, I will. All that stuff I mentioned is hard, and took years for me to take on board and sometimes I do all the things I say not to do, push myself too hard, have a hate fest on myself etc but it’s doable.

Best of luck to anyone starting! ~Sophie

Small steps and achievable goals will help each of us have positive experiences and develop the inner knowledge that we will feel better!

No matter how I feel before a dance class, water aerobics, or strength training session,  I know I will feel better afterward. I believe it based on years of experience. Doing something I enjoy with people I like is also effective for dissipating pain  –  especially while we are on stage performing  –  then there is no pain!  ~Ronda

I couldn’t have said it better myself!  I would add – try lots of things.  It will help you find things you like and help keep you from getting bored.  Consider starting a Health at Every Size meet-up in your community so that you’ll have a group to go try stuff with (so instead of just you trying out the Zumba class, it’s a fleshmob of fatties and friends.)

Also, I would say give yourself time to progress.  I have a video below of me doing something called “short spine” on the pilates reformer. Now it feels really easy (so easy, in fact, that I’m going too fast in this video.)  However, the first time I saw it, it seemed like it would be impossible.  The first time I tried it, it was very much like a fish on dry land and not at all like my instructor (Kate Wodash of Mindful Body Center). It was frustrating to flop around unsuccessfully but I worked hard to be happy with progression and it was so worth it the first time I was able to do it successfully.

Join the Club – Support the Work!

I do HAES and SA activism, speaking and writing full time, and I don’t believe in putting corporate ads on my blog and making my readers a commodity. So if you find value in my work, want to support it, and you can afford it, please consider a paid subscription (it works like a fan club where you get extras, discounts on stuff, free subscriber meet-ups etc.) or a one-time contribution.  The regular e-mail subscription (available at the top right hand side of this page) is still completely free. If you’re curious about this policy, you might want to check out this post.  Thanks for reading! ~Ragen

There are many things that are frustrating about being fat in society, and I do not mean to downplay any of that.  However,  I try to be a “glass half full” kind of person so today I thought I would take a (slightly tongue-in-cheek) look at some of the benefits of living outside the beauty norm.

I’m not scared of losing my thin privilege or that aging will take me outside the beauty norm because I’m already there.

I never have to worry about wearing the latest in designer styles because they don’t make them in my size.

I never have to worry that someone is only dating me/hiring me etc. because I am stereotypically beautiful.

There is a little added bonus to my accomplishments because I did it despite being outside the norm.

I get to be part of the NAAFA-LA chapter (ok, I could do that at any size but if I was thin I might never have found them and they are just so awesome that I had to mention them)

If someone is interested in dating me, I already know that there is a good chance that they have the ability to think beyond what they are aggressively sold in our culture.

My body size is so far outside the beauty norm that I feel freer to make decisions based on what I like or want rather than what is “expected” or “in style”.  (I think nude pumps are hideous so I don’t care if they “in”, I’m out!)

Since I stopped dieting I have so much more brain space to think about other things.

I’m not terrified of becoming fat or obsessed with becoming thin so I can love the body I have and make health decisions completely based on my health.

I’m sure that there are others, as always feel free to leave them in the comments.  And may I suggest taking today to be thankful to your body for all of the amazing things that it does for you (blinking, breathing, smiling…)

Join the Club – Support the Work!

I do HAES and SA activism, speaking and writing full time, and I don’t believe in putting corporate ads on my blog and making my readers a commodity. So if you find value in my work, want to support it, and you can afford it, please consider a paid subscription (it works like a fan club where you get extras, discounts on stuff, free subscriber meet-ups etc.) or a one-time contribution.  The regular e-mail subscription (available at the top right hand side of this page) is still completely free. If you’re curious about this policy, you might want to check out this post.  Thanks for reading! ~Ragen

Brandon McCarthy is a professional baseball player who reminded me of the power of a small but mighty type of activism – calling out oppressive behavior when you see it.

After two men were put on the stadium “kiss cam” as a joke McCarthy tweeted “They put two guys on the ‘Kiss Cam’ tonight. What hilarity!! (by hilarity I mean offensive homophobia). Enough with this stupid trend.”  When interviewed by the San Francisco Chronicle he further said “If there are gay people who are coming to a game and seeing something like that, you can’t assume they’re comfortable with it.  If you’re even making a small group of people … feel like outcasts, then you’re going against what makes your model successful.”

A-freaking-men Brandon (can I call you Brandon?).  Thank you.

Look, I know that a lot of the points of Size Acceptance Activism can be really hard for people to grasp – the idea that long term significant weight loss is not possible for most people, the idea that I take up more space than others and that’s ok because people come in different sizes, the idea that it’s possible that illness in fat people may be caused by the stress of constant stigma and not their fat, these are things that can take some time for someone to wrap their head around.  So let’s start here:

People have the right to live their lives without being shamed and stigmatized for the size and shape of their bodies.

That curb that is two inches high.  We all need to be able to step up onto that curb.  And that’s where the root of this small but mighty act of activism lies.  Brandon didn’t get into an argument about nature or nurture or what any religion believes about homosexuality.  He kept it simple “If there are gay people who are coming to a game and seeing something like that, you can’t assume they’re comfortable with it.”  Gay people should be able to go to a baseball game without humiliated or shamed. Duh.  Two inch curb, let’s all step up.

So if you are trying to figure out ways to fight the tremendous amount of body stigma and shame in this culture, take a note from Brandon.  Call it when you see it and keep it simple. Here are some suggestions for what you can say when you hear body shaming of any kind:

People have the right to live their lives without body shame and stigma.

I look forward to living in a world where nobody would try to shame someone else for their body.

I refuse to participate in body shaming or be friends with people who engage in it.

I think that we are all stronger when we’re not trying to pull anybody else down.

Feel free to add your favorites in the comments.  This is a small but mighty bit of activism that can help people take the first step to becoming fierce size acceptance warriors.

World Tour Update

The World Tour is taking an Ivy turn.  I’ll be at Dartmouth College May 9-11th.  More details as soon as they are available.  I’ll be in Atlanta May4-5.   I’m teaching a dance workshop on May 12th with Theresa Woodsong in Austin.  I’ll also be involved in panels for screenings of Strong!  A documentary about three-time Olympian Cheryl Haworth in Houston on May 15 and Austin on May 17.  More details to come.

Join the Club – Support the Work!

I do HAES and SA activism, speaking and writing full time, and I don’t believe in putting corporate ads on my blog and making my readers a commodity. So if you find value in my work, want to support it, and you can afford it, please consider a paid subscription (it works like a fan club where you get extras, discounts on stuff, free subscriber meet-ups etc.) or a one-time contribution.  The regular e-mail subscription (available at the top right hand side of this page) is still completely free. If you’re curious about this policy, you might want to check out this post.  Thanks for reading! ~Ragen

One of the comments on my blog yesterday asked a really good question that I wanted to address as a full blog.  She asked:

Basically, even though I may be genetically predisposed to it based on my family’s size and the fact that I have PCOS, I feel that I am overweight because I spent 15+ years eating crap and not exercising. This leaves me vulnerable to the blame/shame messages that society sends me about my weight – I feel like I can’t defend myself because I did it to myself.

I understand the FA movement is in part a push back against mistreatment and oppression, but is there a difference between being fat-accepting and being pro-fat?… I don’t see my fat as a natural part of me, I see it as the consequences of mistakes that I am now stuck with.

We know that different bodies react to things in different ways.  Someone else could have engaged in the same behaviors and ended up thin while this person ended up fat, this person could have engaged in different behaviors but still ended up the same size, the truth is that we’ll never know.

Although I knew that, I’ve still been in that cycle of blame and shame.  When I learned that dieting causes weight gain I went through a period of “blaming myself” for my body size because of all the dieting that I had engaged in. I went through a time of alternating between feeling bad about myself, feeling sorry for myself, being mad at myself, and being mad at the people who encouraged me to diet.

The first conclusion that I came to was that even if I could have been thin, even if being fat was my fault, wondering how I got to be fat and who I should blame for it does not serve me in any way. This is the body that I have.  It is fat.  It is also scarred because of death-defying bike tricks as a kid and working with aggressive dogs as an adult.  I don’t begrudge my body those scars, why would I begrudge my body its size.  What difference does it make if things could have been different?  This is what’s happening.  I have a fat body and my choices at this moment are to love that body, or hate it.  I chose to love my body.  At the time I didn’t know how I was going to do it, the important thing was making the choice that I was going to figure out how to love my body no matter how long it takes.

It took a lot of work, and it took fighting to keep my focus on the goal.  This exercise did more to shift the way that I feel about my body than anything else.  I had to fight through a time when I could appreciate the beauty in every body but mine.

After time I realized something deeper – all of this angst about my body size is based on a social construct that a fat body is a bad body.  That’s just not true.  Every body is beautiful as it is right now, at every size.  I sometimes get stuck around the idea of “size acceptance” because I want better than just to “accept” my body, which often comes with a connotation of resignation.  I love my body, I appreciate my body.  I have a fat body and that body is what does everything for me – from breathing and blinking to walking and hugging.  That body deserves to be nurtured, loved, and defended from anyone who dares to say a negative word about it.

I owe this body my unconditional love and devotion. So I’m not just fat accepting, I’m a pro-fat fat-loving fat activist fatty. More importantly,  I am the only person who can decide how I feel about my body.  I can choose to accept other people’s opinions, I can choose not to do the work to make shifts if my current feelings aren’t the way I want to feel; but at the end of the day I have no idea why my body is the size it is, but I do know that the way I feel about my body is on me. I’m the only person in the world who can choose how I feel about my body.  I choose love.

Join the Club – Support the Work!

I do HAES and SA activism, speaking and writing full time, and I don’t believe in putting corporate ads on my blog and making my readers a commodity. So if you find value in my work, want to support it, and you can afford it, please consider a paid subscription (it works like a fan club where you get extras, discounts on stuff, free subscriber meet-ups etc.) or a one-time contribution.  The regular e-mail subscription (available at the top right hand side of this page) is still completely free. If you’re curious about this policy, you might want to check out this post.  Thanks for reading! ~Ragen

I received the following e-mail from a blog reader who is a certified sex therapist.  Her question is one that I hear from and about therapists of all specialties so I thought I would answer it here. (The quote may be a bit triggering, you can skip the indented text to skip the possible triggering language.)

I’m currently a board-certified sex therapist.  My clinical “home” is AASECT – the American Association of Sex Educators, Counselors and Therapists – who do fabulous work and push the envelope mightily when it comes to healthy sexuality.  My other clinical home is a local listserve.  But there are occasions when these two homes can feel like jails – and being part of a small town community and a small, collegial association means that I’ve been reluctant to take on my colleagues despite occasional, and horrendous, comments that are made, clinicians who make a practice out of weight loss therapy, and awful comments linking obesity and health, and obesity and sexuality.

The frequent comments on both listserves concerning obesity are so distressing – and I’m enraged that folks are practicing so unethically.  Here’s one from today…. ” We all know Obesity exists and I don’t see this diagnosis in the DSM.  Addiction is prevalent in our society.  There are individuals eating too much, gambling too much, drinking too much, shopping and spending too much.  All to fill a void or manage emotions.”  People who would consider themselves evidence-based clinicians freely throw around screwed up commentary about fatness and I have so far just sat back fuming.  I’m struggling both personally and ideologically with this as an issue, and can’t figure out how to proceed to take on my colleagues.  I regularly post your blog posts on my center’s Facebook page, cut and paste comments from your blog and put them on my personal FB page to “train” my friends in HAES thinking – but haven’t figured out how to address the issue of my colleagues and their fucked-up thinking.  Part of this is that if I piss off people locally, I’ll be ostracized from my local clinical home  – a big rural landmass, not many people. My business depends on referrals from local doctors, psychiatrists and other therapists.

I’m rambling – and this in itself will tell you how distressed I am.  I don’t know how to address this or where to start.

Let’s talk about the actual issues first and then we’ll talk about the politics.

There are two errors that are likely to be committed here.  The first is the same weight/health conflation and stereotyping that we talk about all the time, the second is an issue that when all you have is a hammer, every problem looks like a nail.

I talk a lot about the fact that “ob*sity” is not a physical health diagnosis – it’s simply a ratio of weight and height.  By the same token, body size is not a mental health diagnosis.  While it’s possible that someone’s body weight may be related to an issue such as binge eating disorder, someone’s body size never ever constitutes a mental health diagnosis.

The people who practice weight loss therapy are engaging in the same mistakes as medical doctors who prescribe weight loss. I find it even more unconscionable coming from  a purported mental health specialist who should know better than to set people up for failure and then blame them when they fail (since they are obviously harboring the delusion that they can help people achieve long-term weight loss despite a complete lack of evidence to corroborate the theory and a ton of evidence that people are likely to end up less healthy than when they started from both physical and mental health perspectives.)

In my experience, people who push the idea that obesity should be in the DSM as a diagnosis come in three basic varieties.  There are well-intentioned people who want to make sure that everyone who does need mental illness treatment gets that treatment and so try to get it covered by insurance in every way possible.  There are people who have bought into the stereotypes and misinformation about fat people and are simply tragically misguided. Finally, there are people who look at us and see dollar signs.  Eating Disorder Treatment centers and weight loss practices can be lucrative for-profit businesses, and if obesity is considered a diagnosis then that’s a whole lot more potential customers for them (and just like the diet industry, their solution will lead to weight cycling which leads to repeat clients.)

This is a very simple concept:  the belief that you can determine anything based on how someone looks (other than how they look) – is stereotyping at best and, when it’s for the purpose of making a mental or physical health diagnosis it constitutes malpractice. Period. Often when dealing with people of size this behavior is engaged in by people, like therapists, who we really wish knew better – and/or who know better for every group except us.

One issue that can happen with health care practitioners is that their specialty becomes a hammer, so every problem they see is a nail.  Remember when Doctor Oz tried to claim that every fat person has heart problems because every fat person on whom he had performed cardiovascular surgery had heart problems?  Obviously this logic is flawed because people with good hearts don’t get their chests cracked (and every thin person he performs surgery on also has heart problems, but he does not assume that all thin people have heart problems.)

This is what sometimes happens with therapists – every person of size they see has issues with food.  Of course that’s because those people come to them because their practice specializes in helping people who have issues with food. Still, therapists are human and can lose perspective and they are inundated with the same incorrect information about health and weight as everyone else. I once witnessed a conversation where someone tried to explain to a binge eating disorder specialist that I did not have binge eating disorder.  Her response was that she was certain that I had BED because, in her experience, people don’t get to be my size without having an eating disorder. The statement is true but the conclusion is false – her experience is completely colored by the fact that it is made up of people who sought her out for her claim that she has expertise is dealing with eating disorders, and I happen to look like those people.

With sex therapists, my biggest concern is a scenario in which someone comes to the therapist because their sex life is being affected by body shame brought on by a culture of fat hatred.  If the therapists assumes that their body size indicates a mental illness, then they will become part of the bullying culture, engage in victim blaming,  and attempt to solve social stigma by trying to get the stigmatized person to change, rather than helping the person acknowledge and cope with the unfair stigma with which they have to deal. The cure for social stigma is not weight loss.  The cure for social stigma is ending social stigma.

Bottom line:  There are fat people who have under-eating disorders, there are thin people who have over eating-disorders.  There are fat people who have very healthy relationships with food and their are “normal weight” people who have very unhealthy relationships with food.  As far as I’m concerned, trying to make a mental health diagnosis by looking at someone indicates gross incompetence.

So those are the basic responses, now let’s quickly talk politics.

There’s not an easy answer here.  Each person who wants to fight fat oppression has to decide what/if they are willing to risk to do it. It’s entirely your decision and any decision that you make will be valid.  The truth is that in order to succeed at ending fat oppression and weight bullying, many people will have to risk something.  Some people will have to risk everything – that’s the nature of revolution – but that person doesn’t have to be you.

Once you decide what you want to risk you can choose what method you think will be likely to succeed and be within your risk tolerance – anything from full on confrontation to doing nothing.

One thing that I’ve found can be successful in a situation where less confrontation is called for, is making the point in the form of a question attached to research – for example:  “I was reading this paper by Linda Bacon and Lucy Aphramor that seems well-researched and talks about the lack of research on weight loss efficacy. I know that you offer weight loss in your practice, can you help me understand how your philosophy differs?”

or

“I wanted to get your thoughts on this – I read a lot of blogs written by people of size and one of the things they talk about is their frustration with health professionals making a snap diagnosis based on their body size.  They say that it’s stereotyping, that it ignores the fact that mental illnesses have many diagnostic criteria and that body size alone does not constitute a diagnosis, ignores the fact that there are people of all shapes and sizes who experience disordered eating and people of all shapes and sizes who have healthy relationships with food, and that it’s disrespectful to them since they are the best witnesses to their own experience.  What do you think?”

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Greetings from LA! I decided to write a post about how there is no such thing as a “healthy weight”.  Then I realized that I wrote one two years ago, so I’m updating and re-posting because I think it bears repeating:

There is no such thing as a “Healthy Weight”.  People have a certain level of health (which can be judged through metabolic tests or physical fitness etc) and people have a weight (which can be judged in pounds, kilos, stone etc.).  These are two separate measurements.

One easy example of this is the girl who ate a diet of almost exclusively chicken nuggets for most of her life, and then got very sick. News stories actually said that it was surprising because she was at a “healthy weight”, as if this incident wasn’t an indictment against the concept.

The idea of conflating weight and health has a lot to do with the use of Body Mass Index (BMI) (a simple ratio of weight and height) as a measure of health by  insurance companies who wanted to save money by not having to perform actual tests. Helping them out were diet and pharmaceutical companies who found that if they could convince people that anyone over a certain BMI would have dire health consequences, it was easier to convince them to buy their stuff.

They got on committees within the CDC,  and soon 3 people with ties to pharmaceutical companies that create diet drugs, in concert with the chief “scientist” at Weight Watchers,  managed to convince the CDC to lower what was considered a healthy BMI and then recommend their products as a solution to the problem that they had just created.  This process meant that about 25 million Americans became “overweight” overnight and we were off to the races. The next day newspapers ran the story “Millions of Americans Don’t Know They’re Overweight”, but failed to mention it was because those millions Americans had been a “healthy weight” less than 24 hours ago.

Now despite having good health by any measurement, many fat people (including me) can’t get health insurance.  Healthy fat people who do have health insurance are often encouraged to undergo a risky major surgery with an extremely poor success rate at 20K a pop so that their bodies can be smaller, and the diet industry makes over 60 Billion dollars a year. Meanwhile plenty of sedentary thin people who eat a poor diet are constantly sold the idea that they are healthy simply because of the ratio of their weight and height.

And we are hearing from everyone and their dog that we need to get to a “healthy weight”.  Often it’s suggested that we should do this by any means necessary, the implication being that it doesn’t matter what crazy unhealthy things we do to get thin, because once we get there we’ll be automatically healthy just because our bodies are smaller.

Except it doesn’t work that way. (Just ask someone who got thin from using heroin.) The best suggestion that doctors can give us if they are being honest and practicing evidence-based medicine is that healthy behaviors have the best chance of creating a healthy body. But even that’s not guaranteed.  Most of us know someone who followed every health guideline and got sick.  Most of us know someone who eats like crap, never exercises and is as healthy as a horse. At the extreme ends Marathon runners drop dead of heart attacks at 45 and sedentary Grandmas eat frozen dinners, smoke unfiltered cigarettes, and live to be 102, in the middle it’s an even grayer area.   There are healthy and unhealthy people of every weight, shape, and size and the medically responsible thing would be to look at each person as an individual and recommend evidence based interventions specific to their health issues, instead of trying to stereotype people based on how they look and then try to find a way to blame them for their health conditions instead of treating them.

If doctors were honest with us, they would say that the human body is extremely complex and they haven’t yet scratched the surface of everything that is involved in being “healthy”.  They would also ‘fess up that even if they could prove that weight loss makes you healthier (which they can’t) they don’t have a single proven method of weight loss.  They would tell us that the caloric restriction method (aka “eat less and exercise more”) has an abhorrently poor success record.  Were it a prescription, doctors would be forced to remove dieting from the shelves for its complete lack of efficacy and all of its safety concerns. But it’s not, so they just keep recommending the same thing, even though it just doesn’t work. More and more we are finding that physical fitness is a much better indicator of health than is weight.

There are so many things to be improved in this system, but let’s do one simple thing today:  Let’s decide to eliminate the phrase “healthy weight”.

As always, this is your decision.  If you’re in for this then I suggest that we start with ourselves – check our own assumptions about people’s health based on their size, including people who are very thin.

Then I suggest the following scripting as an example when this comes up:

Person who still buys into the healthy weight myth:  “blah blah blah healthy weight blah blah blah”

Enlightened person (that’s us) “Actually, there is no such thing as a healthy weight, and I wish people would stop spreading that myth.  There are people who are healthy and people who are unhealthy at every shape and size.”

Now, this can often lead to the VFHT:  Vague Future Health Threat.  This is when someone suggests that even if I, as a fat person, am healthy now (and it doesn’t seem to matter how old I happen to be) “it”  will catch up to me “someday” cleverly using the fact that everyone will die, but insisting even if I die when a group of trained bald eagles drop a piano on my head, it will be because I was fat.

For now:  No more saying “healthy weight”:  Never ever, never ever, never ever.

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If you are here for the evidence list, it’s at the end of the post!

Two patients have high blood pressure.  One is thin, one is fat.

The thin person goes to the doctor and receives recommendations for interventions that, evidence shows, are likely to lower blood pressure.  When that person goes back for a check-up, the doctor will test their blood pressure to determine if the interventions are working.

The fat person goes to the doctor, and research tells them that there is a greater than 50% chance that the doctor will view them as awkward, unattractive, ugly, and noncompliant, and a nearly 30% chance that the nurse will be “repulsed” by them.  (All of the evidence is linked at the bottom of this post)

The doctor recommends weight loss to “cure” the high blood pressure, but does not tell the person that the vast majority of the time people gain all of their weight back within 5 years, or that some methods of weight loss are likely to make the high blood pressure worse. The doctor also doesn’t explain that weight loss is not guaranteed to lower blood pressure even if they are in the tiny percentage of people who successfully maintain weight loss. Rather, they tell the patient that everyone who tries hard enough can lose weight permanently. When the patient goes back for a check up, the doctor puts them on the scale to test their progress.

There are a few issues to explore here with respect to the doctor’s behavior with the fat patient:

The first is the concept of evidence-based medicine.  Even if it’s the doctor’s sincerely held personal belief that weight loss will cure high blood pressure, based on the evidence that we have there is no reason to believe that this patient can lose weight long term.  In fact, since the evidence we have shows that the majority of patients who attempt weight loss end up regaining more than they lost, if the doctor thinks that being fat is the problem, then recommending weight loss is irresponsible and the worst possible advice.

Often doctors try to explain this away by citing the evidence of correlation between fat and various diseases (“but being fat is so bad that’s you should try to lose weight no matter what the odds!”)  It does not matter what issues fat is correlated with, because we don’t know how to make people thin in the long term. Saying that we do is a lie, whether it’s intentional or not.  If your doctor tells you that weight loss works, ask her or him to produce a study where a majority of participants were able to maintain a weight loss of the amount that she/he is recommending for you, for 5 years or more.  They will not be able to do so.  Prescribing weight loss has no efficacy basis in evidence.

The second is an issue of diagnostic criteria.  When we use weight as a stand-in for health, we are putting a middle man where we don’t need one.  Doctors can test a patient’s blood pressure, give evidence-based interventions to lower it, and then test the blood pressure again to see if the interventions are creating the desired result. It doesn’t make sense to prescribe a body size intervention for a health problem.

Prescribing weight loss for high blood pressure is like prescribing weight loss to cure cancer. (the difference being that weight is simply a body size and cancer is a disease, but it still makes an apt comparison in terms of the way that they are both used in modern medicine).  Although we are aware that the treatment for cancer often leads to weight loss, we don’t tell cancer patients that weight loss will cure their cancer.  When they come in for check-ups we don’t weight them to measure the efficacy of the treatment.  We understand that with cancer interventions weight loss is a side effect.  It’s the same with treatment of high blood pressure, diabetes etc.  It’s possible that the behavior changes that are recommended for intervention will lead to a change in weight, but that’s merely a side effect, it’s typically temporary, and it’s not a proper diagnostic criteria or efficacy test.

The third issue is of informed consent.  Going back to the cancer example, a doctor can recommend a risky procedure to treat cancer.  They must tell the patient the odds for success as well as possible side effects and what happens if it fails, and give the patient a prognosis.  They cannot tell patients that anyone who tries hard enough can beat cancer,  both because it’s not true, and because it irresponsibly sets up a situation where patients feel like it’s their fault when the treatment (that almost never works) doesn’t work for them. They also have to let them know if there are other options. Then the patient makes an informed decision.

A doctor can prescribe weight loss, but informed consent would require that they let the patient know that it only works long term a tiny percentage of the time, that the vast majority of people regain their weight and that the majority gain more weight than they lost, meaning that the majority of the time the “treatment” has the exact opposite of the intended effect. They also have to tell them that, not only does weight loss almost never succeed in lowering body weight long-term, there has never been a single study that proves that losing weight will create the health change they are hoping for.

When we talk about dramatic weight loss the figures drop to be almost non-existent. Doctors also have to let patients know that there is a great deal of evidence that shows that healthy habits lead to healthy bodies regardless of weight.  They cannot correctly tell the patient that anyone who tries hard enough can lose weight – that’s not supported by the evidence. They should also inform them that these diseases happen to people of all sizes, but that patients of a lower weight who present with the same symptoms are given a different treatment plan, and explain that plan as an option.  Their fat patient may now make a truly informed decision.

Your doctor may not be making these mistakes intentionally.  She or he may not know about the studies that I am referencing here. All the same, the evidence is there and we trust doctors to be working from the principles of evidence based medicine, proper diagnostic criteria and informed consent. We should be able to go to the doctor with the expectation that they will not make these mistakes, but that is not the situation in which we find ourselves.

So, as my friend Darryl Roberts is fond of saying, we must be the CEOs of our own health.  (Or as I am fond of saying, we must be the boss of our health underpants.) If we are to get good healthcare we must be informed and steadfast in our requirement that doctors treat us based on the evidence.  Most versions of the hippocratic oath include a phrase to the effect “I will not be ashamed to say “I know not.”  If your doctor is still making these mistakes and is surprised to hear about this research, then now is the time for them to invoke that.

Here is the research, including quotes from each piece:

Research about the failure rate of dieting:

Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J: Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer (link goes to article)

http://www.ncbi.nlm.nih.gov/sites/entrez/17469900 (link goes to study)

“You can initially lose 5 to 10 percent of your weight on any number of diets, but then the weight comes back.  We found that the majority of people regained all the weight, plus more. Sustained weight loss was found only in a small minority of participants, while complete weight regain was found in the majority. Diets do not lead to sustained weight loss or health benefits for the majority of people…In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.”

http://www.academia.edu/4796404/Tomiyama_A._J._Ahlstrom_B._and_Mann_T._2013_._Long-term_effects_of_dieting_Is_weight_loss_related_to_health_Social_and_Personality_Psychology_Compass_7_12_861-877._doi_10.1111_spc3.12076

We believe the ultimate goal of diets is to improve people’s long-term health, rather than to reduce their weight. Our review of randomized controlled trials of the effects of dieting on health finds very little evidence of success in achieving this goal. If diets do not lead to long-term weight loss or long-term health benefits, it is difficult to justify encouraging individuals to endure them

Miller, WC:  How Effective are Traditional Dietary and Exercise Interventions for Weight Loss

“Although long-term follow-up data are meager, the data that do exist suggest almost complete relapse after 3-5 yr. The paucity of data provided by the weight-loss industry has been inadequate or inconclusive. Those who challenge the use of diet and exercise solely for weight control purposes base their position on the absence of weight-loss effectiveness data and on the presence of harmful effects of restrictive dieting. Any intervention strategy for the obese should be one that would promote the development of a healthy lifestyle. The outcome parameters used to evaluate the success of such an intervention should be specific to chronic disease risk and symptomatologies and not limited to medically ambiguous variables like body weight or body composition.”

Methods for voluntary weight loss and control. NIH Technology Assessment Conference Panel

A panel of experts convened by the National Institutes of Health determined that “In controlled settings, participants who remain in weight loss programs usually lose approximately 10% of their weight. However, one third to two thirds of the weight is regained within one year [after weight loss], and almost all is regained within five years.”

Bacon L, Aphramor L:  Weight Science, Evaluating the Evidence for a Paradigm Shift

“Consider the Women’s Health Initiative, the largest and longest randomized, controlled dietary intervention clinical trial, designed to test the current recommendations. More than 20,000 women maintained a low-fat diet, reportedly reducing their calorie intake by an average of 360 calories per day and significantly increasing their activity. After almost eight years on this diet, there was almost no change in weight from starting point (a loss of 0.1 kg), and average waist circumference, which is a measure of abdominal fat, had increased (0.3 cm)”

Field et. al Relationship Between Dieting and Weight Change among preadolescents and adolescents

“Findings from this study suggest that dieting, and particularly unhealthful weight control, is either causing weight gain, disordered eating or eating disorders; serving as an early marker for the development of these later problems or is associated with some other unknown variable … that is leading to these problems.  None of the behaviors being used by adolescents (in 1999) for weight-control purposes predicted weight loss[in 2006]…Of greater concern were the negative outcomes associated with dieting and the use of unhealthful weight-control behaviors, including significant weight gain…Our data suggest that for many adolescents, dieting to control weight is not only ineffective, it may actually promote weight gain”

Studies about healthy habits leading to healthy bodies

Matheson, et al:  Healthy, Lifestyle Habits and Mortality in Overweight and Obese Individuals

“Healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index.”

Steven Blair – Cooper Institute

“We’ve studied this from many perspectives in women and in men, and we get the same answer: It’s not the obesity, it’s the fitness.”

Glenn Gaesser – Obesity, Health, and Metabolic Fitness

“no measure of body weight or body fat was related to the degree of coronary vessel disease. The obesity-heart disease link is just not well supported by the scientific and medical literature…Body weight, and even body fat for that matter, do not tell us nearly as much about our health as lifestyle factors, such as exercise and the foods we eat…total cholesterol levels returned to their original levels–despite absolutely no change in body weight–requiring the researchers to conclude that the fat content of the diet, not weight change, was responsible for the changes in cholesterol levels.”

Paffenbarger et. al. Physical Mortality:  All Cause Mortality, and Longevity of College Alumni

“With or without consideration of …extremes or gains in body weight…alumni mortality rates were significantly lower among the physically active.”

Wei et. al. Relationship Between Low Cardiorespiratory Fitness and Mortality in Normal-Weight, Overweight, and Obese Men

…

Research about doctors perception of fat patients

Rebecca M. Puhl and Chelsea A. Heuer The Stigma of Obesity –  A Review and Update

“In a study of over 620 primary care physicians, >50% viewed obese patients as awkward, unattractive, ugly, and noncompliant. One-third of the sample further characterized obese patients as weak-willed, sloppy, and lazy.”

The Fat Activism Conference starts today! 
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A new study shows that “healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index”.  Look, over there…it’s a great big flaming sack of “no kidding.”

Which is not to say that the study shouldn’t have been conducted, but is rather my attempt to point out the utter ridiculousness  of clinging to the idea that getting our bodies to a specific height weight ratio is our best chance for being healthy, knowing the health is not guaranteed, not entirely within our control, not an obligation, and not a barometer of worthiness, in the face of overwhelming evidence that:

1.  It’s not possible for most people who aren’t in the weight range to get into it

2.  There are plenty of people who fit that height weight ratio who are not healthy

The study looked at the association between 4 healthy lifestyle habits and mortality in a sample of 11,761 people. The healthy habits were:

1.  Eating 5 or more fruits and vegetables daily

2.  exercising regularly

3.  consuming alcohol in moderation

4.  not smoking

As you can see on the chart, being “normal weight” is an advantage if you do not partake in any of the four habits (which is still not causal.)  However, even one healthy habit cuts the risk down by about half, and subjects who did those four things and were obese have basically the same outcome as “normal weight” people who did all four habits, and a dramatically lower risk than thin people who didn’t participate in the four habits.

This study is not perfect.  While 14 years is a decent study period, 12,000 people could be construed as a  small sample size, and it speaks only to mortality. The study isn’t overarching proof of anything – in fact overarching proof is very rare – that’s why I waded through brain aching statistics classes.

A very smart friend of mine asked me recently if I put the studies that I tout up to the same scrutiny as the studies on weight loss that I tear apart.

The answer is that I do, but I consider something else as well: risk.  I’m familiar with the idea of downside risk from business – I spent years working in business operations as a consultant and my last gig was as CEO of a multimillion dollar locally owned business so I’ve been steeped in business decision making.  Downside risk is a look at worst case scenarios – you can’t just make decisions based on what will happen if your strategy succeeds – you also have to look at what could happen if it fails.

So the worst case scenario for weight loss is that I fail at weight loss multiple times and end up heavier than I started and subject to the dangers of weight cycling which include high blood pressure, high cholesterol, diabetes, depression and cardiovascular disease.

The worst case scenario of healthy habits is that I exercised, ate vegetables, drank moderately and didn’t smoke and they didn’t make me healthier.

Next we have to determine how likely it is that we will experience this worst case scenario:

The vast majority of people who attempt weight loss will fail long term according to all the studies that exist. In truth if weight loss were a business decision I would probably never get to a risk calculation since the success rate is within the margin of error and not really worth trying since weight loss doesn’t always come with health improvements – sometimes it arrives alone. But let’s finish this exercise.

Based on this and other research such as that by the Cooper Institute, Wei et. al., and others healthy habits have an excellent chance of increasing health – certainly much better than weight loss.

So my decision to focus on healthy habits rather than weight loss is based both on an analysis of the likelihood of success and an analysis of downside risk. It’s also based on common sense – there are “normal weight” people with type 2 diabetes and high cholesterol, and high blood pressure, “normal weight” people get the same health issues that fat people do and “normal weight” people die of the same things that fat people do, so being “normal weight” cannot be a sure cure or preventative.

The only analysis in which weight loss comes out ahead is about what is most profitability for the diet and pharmaceutical industries.

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Become a member: For just ten bucks a month you can keep this blog ad-free, support the activism work I do, and get deals from cool businessesu

Dance Classes:  Buy the Dance Class DVDs or download individual classes – Every Body Dance Now! Click here for details 

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If my selling things on the blog makes you uncomfortable, you might want to check out this post.  Thanks for reading! ~Ragen

Dear people who shame fat people and fat bodies,

I’m going to assume that you are doing what you truly think is best for fat people.  Normally I can see where many different points of view are valid, but in this matter you are just wrong.  Shaming is never the way to go and here is why:

People don’t take care of things they hate and that includes their bodies.  When you encourage people to be ashamed of their bodies, you decrease the chances that they will believe that they are worthy of care.

Shaming may actually create the problems that it’s purported to solve:  Peter Muennig from Columbia found that the stress of stigma and shame were correlated with the same diseases with which obesity is correlated. So every time you make someone feel bad about themselves, you put their health at risk.

Muennig’s research also found that women who were concerned about their weight had more mental and physical illnesses than those who were fine with their size, regardless of their weight.  So telling a fat woman to be concerned about her weight is dangerous.

When doctors are told to shame fat people for their weight, it leads to fat people not going to the doctor, they miss out on preventative care, and they end up not getting treatment until an issue is very advanced (which gives them even less time to wade through doctors who ignore their actual health issues and just tell them to lose weight to get actual evidence-based healthcare.).

When we shame people for getting sick, then they are too embarrassed to get the treatment they need.

We will never know how much all of the shame and stigma affects fat people until we stop shaming and stigmatizing them.

Shame is just never, never the way to go. There is no proof that shame and stigma lead to thin bodies or good health outcomes.  There is plenty of research that shows that shame and stigma lead to negative health outcomes.  You can no longer justify your shaming behavior in any way other than an attempt at putting down others to try to feel better about yourself, or to try to feel superior.  So now you know.  And knowing is half that battle.

Acting on your knowledge is the other half. Knowing the negative effects of shame, the only responsible course is to stop body shaming immediately.

Project Update – VICTORY!

Our e-mail writing and Facebook bombing worked!  Citizen’s Medical Center has ended their policy of not hiring people with a BMI over 35.  Add this to our victories including getting NEDA to remove the STOP obesity Alliance from its list of partners, responding to The Biggest Loser’s marketing that people can’t be loved until they are thin with our own kick ass video, creating the Fit Fatty Forum Photo Gallery, creating the 353 member Rolls Not Trolls Community to spread Size Acceptance and Health at Every Size to the darkest corners of the internet, Marilyn Wann’s incredible STANDards project, and raising $21,000 and putting up 6 billboards and 10 bus shelter signs in Atlanta to show kids of all sizes that they are valued and supported, and the iVillage Diet Quitters slide show that is in production, the HAES/SA Activist Community is kicking some serious ass.

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