CW: mention of weight stigma and eating disorders.
Food labels are a good thing. Otherwise I might have to purchase my own bar code scanner for the kitchen.
In the past few years, we’ve seen an increase in calorie-labeling on foods in restaurants and other places that sell food. In the US, this has been the result of public health and consumer advocacy, aided by the passage of the Affordable Care Act. The motivation for mandating calorie labeling is to provide consumers with information to encourage them to make “healthier” food consumption choices (meaning choices in accord with standards set by government agencies like the USDA).
Full disclosure: in my day job as a public health ethicist, I wrote a short piece about calorie labeling. tl:dr version– food policies aimed at increasing health and health equity at the same time are complicated. There are some positive and negative effects of calorie labeling, and other policies and programs are needed to promote health-according-to-everyone.
But that was so 2015. Fast-forwarding to the end of 2019, we now see news reports of a study suggesting that calorie labeling is out, and activity labeling is in. What might activity labeling be? The idea (such as it is) is to put information on food packaging telling you how many minutes you’ll need to walk or run in order to burn the number of calories in said food. Here are some proposed illustrations from the original paper on this topic:
There are so many objections that this idea (such as it is) raises. I have a bunch of them, but first, let’s see what Dr. Yoni Freedhof (who knows and writes a lot about body weight regulation and health policy, among other things) said on Twitter (thanks Sam for pointing this out to me):
Exercise calorie labeling reinforces unhealthy notions that the only point of exercise is burning calories, that doing so affords people shit food, that exercise is the primary driver of weight, and that people with obesity are lazy gluttons.
Yep. I’d say he hit the nail on the head with that tweet. Just to pile on, here are a few more objections:
Calorie food labeling has been shown to have negative effects on some populations– it can increase weight stigma, trigger those with eating disorders, and further isolate and marginalize groups already burdened with health disparities. Activity food labeling may produce negative effects as well; we’d need to study this a lot more before implementing anything.
It’s not even clear to what extent activity labeling works– the 15 studies used in the original article were small, of variable quality and power, and their results were not stunning.
Using walking and running on the labels is inaccurate and seriously ableist. There are other ways to label energy output (e.g. use of METs— thanks, commenter on FB who reminded me of this) that are more accurate and not activity-specific.
Labels can be a good thing when they are accurate, understandable, relevant, not shaming, not exclusionary, and useful. But honestly, if it’s activity labels or nothing, I’ll just do this:
Hey readers, any thoughts or reactions on activity labels on our food? I’d love to hear from you.
There’s a story we tell here on the blog. Do the things you love, whatever movement fits into your day is good movement, eat what your body feels like eating.
Regular readers, you know our drill. It’s a relaxed, forgiving tune we sing around here most of the time.
Regular readers know too that I’ve been struggling a bit with that tune. These things are all true, I still sing that song, but at the same time things are getting more complicated with age and with injury. I’ve written before about doing things that aren’t fun (so much painful knee physio!) and about rest. Tl;dr: It’s complicated and sometimes I get frustrated.
It’s especially more complicated as we age. It’s especially more complicated for those of us with performance oriented fitness goals. Martha and Marjorie Rose are serious about their lifting. Kim and I have cycling goals. Others run and race. Cate is often preparing for her next big solo adventure. Christine is training for her next martial arts test.
As a group we’ve got a lot going on. We all do some strength work, some aerobic activity for endurance, some aerobic activity for intensity, and some activities for flexibility and mobility. For me, right now, it’s physio, weights, cycling and yoga.
I don’t mean to sound whiney. I’m not really complaining. It is what it is. But what it is is not simple or easy.
So we’re busy but what do I mean by “more complicated”?
Do you remember when if you had a big project due for work or school you could just stay up all night, maybe even for a couple of nights, and push through? If you were working late you could skip meals, no problem. Aging takes away that ability for most of us. We need to be more organized and scheduled with our work and with our lives.
There are new rules for everyday eating too. For example, there’s a whole list of foods I don’t eat late in the day not because I’m concerned about my weight but because of heartburn. Oh, midlife. Lots of my friends are pretty scientific about their caffeine consumption. Luckily, I can still drink regular coffee after dinner but I think I’m the last in my friend group who is able.
All of these changes are present as we age as athletes too.
Here’s Abigail Barronian talking about the aging athlete, “It’s no secret that our bodies change as we age. Muscle mass and strength decline, it takes longer to recover from hard efforts, and our capacity to handle high training volumes can diminish. On top of that, mobility decreases and we become more prone to certain injuries. When an older athlete stops training, their fitness deteriorates significantly quicker than it did when they were young—and building it back is much harder.”
So given all the constraints it’s hard to be relaxed about things. Fitness in midlife and beyond requires more structure and thoughtful planning. If it used to be the fun, intuitive, freewheeling part of your life, that’s a tough psychological change too. Mostly it’s still a lot of fun for me but these days I’m finding the planning and organizing a bit stressful.
First, as we age rest becomes more important and it’s harder scheduling workouts and scheduling rest days, not to mention getting enough sleep. Aging athletes need more rest between tough workouts. I love rest but even for me sometimes the recommended amount of rest feels like too much. In recent years we’ve discovered that aging athletes can still work out hard. There’s no need to dial back workout intensity but there is a real need to rest more between workouts. We don’t recover and bounce back the way we used to.
A colleague of mine, and former bicycle racer, who is now 59 years old, put it something like this: “In my twenties I recall being able to do five or six hard workouts a week and race back-to-back days without any trouble.
In my thirties this changed to three or four hard workouts a week and it was more difficult to race back-to-back days. In my forties, two or three hard workouts a week were more than enough, and racing back-to-back days was a bit of a challenge. In my fifties, one or two hard workouts a week were enough and recovering from a race took me about a week. Now, approaching 60…don’t even ask.”
The rest and recovery time of a 20 year old athlete is significantly different than that of a 45 year old athlete. It’s different again at 55 and so on. But this means that taking training plans off the internet won’t work. Often they don’t allow enough rest.
From Here’s how to get stronger after fifty: “As you age, your body bounces back more slowly from intense exercise. Successful older athletes should take their recovery as seriously as their training. “Younger athletes can get away with a poor lifestyle and still perform, but older athletes cannot,” Swift says.”
When I was younger it was just a matter of juggling, fitting in the activities I wanted to fit in, amid kids and a busy work schedule. But as we age there’s also the matter of resting between workouts which becomes more and more important. I’ve long been a fan of deliberate rest days and every coach I’ve had has talked about their importance. Except now they’re more important and I don’t have a coach to make sure I take them.
Likewise for lifting, as we age there’s more need for rest. I read a study recently that claimed for midlife women lifters the right ratio for strength training is two hard workouts followed by one easier workout with lighter weights. I’m not sure if that’s right or not but the main point stands, it’s complicated.
I’ve read too that after 50 you should move to two rest days a week of which one can be active recovery, gentle cardio or yoga maybe.
What am I trying to fit in? The big and important thing is knee physio and strength training. Say three days a week. Next up is cycling, also three days a week. I would like to do hot yoga twice a week. And I also want to take a complete rest day. Oh and also I have to be flexible and fit things in around a very demanding work schedule.
Second, food is more complicated too. For me, there’s some planning involved. I have medication I have to take each morning on an empty stomach and then wait an hour before breakfast. That’s tricky. I also have medicine I have to take after breakfast because it can’t be taken on an empty stomach. Oh, and I need to get to work sometime.
There’s also this whole thing about aging athletes and muscle loss. Our bodies use protein less effectively so we are supposed to eat more of it, some with each meal. I also need fewer calories to get through the day–thanks also to aging– so protein takes up a good chunk of the calories. Add vegetables. Where’s the room for other food? That’s not easy to organize either.
Thirdly, for pretty much all of us there are complications related to injury. My knee is an ongoing thing and recently Tracy injured her Achilles. When that happens you’re doing workouts but also physio and in my case massage therapy too. It can feel like a lot to manage.
Now maybe you might think that one doesn’t need to take it all so seriously. You can walk to work, stretch once in awhile, and do work around the house. And that’s true. You can. But if your goals are more about maintaining fitness as you age and not losing muscle, it’s complicated. Mostly I’m good with that. But I confess that some days I just want to not think about what I’m eating or when I’m next riding or lifting and curl up on the sofa with a mug of hot tea and a book.
CW: Discusses diets, food, BMI and commonly held misconceptions. If you like to believe everything you think is 100% correct, are prone to all-or-nothing thinking, or want your beliefs reinforced on all things health and fitness, you may not want to read this post.
I think I’ve reached the point that I need a pseudoscience trigger warning. I am finding myself angry to the point of nearly yelling whenever someone mentions their “love languages” like it’s anything more than a convenient construct. The other day, I wanted to ram into the minivan ahead of me on the freeway with their anti-vaxxer bumper sticker. If I have to listen to one more Republican politician espouse a conspiracy theory as if it were the truth, I might remove my car radio and throw it out the window.
I am a science teacher, and trained to think like a scientist. I believe in facts and research and data. And we live in a world in which science is discussed with such ignorance that the presence of a single study is enough to sway/reinforce the incorrect beliefs of people. No one discusses the preponderance of the data. No one is asking for the big picture data over time. And this lack of scientific literacy is hurting people.
I live in a city that doesn’t fluoridate its water because a majority of the voting public considers it unsafe. These voters aren’t thinking about the consequences for the uninsured and underinsured children who don’t receive regular dental care and benefit measurably from fluoride treatments. Instead, there’s a mindset that “impurities” or “chemicals” are “toxins” and therefore things we should all want to avoid. This is pseudoscience.
The debate about organic produce focuses on these fears of “toxins” as well, instead on the very real dangers of overproduction, potential lack of sustainability or concerns for workers’ rights. And don’t get me started on the fear of GMOs. I am concerned about GMOs, but not for any personal health reasons–rather, I don’t like the idea that we are reinforcing monocultures, cloned products with no biodiversity designed to be sprayed with levels of chemicals potentially unsafe from the workers doing the work and the communities that live downwind. On the other hand, if we can design GMO versions of staple foods that reduces environmental degradation while providing sufficient nourishment for the food insecure nations of the world, who am I to say they can’t have it? There is NO evidence that these products are dangerous to human health once they reach the dinner table, and yet that is the only discussion we are hearing. We can’t have a meaningful debate about the real costs and benefits of these products when we aren’t even agreeing upon the basic facts.
Want to get pissed off at some pseudoscience? Watch pretty much any of the food “documentaries” created since Supersize Me became a blockbuster. There you can learn the half-truths behind the values of juicing, eliminating sugar, paleo diets, vegan diets, Twinkie diets, McDonalds diets, and so much more. Look for the warning signs of pseudoscience as you go–are they using anecdotal data and individuals while avoiding comparing larger sample sizes? Do they ignore the facts that run counter to their arguments? Do they set up false dichotomies requiring an all-or-nothing comparison–the worst of the standard diet against the best/purest of the proposed diet? If so, consider this your pseudoscience trigger warning.
Health, diet and fitness culture is rife with this sort of pseudoscience. Every named diet ever formulated has some sort of “data” to argue that it is the best way to make you healthier, happier, and fitter. Every single one of them cherry-picks the data, jumps to conclusions outside the purview of the research, and uses logical fallacies like false dichotomies to “prove” their superiority. Their goal is to sell their books, products, and edible non-food meal replacement products, not to inform you. And every time a friend or family member of mine begins to starve themselves in a new way or to take outrageously expensive supplements, it pisses me off. I’m not angry at them, I’m angry at the liars shilling these products and false promises.
I’m angry at the diet and fitness industry for convincing so many people that it is exclusively their own fault for having a larger body and that the solutions are simple. I’m angry that people believe they need to go “on a diet” in order to live a healthier life in a body that more closely meets their needs. I’m angry at the lie that we should exercise to control our body size and the willful ignorance that avoids discussing the dozens of other actually good reasons for regular exercise, regardless of our body size. Commercials, paid spokespeople, and poorly written news reports that ignore this bigger picture really do deserve a pseudoscience trigger warning.
But of course, it is the nature of pseudoscience to not identify itself as such. It would lose some of its intended power if it had to remind you first that what they were about to say has limited evidence to support it.
But wouldn’t it be wonderful if these warnings existed? Imagine a world in which news broadcasters interviewing the latest fitness guru had to first announce, “Trigger warning, everything we’re about to say has limited or questionable data to support it.” What if dietary supplements came with a bold statement that said “we cannot prove that anything will happen when you take this pill, and maybe it will make things worse.” What if any time your friend/family member/colleague began to espouse how great it is to go Keto they found themselves first saying “there is absolutely no evidence that this is going to work for me long term, but I’m going to try it anyway.”
What if your doctor had to say, “Now, there’s mixed evidence that BMI has a causal relationship to other risk factors, it is only accurate as a measure of body fat percentage for about 60% of the population, and it’s commonly used to reinforce anti-fat stereotypes. Given all that, I’d like to discuss how much you weigh.”
Think of how much more empowered we would be if these warnings were expected and required. I am so sick and tired of hearing bullshit being espoused as fact. We live in an era in which genuine experts are distrusted and suspected of ulterior motives, in which confirmation bias is treated as an acceptable alternative to hard truths. People rely upon the news, doctors, experts and friends and family to help them sort through the data to make the best decisions for themselves and their health. We can’t make good decisions with bad data, and until we find another way to sort through the pseudoscience, I would appreciate a trigger warning.
Marjorie Hundtoft is a middle school science and health teacher. She can be found yelling at her car radio during long commutes, picking up heavy things and putting them back down again in Portland, Oregon.
I do December the same way most people who celebrate Christmas do – a rush of preparations combined with extra social events, with a hearty attempt to fit in all of the things that I meant to get done during the rest of the year.
Of course, I also get the bonus of having ADHD so, like Dirk Gently in the photo below, I laugh at the concept of time. I have to put a lot of mental effort into calculating how much time something will take. If I try to just ‘wing it’ with my estimations, I end up trying to cram 50 things into an hour or I give myself so much time to do a task that my brain refuses to get into gear because there is no urgency.
And, as a life coach, I end up observing my own behaviour so I can use it as an example when I am explaining things to clients.
So, over the past few years, I have been making incremental changes in my December plans. I have been trying not to get caught up in the rush and, instead, be conscious of what I am choosing to do each day and how those choices makes me feel.
This year, I have the benefit of data from having made similar types of choices about September.
Previously, I used to just give myself a break in September and not try to add anything new beyond what had to be there (i.e. an arts festival and two kids starting school.) This year, however, I added a short yoga practice and a drawing exercise to my busy September days.
Instead of feeling rushed and resenting the extra tasks, those two things became my personal anchor every day. Most days, I did them first thing. And I found that creating that little space of personal focus early in the day gave me a sense of accomplishment and a sense of peace.
A sense of accomplishment and a sense of peace is exactly what I am looking for in December, too.
So, I’m adopting a similar practice for the month ahead.
Since I know that one good way to add a new habit is to ‘anchor’ it to something you already routinely do, I am going to add a short ‘warm-up’ to my day right after my yoga practice.
And, to stick with the formula from September, I’m going to write or draw on an index card every day, too.
I’ll check in a couple of times in December to let you know how things are going.
PS – I didn’t realize that my post was going to have two themes today but when I want to talk about how time is a slippery concept, Douglas Adams just springs to mind and when I want to talk about a feeling of accomplishment then I am all about stars. 🙂
CW: talk of fat-shaming and weight connected to health (for purposes of describing my presentation). The past two weeks have been conference-intensive. I was in Guelph, Ontario a couple of weeks ago, listening to talks about Feminism and food and also hanging out with our blog founders and friends Sam and Tracy. I mini-blogged about some of the talks here.
This past week, I was giving a talk at the American Public Health Association Meetings in Philadelphia. It was about health-concern trolling of fat people in the doctor’s office and other healthcare contexts. Spoiler alert: I’m against it.
What do I mean by health-concern trolling? Think of it as fat-shaming speech justified by health concerns on the part of the speaker. Here are some common examples:
I’m just concerned about your health.
You’d find that life was a lot easier if you weighed less.
(insert any disease or condition here) would be less severe/go away/never have appeared if you lost weight.
Before treating (insert any disease or condition here), you need to lose weight.
But of course images speak volumes. You’ve seen it before, but it’s a classic:
Apart from the big problem the woman in the comic has, how does health concern-trolling harm us? I think (as do others working in feminist bioethics– there’s strength in numbers…) that it’s a form of microagression, which wears us down with the repeated message that we don’t matter as patients, as persons who deserve respect and care.
What do I mean by microagression? This: A microaggression is a relatively minor insulting event made disproportionately harmful by taking part in an oppressive pattern of similar insults. The pattern of insults tends to be linked to stable traits such as gender, ethnicity, disability status, or (in this case) weight. Philosopher Regina Rini explained the harms of microaggressions well here:
What makes microaggression distinctively harmful is victims’ awareness that each instance is not an isolated accident. It will happen again and again and again. Further, these minor insults are linked to vast social harms…”
There’s a lot written about microagressions, and I’m just getting started thinking and writing about them. Next year I’m applying for funding to do some focus groups of fatter people to ask about their experiences with health-concern trolling in healthcare contexts. The goal is to find out what they think good health care looks like from their perspective. Stay tuned for more updates on the health concern trolling front.
Readers, what does good health care look like to you? What would you want to change in your encounters with health workers? I’d love to hear from you.
Last Sunday, I ran my first race. I’ve been running for eleven years (and are my legs ever tired!) but I’ve never run any kind of a race before. Mainly because I’ve just never been much of a one for races. I even dropped out of the rat race a few years ago, because – as a funnier and wiser woman than I once pointed out – even when you win, you’re still a rat.
So naturally, for my very first race ever, I chose to run a half-marathon. Because why not?
Actually, it was Andra’s idea. Andra is my physiotherapist, and a former competitive swimmer and volleyball player. She takes no shit from anybody, least of all me.
I’ve been working with Andra for over three years now. For two of those years, I wasn’t running at all. She helped reconfigure my body after my last pregnancy downloaded and installed some updates that I don’t ever remember clicking “OK” on.
The thing is that, apparently, for most of my adult life, I’ve been walking around with an undiagnosed case of scoliosis: a bent spine. Mine curves from side to side, creating a posture somewhat reminiscent of one of Tom Thomson’s windblown jack pines. I always knew I was a bit off-kilter, but I never knew until three years ago that I had A Condition.
Apparently (don’t quote me on this) if you have scoliosis, one pregnancy is OK, but subsequent pregnancies can worsen the spinal curvature. Much hilarity ensues. Like, if you’ve ever wanted to recreate the Grand Canyon between your rectus abdominis muscles, scoliosis plus pregnancy can totally help you with that.
Now, I did not want the Grand Canyon, but it ended up being part of the whole post-partum package-tour I embarked on back in 2016 (you really gotta read the fine print on these things). In addition to scheduled stops at Sleepless Gulch and Hormone Crash Hill, there was also plenty of commentary from the locals: “Already pregnant again!?” “Is this one of those weird twin pregnancies where they’re born weeks apart?” “Wow, I forgot how long it takes to look normal after giving birth!” etc etc.
Worst trip ever. But at least, after the magical “six weeks pp” were up, I’d be “allowed” to run again. Right? Right?!
[Ron Howard’s voice: “She was wrong.”]
In September 2016, I found out that not only did I have scoliosis, but it had also probably worsened during the pregnancy, turning the area under my ribs into a veritable pressure-cooker and creating a gaping 12cm/6-finger separation between my abs. This separation, together with the scoliosis, was setting me up for even worse alignment problems that could result in spinal deformities, disc herniation, urinary incontinence and – everybody’s favourite – pelvic organ prolapse.
And so, given this, I should give up running, forever, and take up race-walking. (If my life were an episode of Friends, this would be the one where Chandler Byng quips, “Because race-walking is such a ordinary, everyday activity that doesn’t make you look ridiculous or stand out AT ALL.”).
Oh, and also? My abdomen would never be flat again without at least ten-thousand dollars’ worth of plastic surgery, followed by a two-month recovery and almost inevitable chronic and incurable pain from nerve damage. Pretty much the best thing I could do, in this strange, new, disloyal, and no longer conventionally-attractive body, was “be grateful” I was a “mama”, and “embrace” my “journey”, along with my “battle scars” and my “tiger stripes”.
I am still mildy amazed that I didn’t “drop-kick” the “physiotherapist” right there and then, but forgive me, my reflexes were pretty shot from lack of sleep.
That was Physio No. 1. Physio No. 2 was Andra. Who, in her no-nonsense, does-not-suffer-fools-gladly, clipped Romanian way agreed with Physio No. 1 that my situation was “not good” (“It feels like gummy bears in here, it feels like a trampoline” she said, prodding my abdomen).
Then she uttered life-changing words: “We will fix this.”
If I’d known, sitting in a tiny office up the street from the Reference Library on a dreary winter afternoon, that the path to “fixing this” was going to involve a two-year slog through electro-accupuncture, progressive core-activation exercises, swimming endless laps, tedious floor work, before finally graduating to modified workouts with a trainer at the gym – I’d have crumpled to the floor. This piece, written then, knowing that, would have been entitled By the Toronto Reference Library I Sat Down And Wept, and I probably wouldn’t be running today. Actually, I’m not sure – I’m a stubborn old cuss when you get right down to it. But knowing that entire years lay between me and me getting back to my preferred – at the time, my only – sport, would have been devastating. Andra was smart. She didn’t say anything about how long it could take. She just said we would fix it, and I believed that we could so I was ready to show up and do the fricken work.
And if you’d told me that in less than three years, I’d run a half-marathon – me, who had never run any race, ever, who had run a continuous 20K exactly one time, in three hours, four years ago – me, always picked last on teams in gym class – me, lugging this living cautionary-tale of a postpartum body around, a “Here Be Dragons” warning made flesh – me? Run in a marathon? I would have laughed so hard I’d probably have busted a gut. (Except it was already busted, so no worries there).
But. Reader, I marathoned. OK, I half-marathoned. I ran the Scotiabank Toronto Waterfront Half on October 20, 2019. My goal was modest: sub 2:30. I crossed the finish line at 2:27.
A year ago, almost exactly, I was running one minute and walking five. I was glad to be running again, even if only for a minute at a time, but I was finding it really, really hard. I had so little endurance, despite all the work I’d put in over the past two years. And when winter came, I quickly got bored of running on the indoor track at the gym. So I took up skating instead, because if you can’t beat Winter, you may as well throw your arms wholeheartedly around it while also leaping around frozen surfaces on sharp blades.
When the ice melted, I moved the skating indoors, but I also went back to running. With Andra’s endorsement, I registered to run the STWM half. I didn’t commit to seriously training for it until June, which is when I made the total rookie mistake of upping my daily mileage by 6K in one day and made the fascia around my right hip “angry”, in Andra’s words. My hip’s temper tantrum set me back weeks.
Nevertheless, I persisted. Andra’s advice plus a tennis ball and a foam roller got me back on track. By September, I was running 10K easily. Then 12, then 14, then 16, and finally my last three long runs before the race were just over 18K.
Seasoned runners joke that running a marathon is simply a matter of putting one foot in front of the other. So too was my recovery. Except, I stopped looking up while I was doing it, because every time I looked up, I scanned for a horizon I couldn’t even see, much less imagine, and this made me angry and scared and sad. So, I just kept my eyes on my feet and kept moving them forward. One foot, then the other. Physio, swimming. The gym, my bike. The stairs in High Park, and then the hiking trails. Run one, walk five. Skate a bit, run a bit more. One foot, then the other. I just kept showing up. I went to the gym and to the rink and to physiotherapy (thank you childcare, part-time job, supportive partner, and generous spousal health insurance coverage!) and somehow, somehow along the way on this metaphorical “journey” (*makes flourishing air quotes with hands*) I upgraded from the all-inclusive Occasional Runner package, to some kind of Choose Your Own Jock Adventure deal. And that’s an upgrade I’m more than OK with.
Jennifer is a writer, mother, wife, runner, cyclist, skater (ice and inline), and non-profit administrator. She lives in Toronto.
Sometimes, when you see a repeated injustice, you get cynical or resigned and roll your eyes. And sometimes, you get teed off. I’m guessing you can guess which one I’m more predisposed to.
Sam shared this twitter story (here and here) from Jen Curran, who had elevated protein levels in her urine during her pregnancy, and she was told to “lose 40 pounds” and come back. Weeks, and a second opinion, later, she learned that she had blood cancer. Her regular doctor ignored what she was saying, and focused on her size instead (as she was pregnant, no less). This is not news.
And it pisses me off.
How is this STILL happening to larger bodied people? How is it that doctors are looking at our sizes, our weights, and our BMIs as if they are useful pieces of data unto themselves?! Do fatter people get cancer? Broken vertebrae? Appendicitis?
We are far past critical mass here–it is long past time for doctors to take a long hard look at their biases. Because make no mistake, that is exactly what this is. In their core, many doctors believe that fatness is of bigger importance to their patients’ health than almost any other factor. The proof of this supremacy is in their persistent focus on weight, above the narratives provided to them by the patients. Every fat person has a story about how their needs and concerns were ignored as their doctor asked them about trying to lose weight.
And this bias is causing life and death decisions to be made, and fatter people are dying.
As an example, people with more body fat are more likely to die after a cancer diagnosis. Is this because of something intrinsic about body fat, or is it because fat people go longer before they reach a diagnosis? Are doctors more reticent to be aggressive with treatments because they are distracted by the “elephant” in the room, possibly assuming that the fat person doesn’t do their part to take care of themselves? Obviously, doctors are not listening to their fat patients as openly–does that mean they miss critical complications until they are too difficult to treat? How much of the “fat is bad for you when you have cancer” conversation is colored by these unconfronted fat biases?
When I was a fat teenager, I dreaded going to the doctor. No conversation at the doctor did not also include a conversation about my weight. I had nearly disabling low back pain from carrying a heavy book bag for years, including on the couple miles walk home from school each day. Did they offer me exercises to strengthen my core muscles? No. I needed to lose weight.
Depression? Have you tried to lose weight? Irritable bowel syndrome? What have you done to try to lose weight? Broken bones in your hand after punching a kid in the hallway for calling you a “freak?” Well, you get the idea. I’m pretty sure my weight came up in that conversation, too.
And, I’m sorry to say it doesn’t get a ton better when you go from being a medically fat person to a merely, nearly fat person.
I changed doctors last year after a frustrating conversation along these lines. I am no longer medically “overweight,” but I am just barely so. Over about six years, I changed from a BMI of about 32 to about 24, just under the “normal” threshold. I have also reduced my health risk factors in innumerable ways–I eat more produce, less processed food, and less added sugar and salt. I do some kind of intentional exercise most days of the week. I don’t smoke or drink alcohol. I have been working hard on managing stress (still a work in progress), and I try to get enough quality sleep. I see a therapist regularly to help me manage my depression and trauma.
And when I went in to get a referral for a physical therapist, what did he say? “Your BMI is ok, it’s in the normal zone, but just barely. You might want to do some work to bring that down.” This had NOTHING to do with my current medical concerns. In fact, the opposite. As I have increased my activity levels over the years, underlying imbalances I’ve lived with for nearly two decades have become problematic. It may not have mattered that my muscles and nerves were out of whack when I wasn’t pushing them. But the more physically fit I’ve become, the more I’ve become aware of how my surgical history has permanently impacted how my body works. I was there to see him so I could continue to be physically active, something I’m sure he would recommend as a part of “fixing” my BMI to a lower end of “normal.”
I challenged him on this and reminded him that I was a weightlifter. That maybe some of the “extra” weight I was carrying might be muscle. He said most people overestimate how much that is a factor. I don’t disagree with him, but I kinda wanted him to lie down on the floor, so I could prove I could deadlift him up off of it.
But of course, my BMI in that moment, or any, wasn’t really relevant. BMI is a poor tool for estimating body fat. And body fat is a poor tool for estimating health. What we’re really seeing time and again, people like Jen and me, and so many others, is the biases of our doctors, who see fat and can’t see anything else.
Fat bias is a habit, and habits are hard to break. Doctors who are serious about improving the health of their patients need to begin the hard work of challenging their own assumptions in these moments. To stop themselves before they bring up their patient’s size and ask themselves, “If this patient were smaller and came to me with these concerns, what would I suggest to them?” Fat people know they’re fat. Most of them have tried, and failed repeatedly, to be less fat. Ask them what they are doing to take care of themselves. Ask them what they are hoping to get from the appointment. Ask them what they think is going on. And for goodness sake, treat them like people, not just bodies.
Marjorie Hundtoft is a middle school science and health teacher. She can be found picking up heavy things and putting them back down again in Portland, Oregon.