diets · eating · eating disorders · weight loss · weight stigma

Losing My (Diet) Religion (Guest Post)

by Mavis Fenn

(This post discusses disordered eating. Please be aware it may be triggering for some.)

 Eating issues began when I was ten. There were two contributing factors. The first was that I was pre-puberty, a time when many children put on additional weight. The second was related to my mother’s health. She died at fifty-eight of early onset Alzheimer’s. It was when I was about ten that her behaviour began to change. Looking back on it now, I realize that this was also the time I began to binge-eat. I clearly remember ketchup and mustard sandwiches on white bread. Yuck!

My parents were older and came from a generation that had survived the depression of the thirties and the Second World War. Not wasting and will power were considered virtues; a lack of frugality or will power was a moral failing. Fat people were considered to be lazy, gluttons with no will power. My dad loved me and wanted the best for me. We were close until he died at ninety-four. He was a great role model and still is. Having said that, family and friends believed that teasing was a good way to correct behaviour. How well I remember, “Your eyes were bigger than your stomach,” when I didn’t finish the food on my plate. Unfortunately, that hurt my feelings; hurting my feelings makes me mad. Thinking, “I’ll show you,” I would eat everything up even if they said I didn’t have to. And the boys that called me names, I ran them to ground and sat on them until they apologized.

For a girl, being fat could be limiting. It didn’t matter how smart you were, how funny or caring you were, you weren’t going to get a good job or a husband who would take care of you if you were fat. So, at about twelve I got on the diet roller coaster. I stayed on it for well over fifty years. It eroded my confidence and sense of self-worth. I was never good enough, strong enough; I was not perfect and it was all my fault. When I was thin, I worried about getting fat; when I was fat, I was anxious and depressed because clearly I was lacking in will power. Eating compulsively was my punishment. It made things worse and I knew it.

I never had trouble losing weight, just keeping it off. I used food in times of stress, knowing that I could lose it when the latest crisis passed. I didn’t know that genetics determines most of your weight range, that only about two percent of people who lose weight are able to keep it off permanently, and that when you begin to gain weight again your body adds a bit more because dieting puts your body into starvation mode. In January 2015 I decided it was time to lose weight again. I struggled and struggled. I couldn’t; I just couldn’t. I was overwhelmed with defeat and shame. I sat down on the bench in the gym, put my face in my hands and cried.

My trainer asked me what I intended to “do” about my situation. I mumbled that I guessed I’d get a therapist to recommend something.  She said not to worry and the next morning my inbox had an email with the contact information for the CMHA Eating Disorders program. I called.

When I met with the nurse, she asked me if I could accept myself as I was if my body stayed the same. My response was, “Absolutely not!” Getting rid of the diet mentality wasn’t easy.

As the introductory workshop wore on, I realized that I had in the recesses of my mind the idea that I was still looking for weight loss. That was not going to work. So, I made the decision to go “all in.” I analysed how I used food, the mind traps I set for myself, and most importantly I examined why I was still allowing myself to be controlled by childhood beliefs about body size. Those were stereotypes of a past generation and they were wrong. I didn’t need to continue to judge and punish myself for not being someone else’s idea of perfect. I was not defined by my body; it is only a part of who I am.

Do I ever think of weight loss or body image? Occasionally, but dieting would cost me my freedom and mental health. I prefer to think about healthy eating and being fit. In the two years since I completed the program, my weight has stayed just above or below my last “set point” (where my body decided we were safe from famine).

The last day we were asked to reflect on completing the course, I wrote this: “I think I have come to peace with my body. Therefore, I am at peace with myself.”

Image description: A plaid pajama clad foot with bright blue toenails stepping on a bathroom scale.

Mavis Fenn is an independent scholar (retired). She loves lifting weights, Yin yoga, and Zumba Gold. She is mediocre at all of them.

fitness · weight stigma

Reducing anti-fat bias among doctors: will a little more knowledge help?

Here’s some good news: medical schools are (finally) paying attention to the fact that their students have a bunch of false beliefs about their fatter patients, which contributes to bad medical care. Johns Hopkins and NYU medical schools created some special 3-4 day courses devoted to better understanding obesity (a term I hate, but they use it, so I will use it here when I have to). Their goal is to help future doctors care better for their fatter patients.

For those who love references: you can read a news article about the NYU study here, and the actual NYU here. For the Hopkins study, there’s a JAMA article about it here, and the Hopkins study in more detail is found here.

Okay, now that the bibliography is done, here’s what the studies discovered about medical students’ beliefs and attitudes toward fat patients.

tl:dr version: lots of future doctors falsely believe that body weight is largely controllable. They also have negative feelings and attitudes toward fat people– a significant percentage think fat people are lazy or don’t make good decisions. Possibly as a result, they are less empathetic to their fat patients. This translates into bad medical care.

Here’s my deeper dive: from studies we know that a large percentage of 4th year medical students believe that lack of willower is an important contributor to obesity. The Hopkins study looked at 6 medical student cohorts who had taken a 4-day course on obesity. Before the course, here is what the students believed:

Across cohorts, 89% of students agreed or strongly agreed that obesity is a disease (range, 85% to 92%), and 89% of students believed it was behavioral (range, 82% to 92%). At the same time, over 90% of students agreed or strongly agreed that obesity results from poverty (range, 90% to 97%), and 57% believed that obesity is primarily genetic (range, 51% to 62%). Finally, 74% of students agreed or strongly agreed that ignorance contributes to obesity (range, 70% to 79%), and 28% had the opinion that people with obesity were lazy (range, 21% to 38%). 

This is appalling but not surprising. The NYU study found similar negative attitudes and false beliefs:

More than half of medical students rated unhealthy diet (62.0%), physical inactivity (56.3%), and overeating (52.1%) as very important contributors to obesity. Only 26.8% of students rated genetics or biological factors as very important. Lack of willpower was rated as less important than genetics or biological factors, but over 40% of students considered it [lack of willpower] to be at least a moderately important cause of obesity.

These disheartening results hold for practicing doctors as well. The NYU study cites this information:

In a survey of US primary care physicians, genetic factors ranked below physical inactivity, overeating, and high fat diet as important causes of obesity. More than 30% viewed patients with obesity as weak-willed, sloppy, or lazy, over 50% viewed them as awkward, unattractive, ugly, and noncompliant, and only 50% of physicians rated genetic factors as a very important cause of obesity.

So, we have a situation in which physicians and future physicians have false beliefs about human metabolism and controllability of body weight. Medical schools (and hospitals and medical associations and patient groups) are aware of this fact, and are trying to educate these populations to give them correct information and a solid knowledge base from which to view their patients more equitably and justly.

But the problem is: knowledge doesn’t seem like it’s going to make things better. In a followup survey, the Hopkins researchers asked the medical student cohorts how (if at all) the course changed their views about obesity. More than 50% of the respondents reported no change at all. 30% reported positive changes in their views. The rest reported either no change or more negative views over time.

As the NYU study authors put it in the last line of their article, “Research about the most effective methods for teaching the basis of obesity and reducing bias is sparse, however and more studies are needed to identify best practices.”

Yeah, I would say that’s right. So, what’s missing here? Some researchers say this: we don’t know how to teach people to be empathetic with others, especially about fatness. You might think that doctors or medical students who have struggled with body image and dieting yo-yo weight changes would be more empathetic toward their fat patients. But no– the data show otherwise.

So how do you teach people empathy? There are actually programs to teach physicians empathy for their patients. Knowing that how a primary care provider responds to us emotionally is a strong influence on how well they treat us (medically and personally) gives us a little more power in an area of life where people are relegated to the status of passive, silent patient. And if we’re up to the task, advocating for ourselves and others by calling out lack of empathy and calling for more empathy training might make going to the doctor less daunting and unpleasant. Here’s hoping…

Doctors walking down a hallway, rearview. Photo by Unsplash.
injury · Sat with Nat · weight stigma

Nat grapples with plantar fasciitis

It started as a dull ache in the summer around the rim of my left heel. It culminated in me limping home 2 weeks ago from work. Did I take the bus? Oh heck no!

So, first, this is a self diagnoses as I am actively avoiding my family doctor after my last visit. Why? I had gone in to talk about my hay fever and how it has aggravated my snoring.

The doctor recommended gastric bypass surgery. I’d never heard of that to treat hay fever before!

I spoke with my Gran, who weighs 80lbs, and she laughed. Apparently she, as her father before her, is a very loud snoring human. As is my dad (her son).

Anyway, no way am I going to see my family doctor about anything correlated to weight gain unless it’s drastic.

So after much research on the Internet and speaking with many friends I’m quite confident self-help options are going to help me recover.

I really liked the detail and approach in this article about stretching, yoga and things that help & aggravate symptoms.

https://yogainternational.com/article/view/yoga-for-plantar-fasciitis

  • Things that have definitely helped:
    • Over the counter insoles
      Calf stretches
      Rolling a hard ball on the bottom of my foot
      Ice
      Ibuprofen
      Rest
      Commuting in running shoes
      Yoga postures that flex & stretch my calves & feet
      Cycling inside on my trainer

    You can see Natalie’s legs stretched out in front of her. She has a yoga belt around the balls of her feet pulling her foot up to 90 degrees, stretching her calves and feet.
    Couch time is a great time to stretch those calves & get!

    It’s taken me a while to get in this much pain so I know it will be a while to recover. Thinking back over the past year I have had a few changes that would exacerbate plantar fasciitis:

    • started commuting with a full backpack
    • stopped doing other activities
    • wore older footwear even when my feet started bothering me
    • Ignored my early symptoms
    • Doubled my walking distances by canvassing
    • Gained some weight

    So, if you start to get that ring of fire around your heel, please, don’t be a Nat! Get checked out by a healthcare provider, try some self help options and talk to friends & family. You may not need to wince in agony for long.

    cycling · weight loss · weight stigma

    Not all cyclists are thin, not all drivers are fat

    This image is said to be from https://twitter.com/modacitylife

    I put it that way–“said to be from”–not because I like that feed, though I very much do, but because although a number of people have shared it and attributed it to them, I couldn’t find it there when I looked. (Update: Found. But they just retweeted it from someone else. I’m glad.) This contrast between fat drivers and thin cyclists drives me up the wall.

    Modacity life is about this: “In the summer of 2010, our family made the conscious decision to sell the family car, embarking on a new and enlightening adventure. Forced to move to a multi-modal commute, relying on public transit, walking and a great deal of cycling, we quickly realized the benefits of living a ‘car-lite’ lifestyle, not the least of which was the increased human interaction with the city we call home. Using writing, photography, film, and the power of social media, we used this revelation to communicate a more human image of multi-modal transportation. Together, we now strive to educate people and cities about the inherent benefits of moving away from a car-centric transportation model, to a more inclusive one that is accessible to people of all ages, abilities, and economic means.Promoting the public health, environmental, and social benefits of walking, cycling, and public transit, our goal is to improve on the great strides already made in many cities, creating a more open and welcoming environment for residents and visitors alike.”

    The Brunlett’s had a book launch in Guelph and I loved the launch. I’ve enjoyed reading the book. 

    Anyway, anyway, there are lots of wonderful reasons to ride bikes. It’s great for the environment. It’s great for your mood and for your physical health. Just so many reasons…

    But on behalf of larger cyclists everywhere, I just want to say IT WON’T NECESSARILY MAKE YOU THIN.

    Also, cycling is for everyone!

    See Big women on bikes.

    Want an example of how to talk about public policy and bike advocacy without false promises and fat shaming? Look here.

    From that interview, ““I got started working on transportation issues, which came about mostly because I love the fun and freedom that comes with being able to ride my bike and walk around my neighborhood.  But when I talk about bicycling from a public-health perspective, it’s easier to emphasize the health and financial benefits of obesity reduction. Which is just plain silly; I don’t want someone to take up bicycling just because it will help them lose weight. That’s a recipe for disappointment and frustration and doesn’t support sustainable healthy choices.”

    Just ride and enjoy!

     

    body image · equality · fitness · inclusiveness · Martha's Musings · stereotypes · training · weight stigma

    Weight bias and obesity interventions: no easy answers

    IMG_4443
    A person wearing a black swim dress and pink flip flops gets ready to swim.

    By MarthaFitat55

    A while ago I had reason to consult with an anaesthetist. We went through the risk assessment and had a chat. The clinic nurse had told me the team might have some questions because of my weight.

    Fair enough. I could hardly fault them given what’s involved in going under, so to speak. But I was cautious because context is so often missing when numbers are thrown around, especially numbers relating to the Body Mass Index (BMI).

    According to that scale, one originally developed by insurance companies, I am obese. Anaesthetists aren’t fond of having to deal with obese people. So we had a chat and it was actually quite good.

    Here’s the thing: I eat reasonably well, with almost all the required fruits and veggies, high fibre foods, lower fat choices, more fish and legumes, and less red meat and alcohol, our health system deems the better diet to follow.

    I’m also pretty active. At the time of the chat, I was weight training twice a week, swimming two to three times a week, taking a trail walk lasting more than an hour weekly, and looking to get my steps in on a daily basis.

    The doctor asked me about the weight training, and I ran through the numbers: bench was around 48kg, deadlift was around 105kg, and squat was 97.5 kg. So those numbers tipped the deal. If I could do all that, then I wouldn’t have any trouble, they concluded.

    It made me think though. For the past ten years, I have acted on the guideline about eating less junk and focusing more on whole foods while being more more mindful about how active I am.

    Truth is, I’m not prepared to starve nor am I prepared to add any more hours of activity (in fact I am at or past the threshold for the recommended 150 to 300 minutes of moderate to vigorous activity per week already).

    At the back of my mind, I always believe I should be able to do more, and yet I can’t. It bugs me when I hear facile comments repeated in every weight loss inspiration story shared by the media. We all make choices, but some times even the good choices don’t make that much difference.

    When SamB shared an article about how such tag lines like “Eat less, move more” contribute to weight bias, I was intrigued.

    And I felt vindicated. Despite all my efforts in the gym, in the kitchen and yes, in my own mind, when I ran up against health professionals, who looked at numbers like BMI as reliable indicators of health, I felt my work was not enough, nor good enough, to make the difference society expected in my body shape.

    Nor am I the only one. Canadian Obesity Network researcher Ximena Ramos Salas looked at obesity prevention policies and messages. She tested the messages with people living with obesity and what she heard was illuminating.

    The short form is those messages don’t work. They are neither helpful nor accurate.

    “Saying obesity is simply an issue of diet and exercise trivializes the disease. It makes those living with obesity feel like it is a lifestyle or behavioural choice, and therefore their fault. This causes them to feel judged and shamed, and to internalize the stigma of weight bias.”

    Ramos Salas also reported “People told me that the public health messages were not relevant to their experiences. They didn’t relate to the messaging, they felt it didn’t consider other factors that contribute to their obesity that are unique to them, like genetics, mental health, medications and so on. It did not reflect the challenges that they faced while trying to manage their weight on a daily basis.”

    I think these are two useful insights that should get more attention. But the best message arising from the research Ramos Salas is engaged in is this: “Not everyone who is big has obesity. People come in different shapes and sizes, so the idea that we categorize people based on their size as ‘healthy’ or ‘unhealthy’ is not accurate.”

    I was fortunate I met with a health professional who was open to hearing about my numbers intead of relying on a flawed indicator to make a decision about my health status. Too many people though do not and some actually close that door themselves because they are not confident they will get the care they need.

    For me, my conversation with the anaesthetist helped validate my choices about the fitness path I am on even though assumptions about weight and health by others may have forced the issue. I may never meet the biased image for health and fitness such weight stigma imposes, but I know I am doing the best I can given my circumstances. To suggest otherwise is limiting and dismissive.

    — Martha is a writer and powerlifter in St. John’s.

    health · stereotypes · weight loss · weight stigma

    6 things Sam hates about seeing doctors, as a larger person

    None of this is true about my current set of health practitioners. But they took awhile to find. Right now I’m halfway between jobs and cities and I’m looking for a new family doctor to start. It’s tough. And here’s why!

    1. They believe ridiculous things about me. See this article about doctors and bias against larger patient. “Much research has shown that clinicians have biases related to overweight and obesity, conditions that affect more than two-thirds of U.S. adults, Dr. Gudzune said. “[With] the magnitude of the effect of obesity in our country, a substantial number of people are experiencing health care disparities as a result,” she said. Studies have consistently shown that physicians associate obesity with such negative attributes as poor hygiene, nonadherence, hostility, and dishonesty, Dr. Gudzune said. “These types of attitudes are pervasive. It’s not just in the U.S. … [but] physicians across the world as well: Australian, Israeli, European physicians. … These attitudes have been documented as far back as 1969, and they continue to persist up until today,” she said. In surveys of primary care physicians, more than 50% view patients with obesity as awkward, unattractive, and ugly, Dr. Gudzune said. “They have less respect for patients with obesity. They also believe that heavier patients are less likely to follow medical advice, benefit from counseling, or adhere to medications, which are some of the things that are really critical in thinking about managing obesity,” she said. She added that these attitudes may extend to other health professionals, such as medical students, nurses, and nutritionists.” Not fun.

    2. They prescribe weight loss for everything. The evidence bar is very low. If there’s even a small chance that weight makes a difference, they mention it.

    3. They don’t believe my attempts at trying to lose weight. I just haven’t tried hard enough apparently. It’s as if once a have a serious medical reason, like putting off knee replacement surgery, I’ll snap to it, get down to business, and the pounds will just melt away.

    4. They don’t have anything useful to say about how to lose weight. See this post on unwanted weight loss advice. “Why do doctors weigh patients and offer weight loss advice? Other than “eat less and move more” which is kind of like the weight loss equivalent of “buy low and sell high,” what recommendations do they make and why?”

    5. But they recommend diets anyway even though the most likely outcome is that the patient weighs more at the end. In this post I wonder if doctors would do that with any other “likely to fail spectacularly” treatment. See Well intentioned lies, doctors, and the diet industry: If weight loss is impossible, ctors-and-the-diet-industry-if-weight-loss-impossible-then-what/

    6. They never believe my blood pressure readings or my cholesterol levels. I’ve had a complete work up with a endocrinologist who gave me a clean bill of fat health but still, it’s an uphill battle being seen. See this post and this one.

    I know Catherine and Nat have blogged here about issues with doctors. I often think, hey we’re all strong feminists with serious amounts of post secondary education and some good attitudes, we’re white, English speaking, able bodied, if we have problems with doctors what’s it like for other women who don’t share our bundle of privileges? If you’re a larger person, what’s the medical world like for you. We want to know.

    fitness · weight stigma

    Obese people? People with obesity? How about this: People.

    Language matters. What words people use for us have lots of effects– they contribute to the way we see ourselves and also how others see us. In school, I was known as “that smart girl” in a way that was definitely not complimentary. It was as if that was the box I had to occupy, never to stray into other territory. Luckily, I got over this once I arrived at university, where being hailed as “smart” was definitely considered praise.

    For people who are living with illness or disability, language does additional harm by burdening them with labels that identify them with the illness or disability they are dealing with in their lives. Calling someone sick, disabled, or other terms simplifies them by identifying them with one feature of their lives to the exclusion of all the complexity and richness of personhood.

    Luckily, there’s a solution to this problem: we can use what’s called people-first language (see here for a good handout on how to shift from harmful to more accurate language).  Here’s what the organization The Arc has to say about it:

    People-First Language emphasizes the person, not the disability. By placing the person first, the disability is no longer the primary, defining characteristic of an individual, but one of several aspects of the whole person. People-First Language is an objective way of acknowledging, communicating, and reporting on disabilities. It eliminates generalizations and stereotypes, by focusing on the person rather than the disability.

    Disability is not the “problem.” For example, a person who wears glasses doesn’t say, “I have a problem seeing,” they say, “I wear/need glasses.” Similarly, a person who uses a wheelchair doesn’t say, “I have a problem walking,” they say, “I use/need a wheelchair.”

    So what does this have to do with obesity? In a blogpost this week, James Fell reported that Obesity 2018 Canada has shifted to using people-first language when talking about people’s weight.  He says:

    From a post by endocrinologist Dr. Sue Pedersen: “Obesity is a diagnosis, and not a way to describe a person. Thus, instead of the terminology ‘overweight or obese people’, the correct terminology is ‘people with overweight or obesity’. This is a critical step in breaking down the stigma against obesity!”

    I thought “people with overweight” sounded a bit weird, but Yoni [Freedhof, obesity medicine physician and writer of this blog ]told me, “people with excess weight” could be an easier way to address that.

    I have a bunch of responses to these developments. First, let me say that people-first language strikes me as respectful and indeed a necessary step in the direction of destigmatizing lots of diseases, conditions and modes in which people make their way through their lives.

    That said, let me turn to its application to the terms “overweight” and “obese”. It’s true that both  the Canadian Medical Association and the American Medical Association having a BMI >30 as a disease (even though scientific and other subcommittees of the AMA recommended against this classification; see here for one such report). However, announcing that people with BMI >30 (the standard medical definition for obesity) have  a disease is both massively stigmatizing and arguably incorrect. Announcing that people with BMI >25 (the standard medical definition for overweight) have a disease is arguably absurd and definitely flies in the face of loads of evidence to the contrary.

    I’m aware that what I’m saying is controversial.  I’m questioning whether all or most people with BMI>30 have a disease/are unhealthy. I think I’m on safer ground questioning whether all or most people with BMI>25 have a disease/are unhealthy.

    So, if I’m right (which of course I think I am, and I have a gigantic bibliography of evidence available), then maybe the language we need is not people-first, but people-only.  Do we need these terms  “overweight” and “obesity” at all? If medicine needs precision, there are actual body weights and dimensions available for help in assessing someone’s health. And BMI can be calculated easily from those measurements using tables (I’m not linking to one, but you can find them anywhere). I don’t think these terms are helpful in medical contexts (I’m working on an article with a colleague– Hi Dan!–  on this now), and as general descriptors they are stigmatizing and shaming (and often an inaccurate way to convey information about a person).

    If we want to describe someone’s dimensions, there are lots of words to use, including large, big,  fat, heavy, etc. These are descriptive words, and many people in fat acceptance movements embrace them. I just happen to think that obese and overweight aren’t helpful as descriptors. And I think that using the terms “people with obesity” or people with excess/over weight” is terrible– its strangeness calls attention to the person’s size, maybe also invites stigma, and presupposes something that I argue elsewhere is false. For more on this, you can look at this blog post. And when the article comes out, I’ll blog about it too.

    So what do y’all think? Do you prefer “obese people”? “People with obesity”? Or maybe just using their names?