Are fat people unhealthy?

There certainly seems to be a lot of evidence to support the conclusion that we are, or at least to show associations between high body weight and poor health.

But I’m wondering, what’s really the most important question here? Whether fat people are unhealthy? Or why fat people might be unhealthy, if they are?

I think you know my bias is going to tend toward the latter.

This is not just an academic question for me: I am a fat person. And not just a little fat; I’m the highest caliber of fat there is — Class III Morbidly Obese. For me, this is an intensely personal question.

Am I unhealthy? Are people who look like me unhealthy? Are we unhealthy in similar ways, and can any of those ways be blamed on our bodies? Can our bodies, subsequently, be blamed on our habits, or our morals, or our characters?

And I think you might also know that my tendency is to answer these questions with yet another question:

What is health, anyway?

The World Health Organization says:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Which, you have to admit, seems rather noble and inspiring.

My only problem is, according to this definition, who on earth has ever been completely healthy?

I would answer, no one.

I don’t believe anyone living now, or anyone in the past, has ever enjoyed such a rarified state of ideal physical, mental and social perfection. At least not for longer than, say, about ten minutes. On the most perfect day of their entire lives. Which also happened to be their sixteenth birthday. And the first day of spring. And the day when Kevin Garnett of the Boston Celtics professed his undying love for them . . .

kevin garnett

. . . with an ice-cream cake.

And while I understand the rationale behind putting forth lofty mission statements for organizations, such as the WHO, whose reason for existence actually is the attempt to eradicate all threats to well-being, and to optimize all people’s health, I don’t believe such mission statements make appropriate aphorisms for the individual to live by.

We are, after all, individuals. So this matters.

And this is why, in my second or third year of university, I proposed another definition of health, based on the work of John Kabat-Zinn, who pioneered the mindfulness-based stress reduction approach, which has subsequently been applied to all sorts of therapies for mental, as well as physical, illness.

I wrote:

I sense a flaw within [the WHO’s] definition of ideal health. It’s the silent assumption that anyone experiencing less than ‘ideal’ health is not only possibly to blame for their predicament, but that their lives are tainted, somehow broken, and possibly less meaningful than the lives of the ‘healthy.’

I propose that our definition of health should have less to do with how sick or well we are, and more to do with how we live inside and with our unique physical condition.

A person’s state of health is what it is, and the thing to strive for is not less disease, or even longer life, but the ability to inhabit, accept, and cope with what is.

We can focus on using our skills [as healthcare practitioners] to help individuals live meaningful and worthwhile lives, no matter what their physical condition, alongside treatment and our search for cures.

And we can revise our definition of health to mean having the skills to face and live with challenges, and call people ‘healthy’ who manage to enjoy meaningful lives in the face of pain, illness, and mortality.

See, the thing is, health and illness, as concepts, are socially constructed.

Meaning — reality is messy. There are no clear lines of demarcation between healthy and sick. We decide — humans decide — how to label each other. And in that deciding, we reveal our biases and our unspoken assumptions about how other people live, and how worthwhile their lives are.

This is not all just pretty talk. The definition of health is at the base of how we structure not only our healthcare system, but also how we structure our society with regard to impairment, illness, and death — all of which are inescapable facts of human existence.

And while I would never propose that we stop treating illness, or ending suffering, or curing actual diseases, I would like to see these things happen within a conscious awareness of where our ideas of illness come from, in the first place.

Who gets treated, and to what end?

Are we banishing disease and improving quality of life, or are we blindly, almost compulsively, seeking to bring people in line with powerful, if latent, cultural ideals?

Why must everyone’s BMI fall within a certain, narrow range in order for us to feel comfortable?

Is this truly a risk-reduction strategy, predicated on the notion that the associations between weight and health are purely causal in nature, as well as reversible if we could just figure out how to turn down the goddamn dial on weight?

For health practitioners, particularly those enamoured with biochemical indices and relative-risk reduction strategies, the notion of one, simple solution to a myriad of chronic diseases — and possibly to mortality itself — is eminently seductive.

Sadly, I also think it’s wrong.

Next, I’ll talk more about why. In the meantime, click on comments, and let ‘er rip.

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46 Comments

  1. Morag
    Posted June 18, 2009 at 3:23 pm | Permalink

    It seems that fat is the catch all/blame all and solution to everything. Questions at the doctors 1) Do you smoke ? – No 2) Do you drink? – within limits – then the elephant in the room – well you are fat!
    Firmly believe we are all different – and genes must play a part. I have a mixed European heritage and like me lots of short dumpy people. The only time I’ve ever looked ‘slim’ I was dieting 24/7, running and living on black coffee. I also fainted all the time and really don’t recommend it to anyone.

    • Posted November 25, 2009 at 6:26 am | Permalink

      ” Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

      Which, you have to admit, seems rather noble and inspiring.

      My only problem is, according to this definition, who on earth has ever been completely healthy?”

      Well, if you go by the exact definition to the letter, no probably no one has, technically. Because even if they were in great shape, and had a perfect state of mental well being, they probably had some unnoticeable/unknown disease or bacteria in their system, or maybe they just had some residual damage from an injury, which in no way impacted their ability or well-being, but technically kept them from being COMPLETELY healthy.

      I mean, if you say “no one has ever done that before!” then you’re wrong! Certainly, someone somewhere in the unknown infinite possibility’s of existence has done that before. But as far as you are concerned, it’s true.

      Assuming you’ve read this far, under the exception that it is true as applies to me personally. I have been healthy has defined above, even if it didn’t last very long.

      You know, I think the one big beef I have against this whole “being fat is ok!” thing, is that it may be “ok” but honestly, do you want to settle for ok forever? Having been significantly overweight before, and now only being slightly over weight and in fairly good shape. I have to say, that the difference is amazing, it makes life more fun to live.

      PS. I feel I could say that last bit better, more poetically, and inspiring, however it is 2:00AM here, so I think I’ll just give it up for now. ^_^

      • Posted November 25, 2009 at 6:34 am | Permalink

        What.

        Sorry, that came off as rude, so I’ll revise:

        What.

  2. Posted June 18, 2009 at 3:41 pm | Permalink

    Morag – fellow short & dumpy-ling (dumpling?) here.

    And, frankly, I think everyone is unhealthy, or disabled, in some way. Though most people don’t choose to frame stuff that way, out of fear of being seen as weak or ill.

    I have a couple of chronic health issues, but not what people would likely expect in a fat person, and nothing that is directly attributable to my weight.

    But am I healthy? Most days, I’d have to say “that depends,” but overall, even though I’m far from perfect, I think, yes. I’m healthy. My life is has meaning, and I’m here to enjoy it.

    Which is the case for many, many fat people, as well as people with disabilities and chronic diseases.

  3. Wench
    Posted June 18, 2009 at 5:52 pm | Permalink

    What really chimed for me was your reminder that our ideas of health and illness are social constructs. I think that is something that gets lost in the conversation about fat and obese people and their health.

  4. Posted June 18, 2009 at 6:26 pm | Permalink

    I’m in that “morbidly obese, death looking for a place to happen” fat (5′ 8″ and 393 lbs) and I consider myself fairly healthy. I don’t have heart problems, blood pressure problems (other than white-coat hypertension), asthma, diabetes, or any of the other ills that are correlated with being fat and supposed to kill me soonest (in 5 years, as I’ve been told for the last 35 years, if I don’t lose at least 2oo lbs in the next 5 minutes). I do have arthritis (but so does everyone else in my family), and I have mobility issues due to a lower back problem (probably caused by having my pelvis fractured in 3 places just before my 19th birthday).
    I enjoy my life, for the most part, and if I could get a doctor to seriously consider diagnosing my back problem instead of saying “You’re fat, lose weight and you won’t be in pain anymore”, life would be grand (but the odds of that happening are slim and none, and slim just left town). But since that doesn’t seem to be happening, I find ways to cope with the pain, and I’m finding ways to do the things I want to do and minimize the pain in order to do them. Shopping is difficult if there isn’t an electric cart available, so I’m buying a 4-wheeled walker with a seat that will give me something to lean on when my back hurts, and when it really hurts, I can sit down until the pain lessens. So, while most doctors would look at me and say I’m not healthy, I disagree with them. My mobility issues aren’t going to kill me, and neither is my weight (I come from a long line of fat people who have lived well into their late 80’s, early 90’s), therefore, health is relative.

  5. Carolyn
    Posted June 18, 2009 at 7:41 pm | Permalink

    I think what you pointed out is so important. The idea of treating the person and not the disease. Okay – goody – you treated me, now what? I’m not just a race horse whose only value is running full speed ahead until I break every system in my body. I’m a human being who deserves the right to appropriate health care that doesn’t just slap a bandaid on the symptoms and call it good.

    I get so frustrated. I currently have a $340 medical bill (plus the $62 I owe the lab for blood work) from my “yearly” visit. What did $340 get me? A speculum crammed in at the wrong angle while the doctor kept complaining about how it was “just too hard to find the cervix on someone MY SIZE”. I must have heard the “someone at YOUR SIZE” thing 5 times. Ultimately she gave up saying “well I won’t guarantee I got any cervical tissue but that’s as good as it gets”. My body was just so damn inconvenient for her. I walked away with a prescription for Metformin (I do have PCOS) but she wasn’t providing Metformin for the PCOS – she said “Anyone your size is obviously insulin resistant and would benefit from metformin”. So yeah, she was actually trying to medicate me for being fat!

    The thing is I walked out with the same problem I walked in with (intense pelvic discomfort), no explenations, a rude & rough exam, and a whole whopping heap of body shame. So by those standards I was definitely not feeling healthy that day.

    I’m 26 years old, 5 feet 9 inches tall and weigh 340lbs. My blood pressure is fine, cholesterol is fine, I’m not any where near pre-diabetic. But you know, I’m fat and I should just stop inconveniencing doctors with my fatness because they have more important thin people to treat with real problems.

    • Posted June 18, 2009 at 9:21 pm | Permalink

      My body was just so damn inconvenient for her.

      That’s really what it comes down to, sometimes, isn’t it? I’m sorry to hear about your crappy experience, Carolyn. You deserve better. Hell, we ALL deserve better than that.

  6. M
    Posted June 18, 2009 at 10:00 pm | Permalink

    If you aren’t familiar with it already, you may want to read Foucault’s “Birth of the Clinic,” in which he analyzes how the medical gaze has constructed and affected illness (this is quite a bastardized summary of his thesis…sigh).

    This is not to say that disease and illness do not exist, of course, but that social and cultural constructs affect how we cope with, regard, and treat disease.

    And may I say, you always bring up unique and interesting perspectives on these sorts of issues. I really enjoy reading your work.

    • Posted June 18, 2009 at 10:17 pm | Permalink

      Thanks, M. I really appreciate it.

      I am familiar only nominally with Birth of the Clinic, as I’m taking a Disability Studies course right now. But I’ll definitely have to read it.

  7. Laura
    Posted June 18, 2009 at 11:13 pm | Permalink

    Your cousin here, just saying, WOW. This is fabulous stuff. I need to treat ME and do what makes me feel good and happy and valued. Yes. :)

    • Posted June 19, 2009 at 12:36 am | Permalink

      Hey cuz — nice to see you. And thanks!

  8. Posted June 19, 2009 at 12:13 am | Permalink

    Michelle,
    This is brilliant. It pains me to have read this earlier in the day and only now be able to comment on it.

    I agree with you critique of the WHO definition, and similar definitions of health and healthy.

    Your definition, “A person’s state of health is what it is, and the thing to strive for is not less disease, or even longer life, but the ability to inhabit, accept, and cope with what is.”

    At first, I read this as somewhat defeatest — but as I read it again, I realize that I really agree, and I have sadness at the same time. When I think about diabetes (and fatness, and PCOS, and fertility issues and hypothyroid, oh, and long-term low-level depression, and heck, because it’s impacting me hard right now, lactose intolerance) I think that for me, learning the parameters of these things, and what health means within them, and coping with them when I’m on what feels like the low end, that’s my path. That’s my boulder to roll up the hill. It doesn’t do me any good to sit on the boulder and cry that I’m not healthy. (Okay, that analogy sucks, but it’s what I’ve got).

    Here’s my lactose intolerance example. When I order a latte, I always ask for soy milk. I enunciate and raise my voice a little (I talk softly ordinarily) to make it clear. At home I drink lactose free milk, but soy is what gets me through out of the house. I ordered an iced SOY latte with sugar free caramel syrup. As I was drinking it, I was thinking, “huh, this tastes like regular milk, non-fat milk.” But I kept on drinking. I had lunch (turkey and hummus sandwich on mini wheat bagels, carrots with hummus, salad, bluberries and raspberries) Fast forward a couple of hours, and I’m feeling very sick. The opposite of the WHO definition of health. I leave work, drive home, consider stopping at the ER because maybe this isn’t food poisioning (I didn’t yet make the connection with the milk), maybe it’s a heart attack, but drive home and proceed to hurl in the driveway. At least I made it home. And now I’m realizing, yes, when this happens (it’s been a long time since it did, and the first time I’ve ever actually had my body so directly reject the lactose) I have to avoid dairy for a long time and slowly reintroduce it. And I forget what an overhaul of my diet this is, and that no, I can’t have a sugar-free pudding cup two days later without feeling like the stomach badness is coming back. It feels humbling and stupid and like it’s my own fault that I’m sick. Only it’s not. I clearly stated I wanted soy. I forgot for once to watch while they pour the milk to make sure it’s the right kind for me.
    Okay, sorry, but it just highlights that I need to inhabit, accept, and cope. When I forget to inhabit (or someone else forgets), I have to cope, and accept, and then move on.

    I will be feeling better somewhat soon, proivded I don’t eat any dairy for about a week.

    I might also want to invest in some lactaid tablets in case I find myself trapped in a high-dairy situation. And throw away a latte instead of drinking it if it’s not soy milk.

    At the very least, people need to accept the human condition — we age, we, like all biological creatures, are prone to illness, are fallable and, unlike some other animals, we don’t have exoskeletons, but like all life, we die.

    • Posted June 19, 2009 at 12:30 am | Permalink

      WRT2 – Yeah, you know, I struggle a little too with the idea of defeatism. Because I genuinely don’t WANT people to have diseases or impairments or whatever it is that makes their lives harder. And I genuinely want to fight against those things, and treat them, and cure them, and end suffering. Really-for-reals.

      But I think it does us all a disservice when we can’t admit that there are just some things we can’t treat or cure at this moment in time. And maybe there will always be something we’re up against that we just don’t know how to eradicate — and that is when acceptance, and COPING, become the most important things we can do.

      That is at the basis of fat acceptance itself, emphasis on acceptance. Because we’re all human, meaning, we all have certain limits. And those limits need respecting, not endless Sisyphean efforts to deny that they exist.

      At any rate, I love your story about the soy milk. Although it’s awful that you barfed in the driveway! That actually sounds very similar to a story someone once told me about having celiac disease. Apparently, if you stop eating gluten for long enough, and then suddenly reintroduce it, that can happen.

      I might also want to invest in some lactaid tablets in case I find myself trapped in a high-dairy situation.

      And this is exactly the kind of acceptance and coping I mean when I write about this stuff. Not that people shouldn’t try to have good health or live their lives as well as they can — but that we all need to have compassion for our limitations.

      That’s really the point of all this acceptance, to me — compassion. For ourselves, and for others.

  9. Posted June 19, 2009 at 1:35 am | Permalink

    Hmm, I think it’s great not to be so black and white about things, or to assume causal connections where there is merely correlation.

    However, I’m confused, it seems like you’re talking about two different things here:
    1. How we define “healthy”. On this point I disagree with you but I don’t think it matters.
    2. The idea that it’s super important that everyone’s BMI should meet a number on a chart – yes, I agree with you that that idea is wrong.

    But these are two separate things.

    As for how we define health, I mean, we could argue semantics and in the end I don’t think it matters. But to me it sounds like you’re talking about how health has lots of different aspects maybe, many physical and many mental aspects, and I agree that all of those should be addressed. And I think one thing you seem to be saying, that I agree with, is that we shouldn’t devalue someone because they are “unhealthy”, and we should encourage them not to devalue themselves. And also of course it’s not a binary thing, healthy or unhealthy.

    But, the fact that it’s not a binary thing doesn’t mean the notion is meaningless. There’s a lot of stuff in life where the extremes are clear but the line between them is fuzzy. So what? It doesn’t mean the whole idea of health as we normally use it is meaningless and we should just use it differently. And it seems like you’re looking for a definition of health whereby anybody can be “healthy” if they just have the right attitude, and therefore nobody need feel defeated. But come on. People aren’t infants. They know when they are sick, or somewhat ill, or have a health problem. And we can encourage them to have a positive attitude about things, and – as you said – do that alongside also treating the disease (and searching for cures of course).

    Also, I dunno, maybe I’m just brainwashed or something but I do generally think that people may have a certain weight that’s healthiest for them at various ages, and that it’s different for everyone of course but there is probably some sort of average range of weights that first most people. And there may be some causation between weight and other problems, and/or there might be common causes for weight gain and certain health problems. I also do think it’s useful to look at things like high cholesterol or high blood pressure or whatever, whether you’re fat or thin, and then try to take steps to improve them, because they put us at higher risk for some pretty dangerous stuff, no? That doesn’t mean we have to sit at home all day and cry about it, but we also don’t have to pretend it’s not happening either. Surely there’s a middle ground there.

    Also, in regards to whether there is some sort of importance to one’s weight or changes in one’s weight, I do think it’s important to remember:
    a. each one of us is different so we shouldn’t all expect to have the same BMI or body fat percentage
    b. people’s perceived ideal weight in this culture is actually very skinny and has little to do with what is healthy for them
    c. nobody really knows how to make fat people permanently thin, so then you gotta find the balance for yourself and make sure not to do more harm than good (meaning, some people diet and end up harming themselves with that instead of helping themselves).
    d. of all the health concerns out there, even if I do concede that weight has some sort of health significance – it is by far overemphasized in this culture, and all the other aspects of health are mostly ignored or deemed irrelvant by comparison

  10. Posted June 19, 2009 at 1:38 am | Permalink

    Oh and I forgot to say – I fail to see how health is a social construct, being based, as it is, on things that physically hurt or limit you, and/or shorten your life. That’s a real thing. No disrespect, I mean, maybe I misunderstood… That’s just my take on it.

    • Posted June 19, 2009 at 1:45 am | Permalink

      Hey cggirl — no, I don’t think the notion of “health” is entirely meaningless. But I’ll be addressing this more in upcoming posts. Thanks for all of your thoughtful critique. It’s definitely stuff that deserves answering.

      ETA: You’ve got my brain-wheels turning, which is a hallmark of good debate. One thing I can offer right now, before I go to bed, is that my definition of health is about far more than just “having the right attitude.”

      When I say “coping,” I mean it, in a very real sense — that means having strategies, many of them physical or pharmacological, as well as social, spiritual, and emotional, to deal with whatever condition needs dealing with. That doesn’t mean the underlying condition goes away, necessarily. Just that the person is able to live meaningfully, even joyfully, in the presence of a disease or limitation. That’s part of what the mindfulness stuff I was mentioning is all about.

      By that logic, someone with, say, diabetes — who is well-controlled and has access to adequate healthcare, as well as good social supports and strong emotional skills, who is therefore truly coping well — would be far healthier than someone who, say, is perfectly “healthy” in a strictly physical sense (if you’re comfortable disconnecting the physical from the mental, which I’m not, but that’s another post for another day) but who has untreated depression (perhaps because they can’t even accept that they have the condition.) Or, hell, even compared to the average “healthy” person who is just completely neurotic and terrified about their health.

      There’s sort of a fine distinction here, and maybe it seems a bit precious. But I believe it’s important, because it scales into something far more significant when we’re talking about entire populations of people.

      It’s also intensely important to me that the definition of health, at its base, be something that can only be defined by the individual who is living it. Because, otherwise, you get into situations where healthcare practitioners are allowed to make decisions about whose life is worth living, and for whom the cord should be yanked.

      This is serious shit to anyone who’s had personal experience with assisted suicide (like me), and it’s weighed heavily on my mind — who gets to decide whose life is worth living, and whose isn’t? The only truly ethical answer, ultimately, is the person themselves.

      Something that makes this issue even more cloudy, at least for me, personally, is that I identify as both disabled AND as pretty much in good health. I guess because I believe those two can, and totally do, coexist for many people. (And also because I think of disability in political terms, not purely physical ones — but I’ll get more into that later as well. Certainly most people would never assume I was disabled by looking at me.)

      Anyhow, thanks again, and more later :)

  11. Carolyn
    Posted June 19, 2009 at 1:45 am | Permalink

    @ Michelle,

    you know, I really appreciated coming back to your post to follow up on comments this evening and seeing that you had commented and acknowledged so many peoples comments. That is just awesome coated awesome with a creamy awesome center!

    Having someone acknowledge all this pain/anger/fear in a supportive way is so uncommon. (how sad is that?)

    Rereading your definition of health this evening has helped it sink in to a new level. I have been struggling this past year as my weight has reached it’s highest point (340 lbs) and I have uncomfortable (both with the number and some general body mobility issues) I have been fretting for the last few days over FA and being comfortable in my body and how seductive calorie restriction and dieting sound. But reading your definition of health I realized, I have the body that I have now and learning to cope, inhabit and accept it as is what needs to be done. Not diet, crash diet, exerciser 6 hours a day or what have you.

    Part of the mental hang up has been the “Well I use to be able to do blah blah blah”. Sure, 70 lbs ago I was able to walk for 90 minutes without pain, that doesn’t mean i need to ignore the pain I’m feeling in my back at this moment. Or that I am any less of a good and deserving person because I’m feeling it now.

    I know this is somewhat rambly, but I guess what I was getting at was this helped align the cognitive dissonance I was feeling. I was stuck in the diet brain training to make the body I have now do what I thought it should do 70 to 100lbs ago. That I need to accept and cope with the body I have now to encourage health.

    Fatnutritionis = My new home page. Love this blog! <3

    • Posted June 19, 2009 at 1:52 am | Permalink

      Hey again Carolyn — you have no idea how much everything you said means to me. Writing this blog as openly as I’m trying to is really an exercise in neurosis and anxiety, at the moment!

      Anyhow, I really hope you find a way to move that works for you and isn’t painful. Truly, this is one of those areas where it’s so easy to just forget about that whole “compassion for our limitations” thing — a lot of us just expect that we need to measure up to some athletic standard, or, at least, be just as mobile as we were at a much different age/stage. But human bodies don’t work that way. What you’ve got, right now, is what you have to work with. Emphasis on with.

  12. Laura P
    Posted June 19, 2009 at 5:15 am | Permalink

    I’m 5’2″, 175lbs, BMI of 32 and 36% body fat, so I fit nicely into the obese range. I also see a personal trainer once a week, go powerlifting once a week, and run 5k once a week. I’d love for someone to come up & tell me I’m fat & unhealthy while I’m benching 30kg at the gym :-)

    My blood pressure & resting heart rate are, according to my trainer, absolutely “normal”.

    That said, though, mentally I’m not so good. I agree with you that health is a wide, wide thing to define, and no-one would ever be 100% healthy.

    • Posted June 19, 2009 at 8:35 am | Permalink

      Dude, I would LOVE to see you benchpress, like, Walter Willett. He can’t weigh much more than 30 kg.

      (Okay, that was just mean.)

      Seriously though, you rule, Laura P! The whole “mental health” thing is a bitch though, isn’t it?

  13. Linnea
    Posted June 19, 2009 at 8:46 am | Permalink

    I think this is a fascinating post, and I’m really glad I stumbled onto your blog. FA has something for everyone willing to hear its message, especially women, and even though I have a “normal” BMI and am abnormally tall, the message of acceptance of HAES, of health as a continuum, of coping strategies can make everyone healthier. And it’s especially cool to see an FA nutritionist, since that profession seems riddled with disordered eaters and unhealthy thinking about food. Keep up the good work!

  14. Posted June 19, 2009 at 10:13 am | Permalink

    I am sort of with cggirl on this, although I do not agree with every single point she made. Still, I think this is taking it a bit too far. So if I have the flu but I am doing a good job coping with it, I am automatically healthy? That makes no sense. When it comes to chronic disease, I understand where you are coming from, but I would much rather hear people say that it is OK to be unhealthy, that you should strive for happiness rather than complete health, and that mental well-being matters even if you’re not diagnosed with anything, rather than change the definition of health entirely.

    That said, I disagree with the WHO’s definition as well. Health is the absence of disease, period.

    • Posted June 19, 2009 at 10:44 am | Permalink

      Tiana — yeah, acute illness is an interesting complication. The thing is, I would still consider someone who lives a pretty good life to be essentially “healthy” even if they came down with the flu. I guess I’m thinking of “health” as more of a global attribute of the person, rather than a situational thing. But, of course, it can be both things.

      In certain situations, like if you have the flu, clearly your health is not as good as it usually is. And that’s mainly because having the flu makes you freaking MISERABLE no matter how well you’re treating the symptoms. There’s definitely a temporary loss of QOL, or else no one would mind having the flu.

      For a comparison, consider someone with seasonal allergies that are well-controlled with medication. Do they have an acute condition or illness? Yes. Are they healthy, though? Definitely — mainly because it’s not affecting their QOL, nor is it directly endangering their life. Anyhow, I think most people don’t have trouble understanding how health applies to acute illness, and that’s not what I’m trying to address here, though it’s definitely a fair point to raise.

      What concerns me is how people with chronic conditions and/or impairments and/or disabilities are automatically written of as “unhealthy” when many of those people are actually coping better than those people who are labelled as traditionally “healthy.”

      This is the kind of assumption that leads people to say “But wait a minute — Health at Every Size can’t apply to me because I have diabetes/Crohn’s/Celiac! I’m unhealthy no matter what I do!”

      It’s discouraging and disempowering for people to believe that, because of X underlying condition, they can never think of themselves as healthy, even when they’re coping as well as humanly possible. And that makes people feel there’s no point to even caring for themselves. Because they’ll never be considered “healthy” anyway, so why bother?

      Anyway, clearly I think that’s crap. I’ve met tons of people with more “serious” health conditions than I have who are clearly coping better, and in my estimation, are thus “healthier” than I am.

      So, to sort of clarify my position (which I really am going to write about in more detail later, so bear with me) I actually believe there are TWO metrics of health — one that is entirely relative to the individual, based on their own standard of QOL and functioning, and one that doctors and health practitioners commonly use to compare your “health” to various diagnostic criteria or averages.

      They both have different functions/applications, but I think people get a little too hung up on the latter, the “official” measurement of health, which is actually circular logic, because those supposedly “objective” criteria? They come from us as individuals in the first place.

      Does that make sense?

      I sense that I am babbling. But this is good! You’re all making me think really hard. I love it.

  15. Posted June 20, 2009 at 12:43 am | Permalink

    So, here’s another way that I think about this question — what is the source of health?
    I think the research on Adverse Childhood Experiences sheds some light, as does the research on health and stigma, and of course we are aware of diseases that have genetic roots, or are genes + environment, or are caused by environment. There is such an emphasis on personal responsibility for health when the determinants of health are largely out of a person’s control.
    Can you smoke and be healthy? Can you have type 1 diabetes and be healthy? What about type 2?

    I think if someone were to look closely at myhistory and life, they would see that the odds of me being 100% healthy (mentally, physically and spiritually) were pretty slim. So, the best I can do is to, as Michelle says, “inhabit, accept and cope.” And the extent to which I can do that is not even entirely in my control — my ability to accept and cope is also based on some skills and brain chemistry that I might not have going in the right direction.

  16. Posted June 20, 2009 at 12:58 am | Permalink

    It’s discouraging and disempowering for people to believe that, because of X underlying condition, they can never think of themselves as healthy, even when they’re coping as well as humanly possible.

    That is what I don’t understand. Why should they have to? You can be unhealthy and happy at the same time. Why would I want to be able to think of myself as healthy, what for? It’s not an achievement, it’s a state of being.

    Perhaps we need different words for healthy people and healthy behaviour. Unsick and healthful? ;)

    • Posted June 20, 2009 at 9:57 am | Permalink

      Tiana — you’re right. It is crappy that people feel “obligated” to be healthy. And I’ve written about that before, because it’s something that concerns me a lot.

      I want to make it clear that, for anyone who genuinely has no interest in “health” — and I think that’s actually a fairly common thing, and a totally defensible position to take — then there is no need to worry about this stuff. Lots of people have lived long, good lives without giving obsessive thought, or much thought at all, to their health. And it is no morally different from any other position to hold.

      So, what I’m talking about here are people who DO have a concern about health. And that’s a lot of people, as we’ve seen in conversations about Health at Every Size. For those people, it DOES seem to be disempowering and defeating to be told that they can’t POSSIBLY by healthy, not by any metric or standard, because they have some underlying condition — including, but not limited to, being fat.

      But I totally agree with you about health not being an achievement. And, most importantly to me, it’s not a moral issue or a statement of anyone’s worth as a human being. As you said, it is just a state of being. But it’s a state that a lot of people are really concerned about “achieving” or paying some kind of attention to, and I guess that’s who I’m sort of referring to when I write about finding different ways to define your own health.

      I also would love to see there be a whole new language and set of terminology to talk about healthy people and behaviours. Maybe we could start a lexicon? :)

  17. Posted June 20, 2009 at 2:47 am | Permalink

    Ah Michelle thanks for the response. I don’t even have the experience – either professionally or personally – to really understand how the medical establishment works and makes decisions, and how various definitions of health affect that, but it sounds like you do and it’s really good that you’re looking into that and thinking about ways to make it better.

    Also I get what you’re saying, that it’s not just about mental attitude but how you actually care for yourself given a certain medical condition. And it does sound like one thing you’re getting at is that when people look at health as a binary thing, they might throw in the towel, especially if the condition they have is something they think is their own fault. I can imagine someone being unwilling or unable to get proper care for their high cholesterol or diabetes or something like that, because they are fat, and they think – or their doctors think – that they have brought the disease on themselves by eating too much. So maybe they sit at home making futile attempts to lose weight to fix the problem, instead of taking medicine that could manage it. And obviously, even if we were to say their own habits, and/or weight is the cause of their problem, (which i’m not saying it is), people have not yet figured out how to really avoid these problems so it’s certainly better to manage them! I mean that’s just an example that popped into my head when I read your reply… With your approach, such a person would be much better taken care of, so I agree with you.

    • Posted June 20, 2009 at 3:09 pm | Permalink

      Hey cggirl —

      when people look at health as a binary thing, they might throw in the towel, especially if the condition they have is something they think is their own fault.

      This is totally what I see happening. I think there are tons of conditions or illnesses that people can live with, and if they’re treating themselves well and coping well (and, in my opinion, the basis of coping is taking a philosophical position of “acceptance” of the condition), then they should be able to consider themselves “healthy.”

      And if they’re not coping well, they should be able to see that there are specific steps they can take, unique to their condition, to become “healthy” (or, at least, “healthier”) without ever thinking that the concept simply can never apply to them because of the underlying condition. We all have a unique baseline of health, based on our unique limitations as people. I don’t think anyone should be aspiring to someone else’s level of functioning, but unfortunately, that’s exactly what we do when we define “health” as a universal ideal.

      Doctors and other practitioners might find more universal definitions clinically useful, so that they can place a person somewhere along the continuum of health in assessing how they are doing and what can reasonably be improved, but I really think it does harm when people attempt to do this to themselves. For example, if I set my definition of physical fitness at the level of a genetically blessed, professional athlete — it’s simply not going to happen for me, an endomorphic, short, fat lady with flat feet. And it would be ridiculous to define my goals that way.

      But, at any rate, I don’t want you, or anyone reading here, to feel you must cede an argument based on my supposed professional credentials or education. I have given this stuff a fair bit of thought, but I’m just learning, myself. I’m not a doctor, or a dietitian, and even if I were, I would hope I’d still be learning. All the points you raised are legitimate points that need addressing. And it helps me write, because such thoughtful criticism helps me to see what people are thinking, what associations the topic evokes, and the thought processes we all have to go through in reconciling this stuff to our satisfaction. So, really and truly, thank you, and I hope to read more responses from you as we go along.

  18. Posted June 20, 2009 at 3:38 am | Permalink

    Michelle – this is brilliant. YOU are brilliant. I’ve just stumbled upon your blog somehow, and I’m in love. Thank you so much.

    I -hate- the idea that fat = unhealthy. I’m 5’8″ and 85kg (so about 185 pounds). I wear size 14 clothing. I’m not -that- different to anyone else… but yet I’m treated as a second class citizen slob because I’m somewhat overweight (I think my BMI – if we’re going to go by that – is around 29).

    I also exercise every day – I’m running a 5k race tomorrow. I (mostly) eat whole foods cooked in my own kitchen. Sure, I drink a fair amount of wine and I occasionally smoke. But so do those people who criticise me and unfairly label me as lazy, unhealthy, and disgusting because of my size. As I get older it’s becoming less of an issue (I’m 24), but there’s still a massive divide between “The Normals” and we fatties. They can lounge on the couch all day, eat rubbish, and binge drink of a weekend – or not – yet if we do the same, we’re criticised.

    I’ve spent my entire life being conditioned to think that I’m less because of my size. I’m the smallest I’ve been in four years right now (down 7kg), but I still battle every day to believe that I deserve to respect myself, and it’s because that’s the what I’ve constantly been told – that because I am fat, I’m just not good enough. It’s rubbish, and I’m sick of it. Thank you for being a shining light, Michelle, that lets us know we don’t have to play second fiddle anymore.

    • Jessica
      Posted July 10, 2009 at 11:12 am | Permalink

      Erin, you are not fat! My knee-jerk, self-hating reaction was to think to myself, “OMG I was so freaking hot at that weight!” (I am the same height as you but I now weigh considerably more.)

      • Posted July 10, 2009 at 9:08 pm | Permalink

        Well, you know, if Erin identifies as fat, she gets to be fat. Perhaps she no longer thinks of it as a derogatory term (I don’t.)

        And if she’s wearing plus-sizes, there’s basically a whole industry telling her she’s fat, as well.

        But, at any rate, I understand the urge to tell people they’re not fat, since it’s such a loaded word. But I’ve identified as fat for almost my whole life, even through periods where no one else would have identified me as such. And being fat, even if it’s still at a level considered “socially acceptable,” or where one can “pass” as thin (and that’s what I’ve always thought of my smaller phases, as “passing,” since I was never truly thin), really makes you feel different in a tangible way from lots of other people. Whether they recognize that in you or not.

        So, if people want to identify themselves as such, assuming they’re not simply pulling an “I’M SO FAT” sympathy card (and I don’t think that’s what Erin is doing here), it’s not really our place to invalidate that, you know?

        I know you’re just being sweet, though, Jessica. But it doesn’t do anyone any good to act as though “fat” is a bad word.

        • Liisa
          Posted March 2, 2010 at 10:59 am | Permalink

          Late, late to the party.
          But, couldn’t resist the ‘if she identifies as fat, she is fat’ bit.
          I’m 175cm, 95-ish kilos (erm, 190 pounds or so), too lazy to find bmi calculator. 30-ish. I don’t look that heavy, I’m that massive big-boned type.
          And, well, silly as it is, since I hit puberty, my mother is trying to give me anorexia or wtf. I remember her horror when the doc weighed me when I was 12 or 13 and said the horrible number of 69. That was before I grew up so I might not be particularly lithe, I don’t remember. The only other time when I was under 70 kilos was some 10 years ago, when I ate regularly, once a week (no kidding). Since I was those 12 or 13, I keep hearing that I’m fat, ugly, nobody will like me, I’ll get high cholesterol and blood pressure and clogged arteries and arthritis, diabetes and what else and die a miserable death, that fat people are stinky and irritating and it’s violating of someone else’s basic human rights to be forced to look at those fatbags who dare to venture to public space and that I might look okayish if I had, like, 60 kilos. How cute to hear from one’s own parents. I do not wish to define myself as fat but under this pressure, it’s hard to resist. I suspect that I’m not the only one in this.

  19. Sansom
    Posted June 20, 2009 at 3:27 pm | Permalink

    I just found your blog. I usually just lurk in the shadows and read. I’ll try putting two cents in. If I am to be fat, let it be because of my genetics, my choices. I accept it under those circumstances. Unfortunately for the past few decades we are now learning that our “free” market has systematically poisoned the public for profit. Meat raised in feed lots are fed harmones and chemicals designed to fatten them (and us) up. Range fed cattle need 2.5 years to make slaughter weight, modern feed lots do it in 6 months. We have learned of food imports having a poison plastic that fools tests into thinking its protien, great for profits. Worldwide sperm counts are down, girls go through puberty younger. If these are natural events fine, if not, its not okay. What is cause and what is effect? What amount of disease blamed on obiesity is in fact the result of toxicity? And then there is marketing and public brainwashing. We drink flouride (toxic waste of aluminum production) in our water, a major component of prozac, also given in the nazi death camps to make people docile and follow like sheep. I accept responsibility for my health to the degree I am responsible. I have lost 44lbs since November by educating myself, and where possible, convenient, practical and economical making better food choices, I have not restricted calories. A recent study showed that lab rats choose sugar over cocaine. Sugar has been around hundreds of years before anyone could have known of its ill effects, but for decades we have known it can be harmful, so my use of sugar, my responsibility. But the companies loading “happy meals” for kids with sugar today are responsible for new sugar addicts. Then there is the diet industry and the doctors, a health care system with bigger profits if people pay into a system when they are young, and die off quickly before they are too great a burden. What about media? Fox “news” wouldn’t run a story about infectious puss in over 60% of milk from a major dairy because they might lose advertising bucks. And this is all just tip of the ice burg. We are taught that if you work at it you will lose weight. The implied meaning is that fat people are lazy and don’t try. Anyone fat for more than just a short time knows better than that. Nothing I hate more than someone 5-10 pounds over telling me how to lose weight. Beautiful women of the ages would be called “Fatso” today. I do not want my life to be designed in some corporate board room. I know I must sound crazy, but there is alot more important than fat, its health. And, FAT DOES NOT MEAN UNHEALTHY. I know I’m all over the page, but I have alot more questions than I have answers.

    • Posted June 20, 2009 at 3:46 pm | Permalink

      I have alot more questions than I have answers.

      I think that’s true for me, too, Sansom. I’m glad you commented, even though I doubt I’ll ever be able to address all of the points you raised!

      I do think the food industry is definitely culpable in some areas for causing health problems, as well as ecological problems. As much as I love food, and as much as I even love food science and technology, I also recognize that there are harms done there. Because, at bottom, businesses are in business to make a profit, not to look after people’s health — and sometimes those two potentialities play together nicely, and sometimes they don’t. When they don’t, who loses out? Not the companies or their shareholders — we do.

      I do have some issues with the idea of sugar as an addictive substance — I believe it’s a highly stimulating natural reward, and the reason it’s so is because it’s a very valuable substance to find in nature. Glucose is basically the prime fuel source for our brains and bodies, and finding highly concentrated sources of it is an advantage. So we’re wired to seek, and enjoy, those sources. But it’s true that we now live in an environment where we’ve made sugar (and other useful substances, like concentrated fats and salt) readily available, and that certainly wasn’t the case when our genome was evolving to the point it’s reached today. I’m also skeptical of painting our food supply as horribly poisoned and toxic, given that we enjoy better health and longer lifespans than ever before — but that doesn’t mean some of the problems you talk about aren’t real, or that things don’t need improving. They do.

      But I see where you’re coming from, especially with the stuff around the media and the health meritocracy we’ve set up, and how the diet industry and the food industry (if you look into it, you’ll find a lot of diet products are owned by the same organizations that produce the highly-processed foods that are often blamed for population-wide weight gains) go together like a horse and carriage. I don’t want to stray into conspiracy theory territory, but as you point out, there is a very complex system that’s sprung up around our food and consumption, and a lot of parts of that system are definitely not doing us good.

      Thanks for commenting, instead of just lurking. Welcome to the madhouse :)

  20. Posted June 21, 2009 at 11:12 pm | Permalink

    Hi Michelle

    I found a good blog a few days back, and they have a good post on June 17, called Food Addiction: Fat or Fiction that made me think of you, the blog is Obesity Panacea, I don’t think my comment will go through if I put the URL.

    I don’t know that these guys are card carrying HAES, but they seem non-judgmental, and are also strong on their science.

    • Posted June 22, 2009 at 12:35 am | Permalink

      Thanks Jules :) I’ll definitely check it out.

  21. Carolyn
    Posted June 22, 2009 at 12:44 am | Permalink

    That site is definitely not a FA friendly site. While the author does have some very witty comments regarding how weight loss and supplements are marketed – he seems to tow the party line for Calories in Calories out and OMG OBESITY EPIDEMIC BOOGAA BOOGGAA BOOGGA!

    Just trying to save anyone else the sanity watchers points of heading over to Obesity Panacea unless you are looking for that sort of thing.

    • Posted June 22, 2009 at 1:09 pm | Permalink

      Heh, thanks for the warning Carolyn.

  22. Posted June 23, 2009 at 1:46 am | Permalink

    Obesity Panacea is kind of interesting. The authors seem to be processing some serious cognitive dissonance, sometimes. I would put them in the Yoni Freedhoff, Arya Sharma camp.
    Canadians!

    • Posted June 23, 2009 at 7:50 am | Permalink

      Yes, that’s how I always interpret stuff like that — as cognitive dissonance. But what I find disturbing is that many people seem to interpret such positions as “moderate,” and therefore necessarily correct. Uhm, no.

      Interesting blog though. I do enjoy reading stuff like that, even if it doesn’t sync with my worldview.

      But I have to say, Y. Freedhoff kind of gets on my last good nerve.

  23. Posted July 3, 2009 at 11:20 am | Permalink

    Your ““inhabit, accept and cope” covers a lot of important ground, but I’m looking for some way to include the possibility of getting stable improvement. “Cope” comes the closest, but it still seems like dealing well with the effects of a problem rather than possibly shrinking or eliminating the problem.

    I realize that accepting present circumstances is crucial, but I’d like to have the feeling of a possibly open future, too.

    I don’t know if there’s anything shorter than the sereniity prayer which does justice to the relationship between the present and the future.

    • Posted July 6, 2009 at 9:59 am | Permalink

      Nancy —

      Your ““inhabit, accept and cope” covers a lot of important ground, but I’m looking for some way to include the possibility of getting stable improvement. “Cope” comes the closest, but it still seems like dealing well with the effects of a problem rather than possibly shrinking or eliminating the problem.

      You’re right about “cope” sounding more like just accepting and dealing with the problem. Maybe I need a better word for it. In my mind, I really do want people to seek cures and treatments, where such cures and treatments exist, but to also not mortgage all their time and energy chasing them if they do not exist, and if there are tangible things they can do to improve their quality of life while living with the illness or condition.

      Hmm. I’ll have to think about this.

  24. Posted July 15, 2009 at 11:06 am | Permalink

    Quoting: Why must everyone’s BMI fall within a certain, narrow range in order for us to feel comfortable?

    Is this truly a risk-reduction strategy, predicated on the notion that the associations between weight and health are purely causal in nature, as well as reversible if we could just figure out how to turn down the goddamn dial on weight?
    *********
    A) People usually like, acknowledged or not, measurable numbers against which to validate themselves in comparison to their peers. It goes from comfort in our clothing sizes to job performance. People often don’t feel comfortable without an “easy” way to measure themselves and know where in the spectrum they fit with their peers.

    B) People enjoying the label of “normal”, falling within the “established” range of normal anyway, usually have a lifestyle that already falls within their comfort zone. Often there’s a tendency to see others through a lens of, “If I can do it why can’t you?”, “You wouldn’t have this problem if you did what I do.”

    C) Weight loss is easy in theory. Find the rough number of calories you burn every day with your weight and activity level. Eat more than that, you gain weigh. Eat less than that, you lose weight. Simple formula. In practice though people usually have emotional issues that affect their eating, they have habits that affect their eating, they have lifestyle issues that affect their weight…

    But people are simple beings in many respects; the average person doesn’t stop to analyze this when they see a 400 pound guy eating a sub in the food court, the same meal that a 140 pound guy at a neighbouring table is mowing down. People tend to look at the superficial aspects of the situation and use mental shortcuts (stereotypes, if you will) to evaluate the situation they see and then mentally write off the 400 pound guy as (lazy, poor, stupid, etc., take your pick…)

    What do you think?

    • Posted July 15, 2009 at 11:22 am | Permalink

      Oh, I think it’s totally true that people *enjoy* those numbers, those categories, those mental heuristics, and those constructions of normality vs. deviance, and also that mathematical, mechanistic model of energy balance. I just don’t know what good these things actually do.

      BMI is interesting, in particular. It is a very easy, very cheap epidemiological tool that practitioners can use to determine where their patients fall on the big, supposedly objective scale of the population’s weight distribution. The problem is — when the population itself changes, why should we continue to use a weight distribution that no longer applies, so that we can label the majority of our population as abnormal?

      And if it’s supposedly based on the relative risk data, then why is the “overweight” category still called “overweight” rather than “normal,” given that that group has showed in the CDC’s own statistics to have the lowest relative risk of mortality?

      I’m not expressing it very well, but there are some major logical and philosophical problems with this.

      Also, BMI was originally designed by Quetelet to address epidemiology — which is to say, POPULATION-based health. Not as an individual diagnostic tool, which it is now being used as. And not just in the hands of trained practitioners, but by individuals, by snake-oil salesmen, by whoever-wants-a-handy-way-to-label-someone-unhealthy. And I think it’s just freaking people out and making them focus more on the proxy of WEIGHT, rather than on health directly.

      I’m rambling :)

      • Posted July 15, 2009 at 11:42 pm | Permalink

        Re: enjoying numbers – that part I was answering your initial question about why people want to have a BMI that falls into that range :-)

        The numbers may not be as accurate or relevant as we have come to regard them. But it’s what the public has as a simple indicator that in concept the public can somewhat grasp, and we want indicators that are simple enough to measure ourselves.

        I’ve seen this principle used in business for job satisfaction…we tend to be most content when we have, among other things, a clear sense of how we’re doing and to do that we need a way to measure our accomplishments at work using measurable goals whether is the number of sales we get or money made or time it takes to clean up rooms. People tend to be less satisfied in job situations where your goals are vaguely defined (or not defined at all).

        We know that the scale is approximate…salt, alcohol, etc. can make the poundage swing like mad. But most still do it…most think most other people are doing it, so we’re following what we think is a standard behavior. It’s a number that we can cement into our heads, and for a lot of people I know it can set a tone for how the rest of the day will go. Because it’s a ruler we can hold ourselves up to and quantify some aspect of progress.

        I fully understand what you’re saying about this tool being misused…or misapplied…today. But think about the psychology behind a simple tool in the hands of the public. It (BMI) has become a marketing darling because:
        it’s simple
        it’s got mindshare now
        it’s a concrete number that can be stamped on ourselves
        there’s a number of studies using BMI and charting it among populations so we can find where we theoretically fall “on average”

        If it were simple for everyone to accurately assess with just a few minutes effort their health, you’d probably see some shifts. But I think it actually takes a few blood tests and a really big tub for dunking and machines and treadmills and scary formulas with math symbols to plug measurements into and the better part of a day to do it accurately, doesn’t it? Most people don’t think it’s worth the effort. Plugging in your height and weight into some simple formula is a lot cheaper and easier so that’s what most choose to do :-)

        That’s just my observation, though.

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