Category: Definitions of Health

The denial of life.

When I was 14, and sitting in a circle with my mom, my best friend, her mom, and her mom’s best friend, I came to a sudden understanding that has become the foundation of everything I write on this blog.

I believe the occasion was a cookie exchange, and it was something my friend did once a year. Her mom’s friend, who also worked at the hospital with my mom, was called Georgia*.

She was delightful in every possible way – warm, funny, sweet, without a sharp edge anywhere. She put up with wild shenanigans during sleepovers and let us dress like Madonna on Halloween and eat as much candy as we wanted. She always kept cinnamon Graham crackers in the house. She let us coax her onto a giant trampoline once, to bounce gingerly and scream in delighted terror. She loved her daughters openly, broadly, and unashamedly, and raised them to be as wonderful as she was.

Her husband had died suddenly of a heart attack a short time before. He, she, and their entire family were large people — tall, broad, and stocky. They were also, I thought, nice to look at, and comfortable to be around. From what I could tell, they ate and moved and lived their lives just like everyone else. I admired that.

After exchanging cookies, we gathered in the living room and drifted into chat. At some point, probably following some hospital gossip, Georgia recounted to my mom the story of a recent doctor’s visit.

The visit had not gone well. I believe Georgia went in for some reason related to her husband’s death, maybe to get help with stress or grief. The doctor — a slender, athletic woman in her 20s — had, after haranguing Georgia about her weight, asked how her husband died. Georgia answered that he had died of a heart attack, and the doctor snapped, “Well, no wonder he’s dead. He was obese and he was a smoker. What did you expect?”

The mothers in the circle fell into a stunned silence. I looked at Georgia’s face, and she seemed somehow apologetic.

How anyone could say something so cruel to a person I knew to be unfailingly kind and sweet, and whose husband’s death had recently devastated their entire family, was an utter shock to me for about two seconds. And then I knew something, and I didn’t know how I knew it, but I knew it with such angry certainty that it just came out.

“That doctor is scared of death,” I said loudly.

How else on earth could you explain a doctor expressing anger and blame at someone for accidentally dying? And to then vent that anger on his grieving wife? You couldn’t. There was no other explanation but the fear of death, utilizing the Just-world Hypothesis as its conduit.

The Just-world Hypothesis is the cognitive bias that causes people to blame other people for their misfortunes, even in cases where blame is not appropriate or not proven. Because we want to believe that we live in a fair world, and that people get what they deserve. If they do something wrong, bad things happen to them. But if they do everything right, and follow all the rules, nothing bad will ever happen to them.

It’s a mental shortcut we use, a theory that seems to have the power to predict what will happen — because to an animal, the power of prediction is essential to survival. It helps you to avoid the very worst bad thing that could ever happen, which is death.

If you die, the doctor was saying, clearly you did something to deserve it. When you deserve it, death is expected, which should somehow rob it of its terror. And because I, a doctor, am smart enough to avoid doing the wrong things, and actually dedicate my life to doing all the right things, I don’t deserve to die, and can therefore predict that it will not happen to me.

Last night, one of my group members quoted Anne Lamott —

I think perfectionism is based on the obsessive belief that if you run carefully enough, hitting each stepping-stone just right, you won’t have to die.

I tend to agree.

I have discovered, through questioning the lovely people I work with, that at the bottom of every fear of eating too much, or of gaining too much weight, resides the fear of death. In the final analysis, it always comes down to this — the awareness that we have to die, someday, and that anything we do might hasten the inevitable.

Some philosophers claim that entire fields of inquiry, entire cultures and civilizations, perhaps the social contract itself, are founded on the awareness and fear of death, and the simultaneous effort to deny it.

Ernest Becker, in The Denial of Death, calls these “immortality projects,” ways that we attempt to create something that might not only forestall death in the immediate sense, but that lives on after we do to achieve a sort of abstract immortality. Great books are written, tall towers constructed, fame and fortune sought, all in the faint hope that our name will live on, long after our body lies beneath the stone on which it is carved.

Even in the absence of dramatic efforts to achieve posthumous fame, our entire lives and all the decisions we make may be interpreted as coping mechanisms for managing, and suppressing, the fear of death. The cracks we step over on the sidewalk, the locks we check over and over (literally or figuratively), the black cats we avoid, the salt we throw over our left shoulder, the pleasure we systematically deny ourselves for the sake of seeming to purify our one immortal organ, the soul — and the trust we withhold from our body, that traitor, who can’t be counted on to keep any promise but the inevitable one.

Fear of physical pleasure, and fear of the seeming bottomlessness of our physical appetites, are disguises for the fear of death.

Responding to your body requires admitting, first of all, that you have a body, that you are a body, that your head does not float on a metaphysical balloon somewhere just north your body, untouchable. This admission requires you to acknowledge that bodies die, and that you will die too. The separation of mind and body, soul and body, spirit and body, is itself a coping mechanism, a sort of immortality project.

All of this would be well and good if it did not cause us to make such tragic decisions during our uncertain, finite, and invaluable lives. Decisions that cause us, effectively, to deny life itself. The fear of death, and the denial of the few concrete things we can touch and cling to as real and worthwhile, can lead to wasted lives. People wrung out and demoralized, lives spent and used up, running on a treadmill toward a mirage that never comes any closer.

How then shall we live?

Health can be redefined as the manner in which we live well despite our inescapable illnesses, disabilities, and trauma.

-Jon Robison

My proposal is that we live in the way that best reflects how we most want to use our precious time, right here, right now. My proposal is that we live well despite our inescapable fear of death. Our time is valuable in more than one way, both in quantity and quality, and neither one should be sacrificed for the sake of the other.

We may instead try, as best we can, to strike a balance between the two, and not go to extremes in an attempt to escape what we all know is coming — but neither to hasten it purposely by squandering what little we do have in a blaze of reckless glory.

This means, then, that I would never suggest running out to smoke and drink yourself into oblivion. Or to gorge yourself on food that makes you feel like shit, even if it tastes like anything but. Or to avoid exercise at all costs, out of a stubborn refusal to (again) admit that you have a perishable body and that it requires a certain measure of care — and in doing so, to deny yourself your life.

Do the things you can reasonably do, without unduly burdening yourself, to be a good steward of the gift of life.

I equally would not suggest that you force yourself to eat food you hate, or eat too little of the things you enjoy and feel deprived, or slog away at life like you’re putting in your time at a dismal job, waiting for the blessed release of quitting time. That you mortify the body to purify the soul. That you sacrifice yourself, your invaluable time, doing things that you hate, hurting yourself mentally and physically, to prove yourself worthy of escaping death, somehow superior to the weak mortals living their pathetically finite lives around you. In short, to live a delusion — and in doing so, to deny yourself your life.

If you genuinely enjoy marathons, run them. If that would be torture to you, don’t. Find something else to enjoy. If you love salad, eat it. If salad is punishment, for God’s sake, there are a million other foods to take its place. Food that isn’t enjoyed isn’t worth a damn. Find something better. You deserve it.

If you feel unfit, if you feel tired and exhausted and find it difficult to move, be good to your body. Feed it good food, give it fresh air and light, and move it gently and compassionately until it is stronger. When it is strong enough, use it to do things that inspire, excite, and even scare you.

Do something that makes you scream in delighted terror.

This is a limited time offer — don’t deny it. Make it count.

*Not her real name.

If only poor people understood nutrition!

French version of this post here, courtesy Stéphanie Potin-Grevrend.

break50

It seems like some people are constantly wringing their hands about how poor people eat (to wit: badly.) And the most popularly proposed solution is to teach them (“them”) more about nutrition! Or educate them in general.

Because obviously they just don’t know what they’re doing. And that’s why they eat so badly, and hence, why their health tends to be poorer!

And eureka! — you have a tidy solution that not only absolves financial and economic guilt, but, as a bonus, allows richer, more-edumacated people to assume the role of benevolent experts.

Here comes the part where I bust up that nice, warm bubble bath.

The reality is that people who don’t have enough money (or the utilities and storage) to buy and prepare decent food in decent quantities, cannot (and should not) be arsed to worry about the finer nuances of nutrition.

Because getting enough to eat is always our first priority.

That’s why Ellyn Satter (yes, her again) created the Hierarchy of Food Needs. Which looks like this:

Hierarchy of food needs, in order: enough food, acceptable food, reliable ongoing access to food, good-tasting food, novel food, and instrumental food.

The idea is that, before we worry about nutrition (i.e., “instrumental food”) we’ve first got to HAVE food. Enough of it. Consistently. And it’s got to be acceptable to us (which, for some people, might mean not coming from the garbage, or meeting certain standards of preparation) and it’s got to taste reasonably good. A little variety is nice, too.

These are not silly little preferences that can be brushed off lightly — even “tasting good,” which seems to always be the first thing thrown out the window when someone decides to change their diet For Health Reasons.

Tasting good is actually a function, biologically, of

  1. food’s microbiological safety and freshness (meaning it’s not spoiled or contaminated with sick-making germs),
  2. food’s caloric density (there’s that pesky ENOUGH FOOD thing again — because calories and water trump everything else, nutrition-wise, and hey, guess what?? Sweet, fatty foods are the order of the day when it comes to caloric density), and
  3. food’s chemical safety (meaning, it’s not naturally poisonous, chemically adulterated, or containing some toxin produced by sick-making germs.)

Of course, flavour isn’t infallibleC. botulinum can’t be detected by taste, for example, and ethylene glycol, a.k.a. antifreeze, is apparently as tasty as it is poisonous — but there’s likely a strong evolutionary reason why we developed certain flavour preferences. And it’s not because we’re totally depraved and destined by our love of Twinkies to doggy-paddle the Lake of Fire forever and ever, amen.

It’s because, for the most part, those preferences kept us fed and out of trouble with food. And they still do.

For most of us, this becomes apparent for the second reason listed above — when we’re hungry. I’m sure you’ve noticed how cake and fried foods and whatnot become SUPER MASSIVELY APPEALING when you’ve either missed a meal or started a diet.

It’s not because you lack willpower or have an inborn preference for BAD, BAD JUNK FOOD — it’s because those foods are naturally jam-packed full of what you need right that instant: energy. Meaning, calories — most of them coming from carbohydrate (whether it’s starch or sugar) for instant energy, and fat for MOAR energy (and tasty, creamy mouthfeel, to boot.)

So, extend this to someone who doesn’t have enough food on a regular basis. In my neighbourhood, which is poor, corner stores sell Ensure and Boost individually for about $2, right up in a big display near the counter. You find empty bottles of the stuff laying around on the sidewalk next to smashed beer bottles.

Ensure for sale at the corner store.

It’s complete nutrition; it’s portable and requires no preparation; and it’s reasonably calorie-dense. Imagine being hungry and walking into that corner store with a couple of bucks in your pocket.

Sure, choosing the Ensure over a chocolate bar or bag of chips might make logical sense, and you might even do that sometimes to ensure you don’t end up with some horrific nutrient deficiency. But there’s one important point I forgot to mention about Ensure and Boost: not super tasty.

So, when it comes down to it, you’re likely to choose the tastier option — which is pretty calorically dense and provides some nutrition (as well as the satisfaction of chewing actual food) — more often than not.

And it’s not because you’re stupid, ignorant, lazy, or just a bad, bad person who loves bad, bad food.

It’s because other needs come first.

The following quote from this book sums things up nicely as it relates to what people really need when it comes to nutrition, and how nutritionists, dietitians, and social workers can best help:

Is it our role to teach the poor how to live quietly on less than minimum standards of health and decency and how to starve on minimum wage? Do we teach them how to budget malnutrition more neatly? Or is it our job to struggle for those minimum standards…?

I think you know what answer I’d choose. And once again, we’re back to the social determinants of health.

You want people to eat better? Give them enough money, a place for cooking and storage, and access to a decent variety of food.

Then you can worry about the finer points of nutrition.

ETA: Further reading: Ami’s Guide to Food Privilege

Don’t be poor (and other New Year’s resolutions.)

Diabetes death rate drops — primarily among rich people.

This is my SURPRISED FACE. Especially since, in 1995, the World Health Organization identified poverty as “the biggest single underlying cause of death, disease and suffering worldwide.”

In a hilarious-because-it’s-sadly-true list posted to the Wikipedia article on the social determinants of health, a typical list of “lifestyle” tips for better health is contrasted with a list of socially determined tips for better health:

The traditional 10 Tips for Better Health [69]

    * 1. Don’t smoke. If you can, stop. If you can’t, cut down.
    * 2. Follow a balanced diet with plenty of fruit and vegetables.
    * 3. Keep physically active.
    * 4. Manage stress by, for example, talking things through and making time to relax.
    * 5. If you drink alcohol, do so in moderation.
    * 6. Cover up in the sun, and protect children from sunburn.
    * 7. Practice safer sex.
    * 8. Take up cancer-screening opportunities.
    * 9. Be safe on the roads: follow the Highway Code.
    * 10. Learn the First Aid ABCs: airways, breathing, circulation.

The social determinants 10 Tips for Better Health[70]

    * 1. Don’t be poor. If you can, stop. If you can’t, try not to be poor for long.
    * 2. Don’t have poor parents.
    * 3. Own a car.
    * 4. Don’t work in a stressful, low-paid manual job.
    * 5. Don’t live in damp, low-quality housing.
    * 6. Be able to afford to go on a foreign holiday and sunbathe.
    * 7. Practice not losing your job and don’t become unemployed.
    * 8. Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.
    * 9. Don’t live next to a busy major road or near a polluting factory.
    * 10. Learn how to fill in the complex housing benefit/asylum application forms before you become homeless and destitute.

So I guess we can all revise our New Year’s resolutions somewhat.

Now, of course, I’m not trying to be fatalistic, and I wouldn’t ever want to take away someone’s feelings of hope of what they can achieve, nor their sense of bodily autonomy — but the trick here is to remember, whenever you’re making “lifestyle” changes for the sake of improved health, keep the bigger context in mind.

Do a sound cost-benefit analysis before embarking on something you don’t enjoy, solely “for the sake of your health.” Keep in mind that certain changes represent only a drop in the bucket of your overall health, and that if something isn’t worth doing for its own sake (intrinsic motivation, remember?), then maybe it’s not worth doing at all.

That said, I’ve made a few…let’s call them “atypical” resolutions of my own — to work hard in therapy, to get better at understanding my limits and boundaries, to speak up when I need help, to work hard on the business-thing, to deliberately build pleasure into my daily life, and to remember that doing all of the drudgy housework-things is part of taking care of myself.

If I had the money and time, I’d add “take a ballet class” to that list, but since that’s not possible for me right now (don’t be poor!), I’ll work on figuring out some alternative. I know it sounds weird for a fat (and fat-accepting) person — particularly one who says “fuck” as often as I do — to be interested in ballet, but I’ve always been a study in contrasts and ballet has always appealed to me.

The idea that it might also be subversive for me now, given my fattitude, only enhances the appeal.

A fat ballet dancer from The Big Ballet

a fat ballet dancer from The Big Ballet

Any atypical resolutions to share?

Accepting the unacceptable.

This summer has been hard for me. I’m not going to lie.

I started it off by turning 30, which I was extremely excited about. I’m a bit sentimental when it comes to numbers, and I was doing the whole clean-slate-fresh-start thing in my head.

And there have been a lot of good changes recently, this website and the idea to strike out on my own as a nutrition renegade being not the least of them — but there’ve also been some hard things that I haven’t gone into detail about.

Now’s probably the time to remedy that.

I’ve semi-identified as a person with a disability for a few years now. I say “semi” because my disability is not visible — it’s “mental” or “emotional” in nature. (Except, because of my bias against such Cartesian dualism, I consider all mental and emotional problems as inherently physical, and all physical problems to carry some emotional/mental weight with them.)

This whole “I’m kinda/sorta/not-really disabled” thing is just now coming home to me in a major way, though I’ve kinda/sorta/not-really accepted it since 2005, when I first registered as a disabled student at my university.

To put it plainly, I have depression.

Yeah, it’s a boring thing to have, and I’m so sick of thinking about it that I can hardly even stand to type out the word. I’ve had it a long, long time, since childhood.

I’ve tried a lot of treatments for it — a fair bit of therapy, a fair number of drugs. None of them worked in any long-term, fundamental way. I’ve also done a lot of self-medicating in the form of, shall we say maladaptive behaviours, and experienced some hard-core avoidance that is more accurately described as TOTAL PHYSICAL PARALYSIS rather than “procrastination,” and SHITTING MY PANTS IN TERROR rather than “anxiety.”

So why bring all this up now?

This spring, I tried a new drug. It started really working for me toward early summer.

It was the first time I can recall feeling “normal,” mood-wise, since before I was about ten years old. It gave me so much hope. It realigned my vision of what life could be, of what it probably is for people without mood disorders. I woke up in the morning not wishing I were dead, and it was…it was…

…it was magic. It was falling in love. It was bringing the dead back to life. It was winning the lottery and the Miss America Pageant all on the same day. It was waking up from a nightmare and saying to yourself, “It was all a dream. It’s over.”

But it wasn’t over. The drug stopped working.

Within a few weeks, my stubborn, intractible brain managed to compensate for the new chemicals flooding it, to return to its cherished equilibrium-state of feeling like utter shit. Of fatigue, of tiredness, of hopelessness, fear and guilt.

My doctor told me I have treatment-resistant depression. I told her that I would rather die than accept that.

She told me to stop fighting.

I went home and bawled my eyes out.

For all my talking the talk about alternative definitions of health, of “inhabit, accept, and cope,” I haven’t been much walking that particular walk, except as it relates directly to being fat.

Depression has been different to me, somehow. For as (relatively) easily as I could accept that I was just going to be a fat lady, and buy fat lady clothes in fat lady stores, and never quite fit into certain social or physical spaces, and that I would commit myself to respecting my body anyway, and fighting for a culture than can similarly respect people’s bodies, it remained totally unacceptable to me that I would wake up every morning with this anvil of utter suck pressing down into my heart, hobbling me from doing the things I desperately needed to do and mocking me whenever I stumbled.

Case in point: it has taken seven years, thus far, to reach my fourth year in university. By the time I graduate, it will have taken me eight full years.

This is entirely because of the depression.

Yes, I have worked at the same time, and gained a lot of experience, and been accepted for jobs that students are not normally accepted for. But I did this as compensation for what I could not do at school, which was face my intense fear of judgment, of being graded, of being praised and shamed like a dog.

Even at my worst, I could function well at work — it provided an escape. School, however, became intolerable. It set me in a cage with my worst fears, and restrained me by the shoulders as they took turns socking me in the gut.

This summer, when the medication stopped working, I wasn’t even able to perform at work anymore. It took me an extra three or four hours each night just to complete my basic tasks. I no longer cared about anything — about being late, about getting things done, about what my boss wanted, about being the perfect little employee I’d been for the last five years.

And I realized the grip of this depression was getting tighter, closing doors and windows through which I’d previously been able to escape for a few blessed hours, in my white coat, to neat desks and the smell of disinfectant and tidy to-do lists and calorie counts.

In plain English, my functioning was getting worse. I was becoming increasingly unable to do basic tasks, and I could no longer avoid thinking about it. The typical treatments were not working for me, except as a temporary stop-gap, and I’d done them so many times that I was frankly exhausted.

So, now my doctor has verified my worst fear: I am stuck with this thing.

It is not temporary; it is not external; it is a permanent part of me.

As such, I am now slowly taking the steps required to accept this, much in the way I had to learn to accept my body.

I am disabled. I will have to learn certain kindnesses and flavours of compassion I previously had the privilege of eschewing, and I will have to practise them on the most unsympathetic character imaginable — myself.

Instead of fighting, we’ll have to make it up somehow. We’re roommates, not mortal enemies. There is nothing to be gained by dashing out my brains against this particular rock, and everything to lose by continuing to fight.

I’m going to work with it, live with it.

And I’m beginning to think that could be okay.

Are fat people unhealthy? (part 2)

Continued from part 1:

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

Sadly, I also think it’s wrong.

Why is it wrong?

Because, first of all, weight isn’t equivalent to health. And therefore, weight loss isn’t equivalent to automatically improving health. But I think we all know that.

More complicatedly, weight isn’t even the most important factor in determining a person’s health. And this is an idea that I think might encounter some resistance. But I’m totally serious.

(And I’m sorry if this is all a little too “Public Health 101” for everyone, but bear with me. All that theoretical crap I learned in school actually DOES, it turns out, have relevance.)

I propose that the insistence on “obesity” as a personal failing, and even the conceptualization of “obesity” as a disease, is actually an artifact of an individualist perspective of health. Which is to say, because we tend to believe (as Americans, as North Americans, and sometimes just as humans) that health is an individual issue, not a social or public one, we revert to blaming individuals for all kinds of conditions and illnesses that do not jibe with our cultural ideals of What A Person Should Be.

But if you start to look at health as more than just a personal balance sheet of good behaviours vs. bad behaviours, and even look beyond genetic underpinnings, or plain roll-of-the-dice random luck, you’ll see that there are broad, societal patterns of who gets sick and who stays well. And thus, we run smack-dab into the concept of Social Determinants of Health.

If fat people experience poorer health than other people — and there are stacks of epidemiological associations that imply we do, the lower mortality risk of “overweight” people notwithstanding — then maybe it would be useful to put down the keys to the blame-mobile for just a moment and consider one question:

Why?

Now, if “obesity” were one of those things that had a single cause, and a single mechanism, and, subsequently, a single, reliable cure — then maybe it would be fair to jump instantly to the conclusion that being fat, itself, is the problem. (And, naturally, losing weight would be the magic-bullet cure.)

Except it doesn’t work that way.

At present, we’ve got so many hypotheses for why people get fat that you could drive yourself crazy trying to read it all. There’s, you know, adenoviruses, and some kind of woo-woo social transmission by which your being fat tacitly encourages your friends to get fat, and there’s the leptin-deficiency hypothesis which turned out not to apply as easily to humans as it did to specially-bred mice, and the whole food addiction thing, the obesogenic environment thing, the evil-carbohydrates thing, and then the genetic component (which, in itself, seems to implicate so many different genes that I don’t think you’d be able to find a police station long enough to accommodate a line-up.)

Fatness, it turns out, is a many-splendoured thing.

And, as a result, we’ve never found that wonderful magic-bullet cure I mentioned, even though people will swear up and down on their life, on their Bibles, on their mother’s-mother’s-mother’s grave, that we have.

In that case, I have only to ask: then why are so many of us — most of whom desperately don’t want to be — still fat?

Because there isn’t a single “Cure.” Because there isn’t a single cause or mechanism. And, not least of all, because fatness isn’t a disease.

A quote I love:

My definition of a disease is a categorization…that has predictive power and, in some cases, enables causal inferences to be made. There remains the difficult but not insoluble problem of distinguishing disease from social deviance.

-Ian R. McWhinney, CMAJ, VOL. 136, APRIL 15, 1987

I’m preeeeetty sure that the whole OMGBESITY CRISIS!!!! is actually more about policing social deviance than it is about concern for our health.

And even if fat people are at higher risk for certain diseases, I still contend that fatness itself isn’t the problem.

So what is?

I posit that the problem is social inequity. To wit: marginalized people have poorer health outcomes.

Are fat people marginalized? You betcha.

Does it affect our health? Quite possibly.

As always, let’s hash it all out in comments.