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:

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 infallible — C. 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.

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.

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

Any atypical resolutions to share?

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.

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.

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 . . .

. . . 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.

Stunning insights abound, such as:

Many people who meet the body mass index criteria for obesity “are really not that sick at all,” says Sharma, chairman for cardiovascular obesity research and management at the University of Alberta and scientific director of the Canadian Obesity Network.

‘Obesity was far less common when it was identified, and then obesity became this gigantic epidemic, with just the assumed outcome that everyone is going to be at risk for vascular disease and a whole bunch of other things,’ says Rachel Wildman, an assistant professor of epidemiology and population health at Albert Einstein College.

‘As it turns out, it seems not to be the case. There is at least a proportion of obese individuals who at this point don’t seem to be at elevated cardiovascular risk.’ Not only is their risk fairly minimal, ‘in some instances it’s better than individuals who are normal weight.’”

‘Treating obesity, like treating any other medical condition, takes resources, you never get it for free and if you’re asking people to do things where you know off the bat that most people are likely to fail then you’re really setting them up for disappointment,’ Sharma said.”

Wildman, of Albert Einstein School of Medicine, agrees that it may be time to deal with the obesity epidemic in a more nuanced way. For one thing, efforts to get everyone to lose weight are falling flat.”

Also, some good quotes from our friend Paul Ernsberger.

Really, I don’t mean to snark. This is a good article, and I’m glad to see the issue getting media play. It’s just that it all seems so fucking obvious.

And here’s the second thing: people are really goddamn preachy when it comes to taking the stairs. I was at work recently when an older man, likely in his 70s, made the morally reprehensible decision to take the elevator down one floor. And when he exited that elevator, the tidal wave of vitriolic spew that issued forth from my young, elevator-taking companions etched a new high-water mark on the jetty of my astonishment. Because an old man in the hospital had chosen the elevator over the stairs.

And a third thing: not only am I fat, I have a weird heart condition (since I was 15 — before I was fat, for the record.) It’s an apparently non-threatening arrhythmia that occurs randomly, and I went to the cardiologist when I was 18 (and still not fat, again, for the record), but no definitive diagnosis was given. Just that, you know, it hasn’t killed me yet, so that’s good. I was rushed to the ER for it a couple years ago, and again with chest pains a few months ago, which turned out to be a false alarm, but which I had to take seriously because of this weird heart thing.

Fourth thing? I just hate climbing stairs. I’ve had foot injuries, knee injuries, and just a plain lot of weight to haul around, such that, in addition to already taking the stairs daily because I live in a walk-up (with the laundry room in the basement), I am just not real enthused about forcing myself to take additional stairs at every opportunity in some bid for moral superiori — I mean, for the sake of my health.

Last semester, when I decided to walk up three large flights of stairs with my schoolmates to visit a professor, we all got to the top somewhat winded. I thought to myself, “Huh, I feel funny,” but I just caught my breath along with everyone else and carried on. Ten minutes later, I felt a sudden, chill-inducing thunk-thud in my chest. It was the familar feeling of my heart recovering normal rhythm. That’s when I realized — I’d been having a tachycardia episode and hadn’t even felt it (these things normally knock me backward, as though the wind has been punched out of me) and it was, apparently, brought on by climbing the goddamn stairs.

As it is, I have to climb a fair number of obligatory stairs each day. (If you live in a city as inaccessible as Toronto, you’ll understand what I mean by “obligatory stairs.”) Whenever I go home to visit my parents in suburban Oregon, I am amazed at how easy the life is. There’s no hauling 100 lbs of groceries home on foot and then carrying them up the stairs. There’s no sprinting for the subway or streetcar. There are no obligatory stairs to the bathroom in every restaurant. No eternally-broken escalators. No walking to work in 100 F heat/90% humidity, or back home in -20 F/three feet of snow. Whatever you want to do, wherever you want to go, you simply get into your car, drive somewhere, walk a few feet, and go inside. It’s the most amazing thing in the world, and as much as people complain about how bad being sedentary is for one’s health, I always feel about ten years younger when I’m there. I find myself running on the treadmill, or taking nature walks, or even doing calisthenics because daily life is not kicking my ass into the ground.

The life in downtown Toronto is just plain hard on me, and clearly, the stairs are not helping my heart. So I try to make it at least a little easier on myself by taking an elevator or escalator when convenient. I like to think of this as having compassion for my limitations, though I admit, I am often embarrassed to be standing by the elevator — even though I am registered as disabled at my school, and have to wear special orthotics in my shoes and blah blah blah. I am still embarrassed because I know what people must be thinking of me — the fat lady taking the elevator instead of the stairs.

In the back of my mind, I always have this episode of Mystery Diagnosis running whenever I’m confronted with too many stairs. (If you haven’t seen it, it’s about a woman with undiagnosed pulmonary hypertension who, in her chubby adolescence, became reluctant to climb stairs and run and things, because she felt instinctively that it would kill her. Naturally, they blamed this reluctance on her weight, shamed her for being lazy — and then she almost died from increasing her exercise.)

I feel this same reluctance when I have more than two flights of stairs to climb, especially if I’ve got textbooks on me. I feel trapped, pinned in a corner, and in grave danger. My heart simply doesn’t want to do it, and who knows — maybe the body has its own rationale behind making me fat enough to slow down my mobility when it comes to really strenuous pursuits, thereby keeping me safer.

So, when I see these little signs start to pop up around school or work, I inwardly groan. I can’t tell you how many times, aside from the episode mentioned above, I have heard people castigate others for not taking the stairs. I myself was harassed by a janitor as I waited for the elevator at my school (which has a large sign, mostly ignored by the other students, to please reserve its use for disabled students), and I had to calmly explain that it was hard on my injured foot to take the stairs.

I shouldn’t have had to.

With the coming of the signs comes the upping of the intensity of the judgments thrown at people who don’t follow them. Personally, I climb stairs (and a loft ladder) every single day in my apartment, but I must reserve the right to make my own judgment about when to conserve my efforts, when it is better for me, in fact, not to take the stairs. For the girl with pulmonary hypertension, stairs are potentially deadly. For one of my (very young, very fit) professors with knee trouble, taking the elevator just makes sense. But when it comes to public health campaigns of this stripe, there are no exceptions, no grey areas — there is only healthy or unhealthy, fat or fit, elevators or stairs, righteous or lazy. And I don’t like it.

One more reason I dislike this program? They measure the “health benefits” of taking the stairs solely in calories burned, not enjoyment had, or mastery gained, or strength attained. Lastly, there is, of course, no mention made of those who cannot or should not take the stairs — we simply do not exist. Maybe because, in some people’s minds, we’re already as good as dead.

But I would also like to make it clear that I believe fat acceptance and the rights of fat people are in NO WAY contigent on believing in, agreeing with, or practicing Health at Every Size.

IN NO WAY.

Quick fat history moment:

I think it is very important that as a movement we do NOT adopt elitist attitudes which tend to weed out the very people most in need of what we claim to support. It is one thing to have as our goal the right of every person, regardless of size, to have access to the resources to become more physically fit. It is quite another to base the acquisition of our civil rights, individually or as a community, on being or becoming “fit”. To do this would be healthist.”

-Karen Stimson, 1983

Fat acceptance has been wrangling with this issue for a while now. However. I do think that, commonly, people who are uncomfortable with the idea of Health at Every Size, are likely uncomfortable due to a misunderstanding of one sort or another.

The misunderstandings are various, but include:

1) the definition of “health” itself — there actually isn’t an official, universally agreed-upon one, and I believe a fundamental aspect of HAES philosophy is to try to create a newer, more inclusive, more compassionate definition of health

2) the fear that HAES must be classist in its practical requirements (it doesn’t; I am dreadfully poor and would never be able to claim a HAES badge if I had to do certain things like join a gym or buy special foods)

3) the assumption that a certain eating style (most often classical ‘demand feeding’ or the newer concept of ‘intuitive eating’) is absolutely required

4) the assumption that a certain type or amount of exercise is absolutely required

5) the assumption that, if you have a limiting or pre-existing health condition of some sort, you are excluded from practicing HAES (most people I know who are HAES-boosters actually have fairly limiting health issues, myself included, in that I have a history of disordered eating which precludes me from practicing demand-feeding, and including my very good friend, aerobics enthusiast, and extreme heroine of all situations, Dee, who has a serious physical injury.)

In my opinion, the behaviours of HAES are much less important than the intentions and beliefs behind those behaviours. The behaviours are simply tools, and there are a plethora from which to choose. Many of those tools have been totally co-opted by the weight-loss establishment, and so have taken on a pungent flavour of negativity and neuroticism — but, if sincerely divorced from the context of weight control, I really believe some or all of them could be adapted and put to good use.

So, in rough format, the essential beliefs of HAES are as follows:

1) You are fat accepting — both of yourself and others. You may not be perfect at it, but you make an effort to be aware of your own biases and to challenge them, both in regard to yourself and other people. You value size diversity.

2) In view of item 1, you are therefore not making any intentional attempts to lose weight. There are situations in which a person might need to purposely try to gain weight (cancer, recovery from an eating disorder, post-surgery, etc.), and I do think this can be done within a HAES framework. But weight loss cannot be intentionally pursued within HAES. If weight loss happens (and it might), it only happens incidentally — NOT intentionally.

3) You are interested, within whatever physical or mental limitations you may have, in pursuing “health” — using a definition of health that means something like “the ability to live a meaningful life, balancing optimal physical functioning with optimal mental and emotional functioning, within whatever inevitable health challenges I will, at some point, have to face.” (I believe Jon Robison has a similar philosophy — “Health can be redefined as the manner in which we live well despite our inescapable illnesses, disabilities, and trauma.”)

It should go without saying that, if #3 does not apply to you, and if you are not at all interested in considering health, no matter what definition is used, then that is your entirely legitimate choice, and you are still eligible to have human rights, and to be involved in fat acceptance, and everything else. For many people, health is simply not something they are interested in thinking about, period. I was that way myself for many years, before I was clotheslined by a love of nutrition, and I can entirely understand and respect that choice.

But, if you sincerely believe in the above, and are not fooling yourself (and this can get tricky) about being on some kind of “HAES lifestyle plan” in order to lose weight — then I don’t really care what tools you use to help you eat and move in ways that work best for you, and that give you the best quality of life, whatever your limitations may be.

If you are diabetic, you may count carbohydrates. Even though this smacks of some kind of Atkins-style ridiculousness to the average fat activist, it is a legitimate tool for some people. If you never end up finding your hunger and satiety signals (and it can happen! It is hard to find them, especially if you’ve dieted for years!) and feel most comfortable using some method to estimate an intake that allows you to function physically without driving you crazy, mentally — then I don’t care. Only YOU can know what your true intentions are. Only you can decide whether you are interested in HAES, and whether or not you “qualify,” based on your sincere beliefs and intentions. Behaviours are, largely, irrelevant.

Everyone is limited, physically or mentally, to a certain extent. HAES must work within those limitations. And because humans come in all shades of disease — from Crohn’s, to diabetes, to cancer and chemotherapy, to eating disorders, to fibromyalgia — there is no tool that can be definitively excluded from being used within HAES.

But ANY tool, no matter how innocuous and HAES-friendly it seems, if used to flagellate yourself, becomes instantly outré. Even intuitive eating. Even yoga. Even anything, if done with the slightest shade of self-hatred.

I would rather someone count calories while truly believing in fat acceptance and HAES, than practice intuitive eating in the secret hope that they will lose weight, or in competition with someone they look up to as a perfect disciple of HAES, and beat themselves up when they ‘fail.’

HAES is a paradigm shift, not simply a new diet. Without the underlying beliefs, the behaviours alone are meaningless.

I am professionally involved in nutrition, so I have a good understanding of food and exercise. I walk at least two miles a day, in all kinds of weather. I don’t drive or take public transit. I eat a varied diet that balances immediate pleasure with longer-term well-being. And all of that is really no one’s business but my own. It represents a mere drop in the bucket — you’d be surprised how many more determinants of health there are than just lifestyle.

What really makes me healthy is that I refuse to allow my health status to be dictated by my weight. I don’t regularly weigh myself. I don’t diet. I don’t engage in punitive or boring exercise. I don’t read women’s magazines. I try to avoid influences, like advertising, that tell me I am not good enough as is, and need to buy X product to be a complete person. I believe in my own beauty aesthetic, and dressing in the way I like.

I’m a feminist and a believer in social equality, so I stand up for myself, and for other people. I don’t believe in blaming people for their own health problems, because even in the rare cases where someone may be at fault, it is not a useful or compassionate response. I believe in kindness not because I am wimpy, but because it is right. And I don’t believe people have a responsibility to anyone but themselves to manage their lifestyle and physical health as they see fit.

I’m healthy because I say so. In school, we studied the various definitions of health, developed over years by the World Health Organization, and then came up with our own definitions. Having worked in health care, I can tell you that a diagnosis of disease and good health are not mutually exclusive. I believe someone’s health is determined by how well they are able to cope with whatever life throws at them, with whatever circumstances they happen to be in. By my definition, people who are physically well, but continually worried about death and disease, are not healthy. Someone who lives with a disease, managing it and maintaining a meaningful and enjoyable existence, is far more healthy.

For a midterm I once had to write on the definition of health, I explained it this way:

I would wager a bet that no one — no one now, and no one at any point in history — has ever enjoyed perfect health. Yet we persist in dividing the population into sick people and healthy people. At any given point in history, and in any given culture, what constitutes illness is at the mercy of subjective interpretation. In reality, we are all ‘sick’ to some degree. The difference exists only in that we decide whom to call ‘sick’ and whom to call ‘well.’ Because of this rather arbitrarily placed point on the seamless continuum of health, 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.”

I believe this because physical health itself is often just a crapshoot. And I believe it’s a crapshoot not because I’m fat and it’s convenient to think so, but because I learned it the hard way, by working at a cancer hospital filled to the brim with young, formerly healthy people. People, who by most definitions, did everything “right” — and were rewarded for that with an agonizing, deadly disease.

That said, I have no diseases that I’m aware of. I’m young, able-bodied, and I live in a fabulously wealthy country with medical care and a food supply that is the envy of much of the world. I’m part of a privileged social class. I have a strong social support network that includes family, friends, and my husband. Aside from being fat, I have no physical traits that mark me for social censure. Being aware of how undeservedly fortunate I am, and working to make human society more equitable, keeps me healthy.

I don’t think BMI is flawed only because it fails to measure muscle mass, or only because it is a population-based epidemiological tool that has been inappropriately co-opted as an individual diagnostic, or because it insults attractive people by calling them ‘overweight’ — but because it reinforces a very destructive belief: that you can make assumptions about a person based on their body size. That you can assume they are unhealthy, or that there is a ‘correct’ size/weight to be, and the subtextual conclusion that weight and health status define a person’s worth. That people on the fringes of the chart are freaks, not even entirely human. That it is okay to diagnose people as ‘diseased’ for not meeting an arbitrary beauty standard. And that traits associated with disease, whether causally or not, can be legitimately treated as diseases in their own right.

Whether or not someone is healthy, and however much they weigh, however fat or thin they appear, they are human. They have rights, and they deserve compassion, or at least basic dignity. Humans are naturally physically diverse — it is a strength of the species that helps protect us from total extinction should some natural catastrophe come calling. We should not dedicate our time and resources to eradicating a certain group of people, or trying to eliminate the natural variation of our population. Simply put, to do so is not healthy.

You are under no obligation to be healthy.

And, as an addendum: even if you were, eating “well” and exercising wouldn’t guarantee your success. There. I’ve said it. And as much as this might chap the ass of every health promoter out there, I feel that personal agency and a basic sense of privacy are sorely missing from most conversations of health promotion, and from conversations of Health at Every Size.

Health at Every Size exists in order to address the health concerns of people who, well, have health concerns. It is not, nor should be, a vaunted ideal that everyone must strive to live up to. It is an alternative. To what? To weight-loss dieting, to punishing “health regimes,” to doctors whose anti-fat bias drives them to diagnose you as fat and send you limping off on a sprained ankle with a prescription for steatorrhea.

An alternative, not an obligation.

It’s sad that we’ve come to the point where this needs to be pointed out. But it seems to be the reality that health habits, and health status, are no longer private matters. When people believe that you are receiving health care services off their backs and their premiums, they believe it becomes their business to police your personal habits. When health becomes not just an indicator of damn good luck, but of social status — because only responsible, smart people know how to avoid getting sick, and have the money for all those special foods/supplements/alternative therapies you’re supposed to buy in order to be a worthy citizen of the health meritocracy! — people forget about respect for their own and other people’s privacy.

This, despite the fact that the definition of health itself has not even been definitively pinned down, that it has evolved through numerous variations through the years, and will likely continue to evolve. Despite that nutrient requirements are different for each person. As are genetic profiles, family histories, and every single one of the social determinants of health.

The factors that determine health are different for everyone — which means it is up to you to decide what to do. No one can do it for you.

But we live in an era, a really strange era, where our life expectancy is better than ever before, and where we have (arguably) adequate access to health care. But, in some kind of terror, we strive continually for a zero-risk situation — and we strive for it not by addressing systemic disparities in access, but through laughably insignificant personal attempts, and individual finger-pointing.

But there are no zero-risk situations. Even people who do everything “right” sometimes get sick and die. In fact, everyone eventually gets sick and dies. Despite attempts to the contrary, our mortality rate as humans remains stubbornly at 100%.

These are the fat acceptance zealots — using fat acceptance and ‘in your face’ fat imagery and messages in order to shock the world into accepting their fat as meaning they are valid, worthy and ultimately just as healthy as the next person.

“And really fat people are valid and worthy, but as healthy as the would be if their hearts weren’t beating much harder in order to accommodate an extra 100lbs?

“No — this simply cannot be.”

–Weighted Long Enough

This is the writing of a woman who was once passionately involved in fat acceptance. Presumably, she still believes in basic tenets like, you know, appearance-based discrimination is wrong. But she got to a point where she felt her fat was detrimental to her health.

Now, I wouldn’t presume to argue with a person about their own experience, except to say that I believe directly addressing comorbidities associated with fatness is probably more effective than addressing the fatness itself, given that there are precious few (read: NO) permanent, safe methods of fat reduction.

But still, a person is allowed to be the expert on their own experience. If she feels that fat was causing her health problems, who the hell am I to contradict her?

This is where I believe Health At Every Size connects with the fat movement. The fat movement, as I see it, is primarily about politics and human rights, and well it should be. These are the critical, the most important, factors determining our experiences as fat people. But because fat is inextricably bound up in matters of health, at least from the perspective of our oppressors, the HAES component is a critical tangent of our movement.

See, the thing is, people who are involved in fat acceptance don’t always seem to fully understand HAES, and this concerns me. It concerns me because it is a useful tool that many of us seem content to toss by the wayside. This woman is a prime example of not understanding the basic structure of the HAES philosophy…the first being that “Health At Every Size” means health at every size for the population, not necessarily the individual.

If you accept the theory of set-point, as many fat acceptance advocates do, then you realize that an individual body has a preferred level of adiposity, for which a handy (though imperfect) proxy is body weight. This not only means that maintaining a weight lower than set-point is not good for you, but also that maintaining a weight much higher than your body’s natural set-point range is also not good for you.

The thing is, despite what the BMI dorks seem to think, set-points, or body weights, or body compositions, naturally come in a wide variety. I like to think of this as one way our species protects itself against extinction by one poorly-timed famine, epidemic, or ice-age. If all our bodies operated identically, the human race could easily be wiped out in one fell swoop, because we’d all react in exactly the same way to dramatic environmental changes.

So there is variety in size. There is variety in nutrient requirements as well…not only for kcalories, and macronutrients like fat, protein, and carbohydrates, but also for vitamins and minerals. Now I know those RDAs and the popular multivitamin supplements and the Food Guide Pyramid and everything seem to suggest that we all have the same requirements, dependent on things like age and sex, but it’s not so. Those things are basically educated guesses on how we can catch most of the population, within its wide range of requirements, so that nutrient deficiencies are no longer widespread. There was a time when things like scurvy and rickets were near-epidemic, so the usefulness of these tools can’t be overstated. But they do not represent some magical, unequivocal number that super-smart scientists have determined to be the perfect amount of X nutrient for everyone in the whole world.

If you doubt this, I would like to turn your attention to the development of the DRIs, which are, basically, a more complex and comprehensive form of the RDAs. There were huge debates, for example, over the recommended intake of calcium. Calcium! A nutrient we all take for granted as being a set-in-stone, God-given prescription for strong teeth and bones! Well, the goddamn scientists argued so much over the RDA for calcium that they never came to consensus. So, yes, you read that right, there is no RDA for calcium at this time. Instead, they came up with a rough guesstimate (the AI), from which specific recommendations cannot be extrapolated.

Okay. Phew. Sorry for the Nutrition 101 lecture. I just wanted to illustrate my point that, if we can’t even come up with solid numbers for the entire population on something as basic as calcium, why do we assume that ideal weight can be so easily established?

It can’t. Just as it is not logistically feasible to thoroughly test and document the nutrient requirements of each individual across the entire population, it is logistically infeasible, and as yet IMPOSSIBLE (since we are nowhere near understanding all of the complex mechanisms that influence body weight), to determine every single person’s healthiest weight. For practitioners of the HAES model, the definition of ideal weight is this: the weight you maintain when you are eating nutritiously and getting adequate physical activity. Not some arbitrary, shame-inducing number on a goddamn table picked out by a bigot like Walter Willett. Sorry, but for all you BMI-lovers out there — them’s the fucking breaks.

So, back to this woman. Is it possible that she maintained a weight that was above her own healthiest weight? YES. Does this mean that anyone else maintaining the same weight and body composition at similar height, age, and gender is also above their healthiest weight? NO.

Health at every size, as I have said approximately 7,386 times on this journal, does not mean that one individual can be healthy at every size. Cause you can’t. You’ve got a basic range, and the range may shift a bit during different stages of life, but you cannot run up and down the huge spectrum of possible body weights, like a pianist running his hands over the keys from lowest to highest, and expect to be perfectly healthy at each step.

It is perfectly possible that, by an individual definition, this woman was ‘overweight.’ The problem, though, with focusing on weight, even if it does prove to be causing health problems for a person (and this is rarely, if ever, proven), is that not only is there no way of predetermining an individual’s ideal weight, there ain’t much we can do about the weight anyway. Weight-loss treatments, from drugs to diets, are dismal failures. GI surgeries are risky and do not have a lot of long-term research to back them up (I won’t even mention the anal incontinence, or possible vitamin deficiences that can cause irreversible neurological damage. Oh wait, I just did. Sorry.) Even people trying to gain weight have some difficulty.

So it’s a bit of a bind, isn’t it? And even if someone buys fully into the political aspects of fat liberation (there, I said it, fat liberation), the health argument is just sitting there, waiting for them to have a bad day, or to get tired of being fat (which is a very real possibility in this culture), or to get sick in a way that a doctor would readily attribute to ‘obesity.’ Under these circumstances, it is very easy to see why even an ardent supporter of the politics of fat liberation might go and do a thing like have weight-loss surgery, or start a reducing diet, or take the newest FDA-approved fat-person extermination pill — I mean, ‘obesity treatment’ — and maybe start to side, just a little, with the attendant propaganda. Because cognitive dissonance is a bitch.

This is the where Health At Every Size becomes not only a useful tangent to fat liberation, but an essential component.

Listen: there is an alternative. We need not be extremists on either end of the spectrum of fattitude — one being the end that says “I am healthy no matter what” and the other being the end that says “I’ll take the Roux-en-Y with a side order of Meridia” — because, all-too-often in my experience, two extreme ends of any spectrum eventually meet in the same, frighteningly psychotic person. Like radio shock-jocks who go from an ultra-liberal upbringing to ultra-conservative vitriol in the brief time it takes to experience one adolescent disillusionment. Like the woman who writes about being “involved in the fat acceptance movement as a way to stay in an illusion that one can be extremely fat and healthy.”

Thing is, there are extremely fat and healthy people out there. That’s how the fucking bell curve works. No, you cannot be healthy at every size. But we can. Here’s how:

You eat well. This is not a moralistic determination, nor is it the same from person to person. There are general suggestions that most people can safely follow, but the most important is to learn to listen to your gut. Try to resuscitate the cues that a lifetime of dieting and an eating-disordered culture have probably killed. If you can’t do it on your own — and many can’t; it’s hard — get someone to help you. Size-friendly therapists and dietitians exist, and many of them believe in an empowering philosophy of health promotion, which in English means: you get to make your own choices. You get to figure out what is best for you. Because even scientists can’t tell you how much goddamn calcium you need.

You move well. This is also hard to figure out, and I’m currently doing battle with it myself. Kell has some good ideas. Like we all have an appetite for food, I think we all have an appetite for movement. Think back to the way you might’ve played as a kid, the times you got restless from sitting still for too long. Try to remember a time when being sweaty and out of breath meant you were having a fucking awesome time (if you’re lucky enough to have such memories.) Think back on those times, and try to come up with creative ways to have fun now. REAL fun, like the kind of fun you had when all you needed was a hot day and a sprinkler in the yard, or a jump-rope, or a piece of chalk and a stretch of concrete. When did adult movement become so boring and medicinal? Who says you need to have ‘proper footwear’ or a gym membership or all sorts of ugly spandex clothing in order to get a little hot and sweaty? If you’re into that kind of thing, cool; you have that many more options than the rest of us who hate all that shit. And if you hate it, take heart: so do I. But I won’t be disingenuous and pretend that physical activity has no bearing on our well-being. Neither will I deny that it’s more than possible to go out and find ourselves a bit of fun.

Third, you learn to deal with your body. Whatever size it’s at, whatever health conditions you might be facing, whatever colour it is, however big your butt is, or small your tits are, or anything. You take what God fucking gave you, and you make the best of it. You do the treatment for any health problems by focusing directly on the problem itself, not by buying into the cultural fantasy that, if you lose weight, you’ll magically lose any physical and/or mental illnesses along with it.

By doing this, your body is going to change in whatever way is best for it to change. You don’t get to control that. It might mean gaining weight, in the form of fat or muscle, and feeling self-conscious. But we have tools to deal with that, because that is what this whole movement is about: creating a society where people of all sizes can feel reasonably welcome.

It might mean losing weight, and you might feel guilty, like you’re betraying your fat liberation buddies. But you’re not betraying anyone. A real betrayal would be to go and swallow shit like “I wanted to believe I could be as healthy as a person whose weight didn’t literally drag them down. This was my greatest lie – a lie that allowed me to get more and more fat, until I’ve now reach the point of do or die.” Betrayal would be to believe that, in order to be healthy, you must first focus on changing your body to a socially-enforced ideal…in order, presumably, to become ‘deserving’ of proper health- and self-care. Betrayal would also be to totally deny the fact that eating and moving well will have a positive impact on your health, and that, if you want to, you deserve those things as much as anyone else.

Most likely, no matter how your weight changes, your basic health indicators are going to improve. Your blood pressure is probably going to improve, as well as your blood cholesterol, and your ability to use insulin and regulate your own blood sugar. These are much more accurate proxies for health than body size could ever be. And if things get worse, it’s a sure sign that something else is going on and you need to see a doctor. But for most people, you can bank on the fact that eating and moving well and treating your body with respect is only going to make things better, whether or not you get bigger or smaller in the process.

Listen: as surely as we are oppressed by systematic external discrimination, we collude in our own oppression by not demanding the care we deserve from health professionals, and by not caring for ourselves in the way we deserve. And don’t you believe for a MINUTE that you have to submit to ‘their’ idea of health and self-care, or the health meritocracy. First and foremost, all of this is a choice. It is optional. But in order for that choice to even exist, we have to have access to good information, and we have to really believe that we deserve to be cared for. I have a sneaking suspicion that an internalized sense of inferiority drives a lot of our rebellion against ideas of self-care and health at every size. And I totally understand. I get panicky, too, when I entertain ideas of ‘making healthy choices’ and what-not because, more often than not in our deranged, pathological society, ‘making healthy choices’ is code for ‘submitting to coercion.’ I know. I know. But we can’t let the difficulty of the fight let us stop fighting it.

There are size-friendly health professionals out there. There are dietitians and therapists and doctors in a number of specialties who are on our side. We definitely need more of them, and that’s another thing we’re working on, but we should be taking advantage of the ones we’ve got. (Check out Stef’s Fat Friendly Health Professionals page.) We also need better resources for general information on health and nutrition — in print, on the internet, on TV — stuff that comes from a size-positive perspective (hell, even a size-neutral perspective would be an improvement over what we’ve got now.)

Pattie pointed out that a lot of the HAES terminology is being co-opted by forces that are anything but size-friendly. This scares me, and I think one of the reasons they’ve been able to do this is that HAES has not yet come into its own. One of the things we’ve got to fight for is to make HAES work, and work in the way we want it to. We can’t let it revert into yet another health-fascist approach that’ll only find creative new ways to blame and marginalize people in the name of health.

Pattie also talked about how “the personal is political.” With the way things currently are, what could be more political than for people to stand up, demand quality health-care, and to make truly free and informed choices about their health, regardless of what size they are? In a true HAES framework, this would never result in dividing us into ‘good people’ and ‘bad people.’ It would simply give people of all sizes the information and support they need to make real choices — something we don’t currently have, since most of our resources are hopelessly tainted by their association with “Brand Thin” — and its mandate would be to then respect those choices, whether they might be classified by the majority as ‘healthy’ or not.

If we’re fighting a war here (I’ll indulge in some militaristic language, since everyone else seems so eager to compare fat people to terrorists and to declare ‘war on obesity’), we need our troops to be as strong as possible. And that doesn’t mean conforming to some arbitrarily defined, absolutist notion of what ‘health’ is. To me, health is a matter of making autonomous choices, and having the resources necessary to inform those choices. Though we may all disagree on which behaviours are healthy or not, I think we can all agree that losing once-fervent supporters to the health meritocracy does not strengthen our numbers. Having an alternative that emphasizes good information, respectful practitioners, and a culture of individual sovereignty will.