Trigger warning: Discussion of weight loss surgery and eating disorders.

So I want to do a little crowdsourcing about weight-loss surgery (WLS). Are you up for that?

There, now I’ll be healthy.

I’ve been interested in the subject a long time, ever since I knew such a thing existed. I remember in 7th grade —before I was fat myself — reading in the newspaper about a fat woman whose jaw had been wired shut by doctors. The sadomasochistic overtones of this extreme act were both horrifying and fascinating: it was exactly like putting your mouth in jail so it couldn’t commit any more crimes.

The woman had agreed to this treatment (obviously she must have agreed to it), but equally obviously there was an aspect of punishment and public humiliation to it. In my daily life back then, I knew only two really fat women: my neighbor and my scary-strict language-arts teacher. When the teacher went on leave in the second half of the school year, I speculated that maybe she was going away to get her jaw wired, and I shared my speculation with other children.

Just before 8th grade started, I was sitting on the floor of the Spanish/French classroom, helping the Spanish teacher organize her new teaching materials, when the language-arts teacher suddenly appeared in the classroom doorway. She was no longer fat, but just average-plump as any middle-aged woman might be.

Once she was gone, I asked the Spanish teacher, “Why did she go on leave?” She and I had a good relationship, but I was certain she would never reveal information about a fellow teacher to a child. Still, the apparition had been so startling that I couldn’t resist saying something. The Spanish teacher paused a long time: “Well….” In her face I could see her rapid ethical calculations. “Did you notice anything different about her?” So I was right, I was right! Something drastic, something deservedly drastic, had been done to the monstrous language-arts teacher.

In three years I would begin to consider myself fat, and an era of heroic secret attempts at self-starvation would begin. For the first four years these efforts failed. Why couldn’t I stop eating long enough to be thin? If only there was a way to enforce the true desires of my best self upon my recalcitrant will! If I could, like Odysseus, have myself tied to the mast, with instructions to ignore all subsequent commands for release. To decide at Time A to render myself powerless to make the opposite decision at Time B.

Just before my senior year of high school started, in 1978, I had a vivid dream of a post-apocalyptic world in which I was being chained up in a line with other slaves. In my sleep, I rejoiced: slaves didn’t stay fat! I could worry about escaping once I was thin again. FYI, not that this should make any difference, but I weighed about 140 pounds — at 5’6″ — when I had this dream.

Awake, I pondered the paradox: I yearned to be a strong-willed person in control of her own body, yet the best self-improvement technique I could imagine involved renouncing the freedom to satisfy my appetite.

The harder I tried to be thin, the more I fattened. I finished out my teenage years as a fat anorexic, though that certainly wasn’t how I thought of it at the time. I thought I had somehow turned into a secret glutton. How I think now: there are part-time anorexics, wannabe anorexics, failed or temporarily successful conventional dieters — it’s all just different points along the same misguided spectrum of food shame, food restriction, body shame, and the pursuit of thin privilege.

During those years I saw occasional media references to the new technique of “stomach stapling.” The idea was queasy-making for me, even worse than the jaw-wiring. I thought at the time, and I still think now, that even if we make the assumption that it’s good to control food intake, the digestive organs are a dangerous site at which to exert that control. Essentially, surgeries like these remove anorexia and bulimia from the behavioral realm, and enforce it at an anatomical level instead — generally permanently.

How can it ever be a good idea to deliberately damage the functionality of healthy digestive organs? In 1983, I read shadow on a tightrope, which included a few first-person stories by women who had had either gastric or intestinal bypass operations. The pain and side effects they described were horrific. I could hardly stand to think about it.

Three decades later, I figure I’m just about grownup enough now to enter the global intellectual conversation about weight-loss surgery, though both the specific techniques and the prevalence of WLS have changed in that time. Last year I co-wrote an article with a team of Norwegian researchers who were interviewing gastric-bypass patients about their experiences following surgery. What’s next?

Over the course of my own life, I’ve felt both a visceral revulsion at the concept of weight-loss surgery and also a visceral understanding of its attractive logic. I think having had this range of feelings is useful; feelings are relevant, necessary even, when we’re debating the wisdom of cultural values and practices. Some questions (e.g., Does technique X produce lasting weight loss?) are purely empirical. But others (e.g., Should technique X be used?) have both empirical and moral components. And how could you grapple with questions that involve a moral component without making value judgments?

But we still need data; feelings alone aren’t enough. Currently my Norwegian writing buddy is continuing to study the personal narratives of post-surgical patients. The patient success stories featured on the websites of for-profit clinics are glowing and happy, of course, but it would be silly to imagine that they’re typical. Does anyone out there in FFF-land know of, or know how to find, the Norwegian equivalent of WLS-survivor groups that would provide stories from the other end of the spectrum? Or, more generally, where would you start networking or what would you read if you were attempting to grapple with the question of what constitutes a typical post-WLS experience and how many WLS patients get an average result, as opposed to fairy-tale happiness or sheer horror?

Trigger warning: Discussion of weight loss, weight loss surgery and diet talk.

Over the past five years, I’ve done a number of book reviews, both fiction and nonfiction. I’m not a huge fan of doing book reviews because once I agree to review a book and receive the review copy, I begin to feel a kind of pressure. Almost all the books I review are written with a Fat Acceptance (FA) or Health at Every Size^® (HAES) perspective and, as such, I feel pressure to positively promote the work of my fellow writers.

And yet, I hold myself to a ridiculous standard of intellectual honesty. I’m not going to promote a book that isn’t worth my time or yours. Personally, that’s a fairly high bar because I am the world’s slowest reader and any investment I make in reading a book feels pretty significant for me.

So there have been times where I’ve begun reading a review copy of a book and found it either dull or uninformative or terribly written, at which point I decide it’s not worth it. If I can’t get into a book, I’m not going to continue reading it, but, more importantly, I’m not going to review it.

The reason I don’t write a negative review of FA or HAES books is simple: as a relatively small community of activists, we simply can’t afford to shit on each other. Yeah, I might not find Book X useful, but others may find it riveting. So if I write a negative review of Book X, I may discourage people from discovering a work that, from another’s perspective, is invaluable.

I consider it a favor to the author that I’m not going to say a single negative thing about something that they’ve worked so hard on. I know how much time, energy and love goes into writing a book, so the last thing I want to do is discourage anyone from writing about self-love and self-acceptance, a subject which needs more writers, not less.

And yet, there are books with which I have a complicated relationship; there are parts that I love and parts that I’m ambivalent about at best. For example, I was recently asked to participate in a “blog tour” by writing a review of Body Respect by Linda Bacon and Lucy Aphramor. I love how the book attempts to incorporate the social determinants of health (SDH) into the HAES world, something I have personally been discussing for years.

But something about the way the authors framed the SDH in relation to personal health choices rubbed me the wrong way. In my view, HAES has always implicitly incorporated the SDH into practice by tailoring health behaviors to individual circumstances. Or, to quote the original Bull Moose:

In my view, the new framing in Body Respect made it sound like personal health behaviors are futile in the shadow of the SDH, a viewpoint I cannot agree with entirely.

And so, about halfway through the review, I raised those questions that I felt were unanswered as a way of laying the groundwork for an interview I had scheduled with Aphramor a few weeks after the review was published. I felt like I had given their book an overwhelmingly positive review, while raising some important questions for the future of HAES.

Apparently, the authors felt differently.

Bacon contacted me the next day and told me that she felt that my review was disrespectful because I critiqued their book during their blog tour. Presumably, I should have saved my criticism for a later date. Bacon then asked that I either delete my review entirely or else remove any reference to Body Respect from the review.

Concerned that I had violated my own cardinal rule of “do no harm” in promoting books, I consulted several people I greatly admire and respect — people who will happily tell me I’m full of shit — and asked if I had possibly been too negative or discouraging of the book. Each person told me my critique was even-handed and fair.

And so, I told Bacon I could not in good conscience delete my review. I felt my critique was an important part of the discussion of HAES and the SDH, and that it would reflect poorly upon my editorial judgement to remove it.

As this back and forth continued between Bacon and I, both Bacon and Aphramor posted the following comment on my review:

It’s understandable why SDH and self care get so polarised from the cultural starting point we have in constructing health narratives. Lucy’s got an interview with you scheduled, perhaps this could be a fun topic to delve into.

I had been quite concerned that my decision to stand firm on the review would negatively impact my relationship with Bacon or my interview with Aphramor. This comment reassured me that I had raised a valid point that could be discussed more thoroughly in a robust discussion of HAES and the SDH.

But then, a few days before I was supposed to interview Lucy, she sent me an email informing me that she “decided to leave the conversation now.”

And that was that.

My questions would not be answered, my concerns would not be addressed. It seemed that in their view my review was so negative, so hostile, so harmful that I no longer deserved an interview.

Even though I could not agree that self-censorship was the appropriate solution, I did contact their publisher and request that my review was removed from the blog tour so as not to negatively affect their promotion.

When this first happened back in September, I had intended to write about it immediately. But those same trusted advisers recommended I not rush into anything, that I not cut off my nose to spite my face.

And for a while, I agreed.

There was still a “do no harm” principal at stake and I felt that there was no legitimate reason to mention Bacon’s attempt to persuade me to censor myself. I understood that she was simply protecting a project that she and Aphramor had worked long and hard to produce, and from their perspective, my review may have tainted the promotion they were expecting.

But since then, something has changed.

In October, Rebecca Jane Weinstein released her book, Fat Kids: Truth and Consequences, a project she’s been working on for years. It’s a kind of follow-up to her previous book Fat Sex: The Naked Truth (a book I reviewed, BTW).

I’ve personally seen how much time and energy Weinstein has poured into both of these projects, which she passionately felt needed to be covered. In a world where stigmatizing fat kids is seen as a means justified by the ends, it’s invaluable that someone would dedicate years interviewing subjects and sharing their sometimes traumatic, sometimes uplifting stories .

For a book focused on such a specific subject as fat kids, Weinstein covers a broad spectrum of issues from forcing kids to diet to the cost of being a social outcast. It’s a thorough examination of the subject, and includes diverse perspectives, as well as fascinating contributions from FA thought leaders like Peggy Elam, Pattie Thomas, and Daniel Pinkwater.

It’s an anthology of sorts, with each chapter contributing a piece to the overall mosaic of life as a fat kid. It would be incredibly cynical and myopic to take a single chapter and base an entire recommendation off of it. And yet, that’s exactly what happened to Fat Kids.

Indeed, the chapter in question is not from a HAES-friendly physician. It’s a Q&A with Emily Dhurandhar, assistant professor in the Department of Health Behavior at University of Alabama Birmingham and chair of The Obesity Society Advocacy Committee.

It’s a mainstream perspective on childhood obesity. Does it comport with FA or HAES? Not exactly. But the fascinating part is that it’s the perspective of a mainstream researcher which includes elements widely understood and accepted in FA and HAES circles: namely that stigmatizing fat people is a terrible way to promote health.

At no point does Weinstein frame this interview as reflective of HAES. In fact, she explains that this is a controversial chapter with a controversial perspective (at least when viewed through a HAES lens). As Weinstein says, “In this interview, we are given essentially a primer on weight from the perspective of a clinical obesity researcher.”

Is this chapter meant to change how HAES views childhood obesity? Nope. Is it meant to convinced readers that fat is a disease? Nope. Although Dhurandhar says that she believes obesity is a disease in “some cases,” her opinion raises more questions than it answers (e.g., how can something be a disease just some of the time?). It’s a discussion with someone outside of HAES circles whose research validates significant portions of HAES, like the idea that “treating obesity” is as simple as calories in/calories out.

If you overeat, what your body chooses to do with those extra calories is less clear. But we do know that in general, if you eat less than you should to maintain your current weight, you generally will get hungry and eat more.

But where Dhurandhar’s view conflicts with HAES, Weinstein asks critical questions, as with regard to pregnant women who have had weight loss surgery. She doesn’t simply accept Dhurandhar’s answers, she probes her for greater clarity. Personally, there are more questions I would have raised in the interview to distill her view further, like whether weight is an independent risk factor when a subject’s fitness is accounted for. But Weinstein does her best to question the assumptions Dhurandhar makes.

In general, Dhurandhar’s own view seems conflicted. She believes that in extreme cases of metabolic disorder, caloric restriction is the only means of treating the child, but not in cases where the child is simply heavy. Even her claim that obesity is a disease is framed as dependent upon comorbidities.

Again, is this HAES? Nope. But at no point does Weinstein present this chapter as representative of HAES.

But the great thing is that there’s another chapter that serves as a direct response to Dhurandhar’s claims. Titled “Collateral Damage in the ‘War on Obesity,’ Peggy Elam eviscerates the “fat as disease” paradigm and acts as a deeply-sourced check on Dhurandhar’s interview.

In the context of the full book, we are presented with two sides of an argument on childhood obesity and readers are left to decide where the truth lies. If you’re a cynic, then you don’t trust readers to find Elam’s arguments compelling enough to serve as an adequate response. But I’m of the mind that readers are capable of digesting complicated, nuanced arguments and finding the truth without being led by the nose.

Not every FA/HAES book needs to present all your answers neatly packaged in pre-approved format. In fact, FA/HAES books can be quite effective when raising questions that challenge both the mainstream view, as well as our own. To fear anything short of obeisance shows cowardice, in my opinion.

As a result of Wann’s criticism, multiple commenters said they would not buy Weinstein’s book. As a de facto gatekeeper of Fat Acceptance, Wann’s disendorsement directly discouraged people from supporting a project that serves as a powerful testament to the damage of mainstream views on fat kids.

And then Linda Bacon threw her two cents in:

Weinstein’s comments are no longer there, but at the time I copied the text because I found the exchange disturbing. Bacon references this response to Wann in which Weinstein explains what’s in the book:

There is a highly critical chapter on a residential school for “overweight” teens, one on stigma and another on eating disorders. Marilyn, Linda Bacon, Ragen Chastain, and many others in the “movement” are discussed and quoted. There is also the interview with Daniel Pinkwater.

I’m not exactly sure how Weinstein was being disingenuous here, as she mentions Wann, the very person who says she wouldn’t read more than a single chapter. Weinstein never claims that Wann, Bacon or Chastain agree with her or that the book is “congruent” with their ideas, just that she included discussions of those thought leaders elsewhere in the book.

Regardless of whether you agree with Dhurandhar or not, it’s clear that the chapter isn’t an FA or HAES perspective. But it’s also not exactly “all fat kids are diseased and need to diet” either. So, the question seems to be what purpose does this interview serve the book?

In my view, Weinstein seems to be present Dhurandhar’s viewpoint as an objective figure who is not personally vested in HAES or FA. This is a problem in Wann’s estimation:

The book positions this particular scientist as the authority on questions of science and health… There are certainly laboratory scientists available who don’t view fat people as diseased and in need of a cure. There are certainly laboratory scientists who know about and opt for a Health at Every Size^® approach, who show concern about how their work participates in or challenges weight oppression, and who are knowledgeable about the psychological impact of the weight=health belief system. The author chose to present as an expert on fat kids someone who did not have those points of awareness.

The implication seems to be that any author who wants to discuss weight-based oppression must only present HAES-friendly experts. While I understand the need for books with HAES-friendly views, to make such standards a litmus test for fat-friendly media is awfully short-sighted.

I don’t think anyone can question my commitment to promoting HAES as the best evidence-based approach to healthcare, but what kind of advocate would I be if I completely ignored people who did not share my perspective? In my interview with Harvard’s George Blackburn, I found much common ground with someone widely regarded as an expert on public health policies. Was I only supposed to interview HAES-approved public policy experts? What kind of advocate would I be if I can’t converse with those I disagree with and share both perspectives? Are our beliefs so fragile, so frail that they cannot withstand the examination of diverse perspectives?

The thing is, someone like Emily Dhurandhar might be really receptive to a HAES perspective (as Blackburn seemed to be), but far too often we’re so recalcitrant that a real conversation with mainstream experts is over before it even begins. There is no “authority on questions of science and health” that a book-writer can cite and ensure 100% agreement from the rest of the medical community.

What there is, however, is a preponderance of evidence that eventually persuades a majority of the medical community to view one perspective is more valid than another. And that evidence exists, regardless of the context we try to put it into.

What I saw in Dhurandhar’s interview was some really great information on the evidence that she’s aware of that weight is far more complicated than calories in/calories out. That information was spun to fit her own weight-centric worldview, but that worldview, in my reading, seemed to be one more concerned with the extreme ends, rather than the vast majority.

I think it’s incredibly disingenuous to suggest that there aren’t health problems at the extreme ends of the BMI bell curve. What I thought I had learned from HAES is that health is complicated; sometimes weight can affect one’s health at the extreme ends, but weight is not as central to health as the weight-loss industry wants us to believe.

Dhurandhar’s view was seemed like the weight-centric version of that viewpoint, as though gazing back from the other side of the HAES looking glass. And she’s mainstream. So if you read the entire book, I would imagine that setting that interview beside Elam’s epic review of the evidence in favor of a weight-neutral approach like HAES, a person would have enough context to see that being shitty to fat kids does more harm than good and does not result in fat kids becoming skinny kids.

And here’s the thing: Weinstein requested that Peggy write her chapter as a response to Dhurandhar.

Neither Wann nor Bacon read Elam’s chapter. A single chapter was enough to dismiss an entire book that Weinstein poured her heart into. With a single Facebook post, Marilyn Wann convinced countless people to not buy Fat Kid, and Bacon cosigned that view.

I’m not here to say that nobody should criticize problematic fat media. Far from it. I began this post explaining my own trepidation at daring to stick by my criticism of Body Respect. But I would hope that rather than attacking a reliable ally for publishing something we disagree with, we could open a dialogue on whether conflicting viewpoints are worth exploring. I find it incredibly disturbing for such prominent leaders in FA and HAES to swat a book out of the air because they found something disagreeable in its content. Fat Kids deserves better than that.

Instead, the attack on Weinstein’s work seems like petty sabotage that has literally impacted the livelihood of a longtime promoter of FA and HAES. Does the context of Weinstein’s history mean nothing? Does a single perceived misstep really justify the social media equivalent of the stockade?

It’s this kind of reactionary litmus test that drives people away from FA and HAES. Can you imagine investing hundreds of hours of time conducting interviews and going through the painstaking writing and editing process, only to have one of the most influential fat activists essentially give you the hook?

It’s a shitty move.

But what really bothered me, more than anything, is the way Bacon insisted that I respect the promotional stage of her book, while simultaneously twisting the knife in Weinstein during her promotion. If you’re going to hold people to a strict standard of mutual interest, then I expect you to do the same. Anything less smacks of hypocrisy, in my opinion.

Since I first began blogging, I’ve felt like an outsider in the Fatosphere. It’s almost like reliving high school, where you must affiliate with a popular group or else be excluded from participation. That exclusion discourages people from contributing their voice to the chorus of self-acceptance, and it will ultimately force out people who may otherwise be useful to a small, but vital movement.

The saddest part of all this drama is that because of a few loud voices, many people won’t give Fat Kids a chance, and they’re going to miss out on some important, moving stories that shed a much needed light on the collateral damage from the War on Fat. But I guarantee that if you are willing to look past the controversy and keep that one chapter in perspective, you will not regret owning a copy of Fat Kids.

Trigger warning: This post touches on issues of health and wellness, weight loss and eating disorders.

Perhaps you aren’t aware, but there’s a seismic shift happening within the Health at Every Size^® (HAES) community. It all started with the book Body Respect by Lucy Aphramor and Linda Bacon.

As most of you know, Bacon wrote the groundbreaking book Health at Every Size, which tackled the way in which personal health behaviors can have a profoundly positive effect on metabolic health even if weight loss is not a  consequence of those behaviors.

Bacon’s book was a seismic shift in itself, directly challenging the orthodox view that weight loss is the end all, be all goal for overall health and well-being. When I began blogging back in 2009, my goal was to explore the science of HAES and to find out for myself whether weight loss was necessary for health. I’m pretty sure you all know where I stand now.

The seismic shift caused by Body Respect adds a depth of understanding to HAES that had previously been lacking. Namely, that the social determinants of health (SDH) have a broad-ranging effect on the health choices of both the privileged and unprivileged classes of every culture.

If you’re White, middle class, cis, heterosexual, able-bodied and male, then odds are in your favor that you’ll have better access to healthcare, quality education, a variety of nutrition and exercise options, economic security and overall stability than someone who is a PoC, poor, transgender, homosexual, physically or mentally disabled, and/or female.

There is broad global agreement (starting with the World Health Organization) that the SDH affects health across the spectrum and has an enormous impact on the health and well-being of everyone, but a particularly nasty impact on marginalized communities. The stress of economic insecurity alone has been indicted as a primary driver of poor health.

In my review of Body Respect, I praised Aphramor and Bacon for incorporating the SDH into HAES as long overdue. I strongly believe that socioeconomic inequality is the biggest issue of our generation, and HAES can play a pivotal role in drawing attention to and addressing the SDH.

Image from the Centers for Disease Control and Prevention

But in that review I raised some questions as to where this new focus on the SDH leaves the promotion of individual health behaviors. As the authors said in Body Respect, “Health behaviors account for less than a quarter of the differences in health outcomes between groups.” If that’s the case, then how should we frame personal behaviors within HAES? Does this signal a decreased emphasis on the health effects of diet and exercise? And if the SDH is the number one issue for HAES, then how can we, as HAES activists, fight against their toxic effects?

These are some of the questions I planned to ask Lucy Aphramor in my interview that she cancelled. So my first stop on my search for answers was the Association for Size Diversity and Health (ASDAH) blog, where Fall Ferguson wrote this post on health inequities. So I posted this comment and got no response.

After some consideration, I decided that maybe I could put together a panel of HAES experts to discuss the SDH. At first, I approached six HAES experts and arranged a sort of weekly email roundtable. But due to conflicting schedules and the impending holidays, it fell apart shortly after it began.

Still hungry for answers, I approached the Show Me the Data group, a private email list which includes most of the prominent HAES experts we know and love. I sent a message to everyone explaining the roundtable and how I would like to ask six questions and publish their answers here. Finally, I got a response and I was able to begin.

The First Three

The questions I chose were complicated, there’s no doubt. Asking “What do we do about the SDH?” is like asking “What do we do about that meteor heading for Earth?” We might have some suggestions, but the scope of the problem is so broad, so enormous, so all-encompassing that any answer will be, by definition, inadequate.

The SDH is woven into our systems, our culture, our heritage, where we equate success with hard work and poverty with laziness. And interweaving those economic issues are issues of racism, sexism, homophobia, transphobia, ableism and the inherent bias directed at marginalized groups. So, I came to the table knowing that we weren’t going to resolve the issue on a listserv.

However, I am optimistic that if we organize our thoughts, our knowledge, our understanding, perhaps we can construct a framework for advocacy so that we, as HAES advocates, can all push in the same direction. For example, a small, but (relatively) simple proposal that could have a net positive impact on millions of Americans is to raise the minimum wage. Hell, if I were King, I’d push for a living wage pegged to inflation. As they say, a rising tide lifts all boats.

If ASDAH and HAES advocates were to rally behind this economic issue, we could join the countless other social movements pushing for economic justice.

And so, it is with all of this context in mind that I asked my first three questions. I hope that this dialogue will provide insight into how HAES can play an effective role in addressing the SDH.

Question 1: If HAES is focusing more on the social determinants of health, what can individuals do to either reduce, mitigate or counteract the effects of the social determinants of health? What can/should we expect from the future of HAES advocacy in terms of addressing the root causes of the SDH (e.g., economic inequality, social injustice, institutionalized discrimination)?

David Spero, R.N.
A registered nurse with 35 years experience focusing on diabetes and the SDH

This is a very difficult question — what can individuals do about social causes of illness? It’s why my diabetes book was never popular with people with diabetes — learning about the social causes only made people feel more disempowered than they already felt. I usually suggest:

1. Use knowledge of the pathways from economic and social inequalities to illness to stop blaming yourself.
2. Be more open with others in your community about SDH to provide mutual support.
3. Use knowledge of the health effects of oppression to make plans to reduce those effects in the limited, but still useful ways, that are available to you (e.g., relaxation, exercise, social support).
4. If willing and able, get involved in trying to change some of the SDH that are affecting your community directly, which could be stigma, environmental pollution, poverty, lack of access to care or to food, etc. … there are a lot of them. The act of fighting back reduces the feeling of hopelessness, which is a major stressor, maybe the worst. Remember that stress is the number one way that oppression damages health in most cases.

Hope this helps. I am in no way saying that these are the only measures or the best measures. They are just the ones I know and use. People seem to like the sound of them, but I have no data on people putting them into practice.

Laurie Klipfel, MSN, RN, BC-ANP,WCC,CDE
Nurse Practitioner and Diabetes Educator

Well said David. I also am not sure we have the power to change socioeconomic status, but we can stop placing blame that only adds to the oppression and makes the effect much worse.

Lisa Du Breuil, LICSW
Clinical Social Worker who treats people dealing with addictions, eating disorders and problems post-weight-loss surgery at an outpatient psychiatry clinic in Boston

I really like David’s response to your question, Shannon.

In addition: Right now when I think of what HAES-oriented people can do to address root causes of the SDH, I think of working to get different voices heard by the people who currently have power in our health care system. I think about helping people actually see the systemic discrimination — what people used to call (still call?) “raising consciousness” — happening around these issues.

Question 2: How does one look at the effects of the social determinants of health, and the enormity of the institutions that ensure its ongoing existence, and not succumb to feelings of futility and immutable fate regarding one’s health and wellness?

David Spero

Shannon, you are asking the questions that politically-minded public health people have been wondering for years. A health approach to oppression, inequality, and environmental degradation gives the same picture that a social or political approach gives — the same problems and the same alignment of forces on different sides. If the 0.1% remain unwilling to share and willing to use all their power to maintain and exacerbate the status quo, it will be very hard to change conditions. Appealing to their sense of fairness or compassion sounds like a total waste of time to me. They don’t have such concepts about us.

So, to change SDH in a positive direction would require a very strong class-based movement, like in the US in the 30s or 60s, and in Europe until recently. On an individual, community, and family basis, we pull together to take the best care of ourselves and of each other that we can, we fight on issues where we have a chance, and we don’t give up. Beyond that, I don’t know.

Your questions aren’t new Shannon. Many activists have written books about how to keep strong in the face of the powers we are up against. Check out Joanna Macy for one, or Nelson Mandela.

Deb Burgard, PhD
Eating Disorder Psychologist and Past President of ASDAH

I guess I fall back on the skills that I use in the face of almost anything that seems overwhelming to me: I think, OK, this isn’t going to get fixed right away, but what can I do today to chip away at it? What can I do every day to chip away at it? How do I think about this so that I integrate it into my life as a part of my daily self-care? Care of the world = self care.

Practically speaking, I start with the low-hanging fruit and then build from there. What is right in front of me to do? Just start. And then just repeat. And then, just return (after I — inevitably — get interrupted).

Part of the problem is the dealing with the confusion about what is enough to do. It will never be enough, so how do we figure out whether doing anything is worth it? How do we figure out how much is worth doing?

I guess I am proposing Intuitive Activism — that there is something that is possible and worth it, and we need to free ourselves up to do it, and manage the sense of overwhelm/guilt/despair that lurks constantly over our efforts.

I think people underestimate the power of small, consistent, irritations on the status quo. I may not be able to change it all in my lifetime but that doesn’t mean I can’t use the opportunities that I have for being an obstacle to the Death Machine. If everyone did that there would probably be enough lack of cooperation that many of these big forces would lose at least some of their momentum. And because the big forces come down to money, if it becomes too expensive to fuel the big forces, then they stop getting fed.

The other thing that really helps me is to understand that the world I inherited was made better by those kinds of efforts that people before me made. I feel like I am part of a long chain, a long tradition that is the best human company there is. I want to be part of it. So I don’t want to do nothing, because I want those efforts that other people made to come to some fruition eventually. It is not just numbers of people who get momentum going, it is persistence over time and generations, and that is something that we do through institutions, traditions, oral history, activism. We are a team, it is my turn with the ball.

Jon Robison, PhD, MS
Researcher, assistant professor at Michigan State University and co-editor of the Health at Every Size journal

Love the sentiment — and for me it is always about the music — chippin’ away.

David Spero

Beautiful, Deb. It’s harder for me to maintain belief in the long-term when the long-term seems to be disappearing, but as long as we can hope for a future, I guess, we can keep trying to make it better.

Deb Burgard

Yes, David, many times before humans have had to face the worry that they will not be here much longer, even in my lifetime. I think our work is directly impacting the available energy for people to face those pressing and urgent problems and stop frittering away time and energy on fruitless weight loss projects.

I heard somewhere that pilots learn and practice to keep flying the plane no matter how close to crashing they are (I guess as long as they don’t have the option to parachute out!). I can see that being quite useful since you never know for sure.

Laurie Klipfel

Beautifully said Deb. Even after you are long dead, your chipping lives on. You really have no idea what your impact will be, or how big the small changes will grow. Watching It’s a Wonderful Life shows how little impacts can make a big difference.

Keep chipping!!

Carmen Cool
Psychotherapist with a focus on eating disorders

I am so grateful for this discussion — thank you everyone! I am totally in love with the idea of “intuitive activism”!

One of my favorite authors is Margaret (Meg) Wheatley. One of her most recent books, So Far From Home, was a tough but important read for me  because she takes on this issue of “feeling exhausted, overwhelmed, and sometimes despairing even as you paradoxically experience moments of joy, belonging, and greater resolve to do your work.”

This is the text of one of her posters, made from the book, and I was reminded of it while catching up on these wonderful emails!

A Path for Warriors

We are grateful to discover our right work and happy to be engaged in it.
We embody values and practices that offer us meaningful lives now.
We let go of needing to impact the future.
We refrain from adding to the aggression, fear and confusion of this time.
We welcome every opportunity to practice our skills of compassion and insight, even very challenging ones.
We resist seeking the illusory comfort of certainty and stability.
We delight when our work achieves good results yet let go of needing others to adopt our successes.
We know that all problems have complex causes.
We do not place blame on any one person or cause, including ourselves and colleagues.
We are vigilant with our relationships, mindful to counteract the polarizing dynamics of this time.
Our actions embody our confidence that humans can get through anything as long as we’re together.
We stay present to the world as it is with open minds and hearts, knowing this nourishes our gentleness, decency and bravery.
We care for ourselves as tenderly as we care for others, taking time for rest, reflection and renewal.
We are richly blessed with moments of delight, humor, grace and joy. We are grateful for these.

Question 3: How has HAES been supportive of and successful for marginalized communities? How has HAES fallen short? What are some specific ways in which we can support and reach out to those most affected by the social determinants of health?

I received no response to this question.

Tomorrow, I shall post the second part of this roundtable, which is a single question that got an overwhelming amount of response. Many thanks to all the HAES experts who participated.

Serious trigger warning: Frank discussion of health, weight loss, weight loss surgery and eating disorders.

When I first began putting together a roundtable of Health at Every Size^® (HAES) experts to discuss the social determinants of health (SDH), several people recommended that it would be valuable to have a similar roundtable with people who have felt the negative impact of the SDH.

It took me months to find the seven participants who volunteered their time to answer a few questions about their experience with HAES and the SDH. My hope is that their input will help HAES experts and advocates to approach the problem of the SDH with help and input from the grassroots level.

I would like to thank all of our participants for being so open and honest about their experiences. Tomorrow, I will share the second part of the roundtable, where they discuss how they would address the SDH and how HAES can be more effective in their lives.

Question 1: What are some of the barriers that you have faced over the course of your life in your efforts at self-care?

Lorenzee Cole

I have an aggressive clotting disorder and take blood thinners to keep it under control. Vitamin K counteracts the effects, so I have to be wary of green veggies and fruits. It has been difficult for me to create a balanced diet for myself in which I am getting all the vitamins and nutrients I need to stay healthy. I’ve sought assistance from nutritionists, who I’ve learned are simply glorified diet doctors more concerned with me losing weight than me losing my eyesight or other faculties. It’s very difficult being taken seriously, as my weight looms large in the minds of every professional I’ve met so far.

Rene Rice

I grew up poor in a fairly rural community. So as a kid, despite my desire to participate in certain sports, the few things that were offered were not things that I wanted to do, nor was my family able to financially handle the cost of my participation. For example, in middle school I desperately wanted to join the dance team. I was able to scrape together enough money to pay for my costume/uniform and required gear (shoes mostly), but the daily before-school practices meant that my mom had to drive me to school. I know it was difficult for her to afford, and I think she breathed a sigh of relief when I didn’t make the team in high school.

So from an early age, I associated group or team fitness activities with not-belonging on two levels: as a fat kid and as a poor kid. Those kinds of experiences make it difficult for me to seek out fitness opportunities, something I know is essential to my self-care. Being involved in movement that I enjoy helps to alleviate depression, and just makes me feel better all around.

Sonia Marron Alonso

I must say that the first barrier is the culture we live in, where being thin is one of the most important things you “must” do as a women, and for some, as it was for me, it’s even more important than health itself.

I grew up as a fat kid, I wore an adult size 5 at age 9. My father is a doctor, so he took concern at how this was affecting my life, and he took me to a nutritionist.

I know he did this out of love, and my nutritionist always had the best interest in my health. Even so, I began my first diet at 9, and this left a big impression in my mind. I learned that certain foods where bad and that, for me, being a good kid meant sticking to the diet. So every time I failed and came back to the nutritionist office after I gained the weight back, it made me feel like I was a bad kid and a failure. It didn’t matter that I was smart or a great martial artist or talented, I always distrusted all my abilities and felt that if I wasn’t thin I was still a failure.

I went on and off diets ever since, until I turned 25. At 23, I said to myself that I didn’t need the humiliation of going through another appointment with my nutritionist, so I decided to take the matter on my hands and that is when my eating disorder started.

I didn’t think I was doing anything out of the norm until last year. When I really analyzed what I did, I discovered that my behavior was not normal. I was eating very little and I restricted my diet to a certain amount of calories, and I was exercising for two hours a day, six days a week as a way of purging. I skipped meals and in 2010 I ended up binging, until I learned that I needed to stop. So with help I did, I’ve been diet-free since 2010. Still, I get obsessive over exercise and I tend to overdo it. I’m trying to figure out how to keep moving without obsessing over it.

This idea that being thin was the most important thing in my life led me to do things that weren’t healthy at all, I would say that my first barrier is in the culture itself, and our standards of beauty.

My second barrier, perhaps, is the work ethic that I was brought up in.

We live in a world where we value working over resting, so I was the kind of person who would much rather not sleep than fail on my obligations in school. I ended up not sleeping at all, or sleeping just about four hours each day.

And this, I think, had something to do with my weakened immune system. I think that sort of thing keeps a lot of us from resting properly and, of course, keeping us from trying healthy habits.

Third, I must say it’s economic status. Ever since I was diagnosed with Hodgkin’s lymphoma, I’ve said to myself that I have to make my heath a priority. I’m not in poverty; I’m middle class and so far I have insurance, and my family manages to pay a psychologist for me. I’m truly grateful for this.

But ever since I finished my master’s degree, well, I ran out of funds since I’m also unemployed because I still have a weak immune system.

So I live of what my father can give me at the time. I know I need help with my eating habits, since I still have issues with food and movement; I still tend to skip meals and binge sometimes, and I know that I can’t overcome this alone. Where I live, all except one nutritionist focus on weight management. There is just one nutritionist specialized in eating disorders in my town; even so, I can’t afford it, nor I can afford to travel to the USA to San Diego to meet with a nutritionist who manages HAES.

Also, accessing healthy foods is kind of difficult because of the lack of money. Mexico is having an economic crisis, so even when I want to eat better quality foods and avoid chemicals in my personal hygiene products, I can’t afford it all; I have to eat whatever we have around, when we have it available. My dad is retired, my mom, my brother and I are unemployed.

Last year I had my scholarship and I earned around $700 a month, which was a big economic help in my house, but I have no scholarship anymore because I finished my degree.

Mey Rude

One barrier for me has been anxiety and depression tied into my being transgender. For most of my life (and still sometimes today) I have avoided going out with friends or doing things in public that I enjoy doing because I’m afraid of the negative reaction I’ll get as a trans woman. Also, being a fat trans woman who lives in a smaller city, I’m not able to find very many clothes that fit me locally, and expressing myself through fashion is definitely one way that I practice self-care. At first I loved going shopping with my friends, trying to find cute outfits, but that soon turned south. Trying to go shopping for new clothes I like here where I live got to be so fruitless and depressing that I haven’t done it in over six months.

Lisa Mendez

Lack of workout wear available/affordable in my size. Lack of affordable natural and organic foods. I’ve had people not take me seriously when talking about nutrition or exercise, thinking I wouldn’t know about nutrition because of my size. Assumptions that my attempts to better my health meant, often exclusively, that I was trying to lose weight. I’ve also worried about weight limits on things like workout equipment, and when I was shopping for a new bicycle, I had to keep reminding the store clerk of my needs with regard to weight limit.

Kendra Jory

My own beliefs of my worth have kept me from a lot of self-care. I felt like I wasn’t worth anything because I didn’t fit the typical society standards.

Melanie Walters

Time is the biggest barrier to self-care. I would give anything to be able to arrange my work schedule so that I could have more time to myself.

The older I get, the less I care about what people think, but I still have that nagging voice in the back of my mind. What if I go somewhere or try a new activity and I am the biggest person? What if I don’t physically fit? Are people going to laugh? What if I am actually not capable of doing said activity? I’m sad that I haven’t been able to completely shake these thoughts.

Question 2: What kinds of self-care would you like to engage in or adopt if there weren’t barriers to access or ability?

Lorenzee

Honestly, I’d like access to an aqua-aerobics class. Unfortunately, most of them cater to seniors and retired people and won’t fit around a full-time working person’s schedule. Also, clubs with pools tend to be more expensive and are not handicap accessible (narrow ladder entry, etc.)

Melanie

I’d like to get back my gym membership, but I can’t afford it right now. Gyms tend to be super-expensive. The gym I used to go to was nice, but I would have to take the stairs two floors down to get to the change room, then two floors up to get to the pool. I’m currently walking with a cane due to a knee injury, so that’s not going to work.

Rene

I’d like to take the fat-positive yoga classes offered in my city, but as a public transit user, as well as being a student and working half-time, I just can’t make it to any of the scheduled classes, all of which are at a studio on the other side of the metro area. Even if I could fit it into my schedule and have transportation, the cost would be a barrier.

I’d like to be able to chose movement options that I enjoy, but instead I currently only have time to do the walking needed to supplement my use of public transit in going about my normal, everyday life. I like walking, and I would otherwise walk for pleasure, but with the current state of things, I’m walking routes that aren’t very fun or interesting.

I’d like to cook all of my food from scratch, gardening and raising most of it myself. Again, the time limitations of a long-transit commute on top of working and going to school. Plus, with space limitations of being an apartment dweller, there’s only so much you can grow in planters on your patio, assuming you’ve got enough sunlight each day for growing things.

I’d also like to have dedicated time for my hobbies, as a way to relax. Time and space are major factors right now; my sewing table has been taken over by my fiance’s computer because we only have room for one desk in our bedroom. We’ll be moving soon, and I’ll have the space for my sewing things again, but the decision to pay more for an apartment that has a second bedroom we can use as an office was tough. It’s $200 over the budget we were comfortable with, which probably doesn’t sound like that much to most people, but to us it nearly broke the budget.

Lorenzee

^^^^^ This.

Sonia

I would say that I would like to have the help from a HAES-trained nutritionist who would help me to learn to eat normally, and make better choices without obsessing about eating the perfect meal. I think that that, along with the help of my psychologist, would help me overcome my issues with eating and food, and would contribute to a better general health after cancer.

I would also buy a lot of more healthy food more often, and I would like to go to yoga classes, since I am the kind of person who needs instruction.

Melanie

There is a great fat yoga place that I would love to go to, but every class conflicts with my work schedule.

Mey

I’d love to be able to experiment with my wardrobe and be able to wear whatever clothes I want, but I can’t afford to and I can’t find many clothes I like that are my size. I’d also like to learn to dance, but again, there’s the money problem, and I don’t know how fat-friendly any local dance classes are.

Lisa

Gym workouts, dance, naked yoga. Shopping for clothes somewhere other than online stores. Nutrition advice that doesn’t revolve around weight loss. Eating organic.

Question 3: Have you faced any forms of discrimination by healthcare professionals? If so, what was your experience? How did it affect your view of the healthcare industry?

Sonia

Personally I have not.

I’m able-bodied, and I’m Mestiza (mixed race), middle class, and a “small” fat women.

The persons who experience the most discrimination in my country are the persons who belong to Mexico’s different ethnic groups. Things are so bad for these persons that even public hospitals have denied their service to people who belong to ethnic groups.

Because my BMI is just 30 (I’m officially considered by my doctors obese, but a barely obese women), and because I have a very curvy body, I have not experienced discrimination in my doctor’s office. Just a bit of biased treatment when one of my doctors send me to test for diabetes. Still, it didn’t bother me because I have diabetic relatives, and I’m not sure if this was routine.

I have also noticed that the distribution of fat plays a role in how people treat you. When you tend to carry your fat over the abdomen, you get more social rejection than when, as a women, you carry it at the hips and breasts.

I used to think that weight discrimination didn’t happen in Mexican doctors’ offices, but I was wrong, since several of my friends have faced this kind of discrimination in a doctor’s office. It enrages me.

Also, the government is planning to change the health laws by modifying the Mexican Constitution. In short (among a lot of other awful policies), they are planning that we, the fat and the chronically ill, will have to pay extra to compensate the State, along with complementary insurance that would cover the illness that are not included in the basic service.

Lots of us in Mexico are hoping that these laws never come to reality.

Lorenzee

I went to see a new doctor. Things went well. We talked about my weight, my health goals, my obstacles, etc. He bid me farewell and made a follow-up appointment for two weeks later. I went and he must have been busy. He merely gave me a cursory once-over and was trying to rush me out. Whatever, I didn’t really want to be there anyway.

A little while after that I became very sick. I had pain in my joints, swollen glands and a high fever. I went to see him and when he finally came in after the nurse’s initial exam he insisted that I be weighed — would not proceed any further unless I got on the scale. I was sick and had no fight in me so I obliged. Turned out, I had lost weight (alarming since I wasn’t trying). He was ecstatic and congratulated me — talked about my diet, what exercises I was doing, what more I could add on to my efforts, recommended a nutritionist.

My time was near up before I got to talk to him about the roaring fever I had that the nurse discovered before he came in. Suddenly, he couldn’t be bothered. Told me it was probably a problem with my teeth, gave me a script for a mild dose antibiotic and told me to see my dentist. I went to the dentist who, after an exam, became quietly alarmed. After an X-ray, that I had to pay for out of pocket because I had already had one at my last appointment, he found nothing at all wrong with my teeth. He called in a script for a higher dosage of the antibiotic and told me to get to the emergency room right away if I suddenly found it difficult to swallow.

I was furious and decided to do something about it. I wrote a nasty letter to the clinic abut how unimpressed I was with the new doctor and how he ignored my initial reason for coming in to the clinic. He replied to the other doctor but accidentally hit ‘Reply All’ and I saw him blatantly lying about what occurred during the appointment. I called him out, which made me feel better, but nothing really became of it. A year later and he is no longer practicing there, but I felt good about calling him to task, something I would not have done several years ago.

Rene

I think the clearest memory of discrimination I have in a healthcare setting was when I went in regarding menorrhagia (excessive menstrual bleeding). At the time I wasn’t making more than about $12,000/year, so my only healthcare was through the local health department’s sliding fee scale clinic. I could receive routine care through the clinic at very little or no cost.

The practitioner I had been assigned was a male Physician’s Assistant who seemed to be very unenthusiastic about being there. We had several interactions where I just felt like he wasn’t hearing me, and I got the usual “stop drinking soda and you’ll lose weight!” sort of crap. When I went in about my periods, as I’m asking the question he’s getting up and doing the whole hand-on-the-door-knob-I’m-done-will-you-shut-up-already thing.

His response? He shrugged and said “Well, you’re probably just built that way” and leaves. He asked zero questions about the frequency and regularity of my cycles. He asked zero questions about volume or flow rate. He didn’t ask about my risk factors for sexually transmitted infections. He didn’t ask me to keep records and check back in after a couple of months.

Five years later, I’ve finally pinned down that it’s likely a symptom of polycystic ovary syndrome (PCOS) for me, but I’ve still yet to find a treatment that doesn’t involve birth control, because I’ve already experimented with multiple forms of that with poor results.

I’m at a point where I don’t go into the doctor’s office until I’ve researched my symptoms and come to a preliminary idea of what might be going on. Whenever possible, I even have a method of treatment in mind, which leaves me in a position where I’m only seeing the doctor for confirmation and to write the prescription. I’ve had doctors treat me even more poorly for being so well-informed. One said outright that I couldn’t possibly know how to read medical research appropriately, and then dismissed my suggestion of what might be wrong out of hand, insisting that it must be something else.

Because I’m poor and don’t have a college degree, plus I’m fat, I must be lazy, stupid, and deluded. I hate that healthcare is an industry, and I think that’s one of the biggest problems we face. We’ve put our survival and well-being as a race in the hands of a for-profit industry, from health insurers to pharmaceutical manufacturers to doctors who pick specialties based on potential annual income. It’s completely messed up, when you step back and think about it.

Lorenzee

In my early 20s, I decided I wanted to be thin. I threw out all the food in my apartment and started from scratch, joined a gym, started going three days a week, started riding my bike to work and being active on the weekends. I never managed to lose weight, but I started having irregular periods — was spotting in between. I went to a gynecologist who railed at me about my weight, and wanted to prescribe the diet drug Fen-Phen and weight loss surgery for me.

I refused those, but she convinced me to take birth control pills to prevent ovarian cancer. I started them and by the end of the month I had a blood clot in my calf. I thought I’d pulled a muscle hiking in the mountains, so I worked it out and kept going — had a new blood clot by morning. Over the course of several months, I had more episodes of calf discomfort and shortness of breath that I didn’t realize were related to each other.

Trips to the ER resulted in doctors telling me I was out of shape and needed to get more exercise to lose weight. They had cognitive dissonance in what I was actually saying to them against their own beliefs. Knowing something was terribly wrong, I stopped going to the gym and schlepping around on my bike.

Long story short, I went to a new doctor who, by the time I got to him, discovered I had legions of blood clots in my lungs. I could not walk from the chair to the desk without panting like I’d run a marathon. Doctors from other hospitals came to my bedside astounded that I had survived pulmonary emboli of this severity.

This experience and many others I have had give me a cautiously cynical view of the medical profession as a whole. I know that the help one needs often comes filtered though a medical professional’s personal beliefs. I will often seek another opinion when I feel it’s necessary and will do my own research.

Lisa

Yes, and often. I had a doctor who wouldn’t give me contraceptives because I couldn’t possibly need them, as a fat woman (mid-1980s). Another would pick fights with me, then take my blood pressure, and when it was high (from fighting, duh!) he’d prescribe me medications that had terrible side effects. When I said I couldn’t handle the side effects, the doctor told me that those were not the side effects of that drug (FWIW, my blood pressure has been on the high side of normal pretty much forever — not medication-worthy).

When I changed doctors, the new one would all but ignore anything I went in for, in favor of lecturing me on my weight. The worst was telling me to go on a diet as treatment for a knee injury (I fell… not a stress fracture), and prescribing diuretics for what I thought was a bone spur on my heel (as a weight loss surgery survivor, diuretics can put me in the hospital).

I haven’t seen a general practitioner in over three years. I know I’ll get nowhere with anything that is actually afflicting me. Fortunately, I’ve had a great gynecologist. I’ve never had a single issue in her office. They have large gowns, and large blood pressure cuffs, and we discuss real medical issues there.

That’s just a small sampling of what I’ve experienced.

Mey

The only thing I can think of is that I’ve had doctors spend a lot of time talking to me about how I should lose weight when I’m at the hospital for completely unrelated things. Like when I broke my foot, when I broke my finger and when I’m getting check-ups for my epilepsy. Still, the doctors tell me that I should lose weight.

Kendra

My Mom and I share the same doctor. My mother was suffering for over a year with a nonstop period. She was cramping and uncomfortable. He told her it was because she was fat and smoked. My sister got really frustrated and made her a doctor’s appointment with someone else since my Mom’s doctor refused to refer her. Turns out she had uterine cancer. Luckily they caught it in time.

Personally I am afraid to go to a doctor for two reasons: 1) I have depression and anxiety, and 2) I am overweight. All of my symptoms have been blamed on one or the other or both. I am due for a check-up and have been putting it off. I have a new doctor now, but I am still afraid.

Rene

I’d like to share something I witnessed within my own family. My grandmother knew for a long time that she had sleep apnea, but she didn’t want to seek treatment because she didn’t want to wear a restrictive face mask. When we finally convinced her to be officially tested, she was already unable to transfer from her wheelchair to the bed on her own, and we were using a Hoyer lift for transfers.

The sleep clinic was aware of her mobility limitations and size well in advance. When she arrived, there was only one staffer there for the night, and my mom (her caregiver) had been told she wasn’t allowed to stay the night to assist. They had a lift for transfers, but upon getting her out of the wheelchair and over the bed, they discovered that the lift was broken and they weren’t able to lower her to the bed or back to her wheelchair.

The staffer left her dangling in the broken lift, no longer over the bed or the wheelchair, and left the room to get a different lift. The next one wouldn’t function either. Finally, the third lift worked and they got her wired up for the sleep study. Unsurprisingly, by this time she was so upset and humiliated by the treatment that she was unable to sleep.

This was no rinky-dink, backwater doctor’s office. This was at a major regional hospital that otherwise has an amazing standard of care. She went on to refuse to be tested again, and almost a year later sleep apnea, along with congestive heart failure, contributed significantly to her death.

Her experience was so horrific, that others who work in the same healthcare system heard the story (without her name of course), in some cases working in different towns! Who knows what might have happened had she been tested and treated appropriately.

She had plenty of health issues, but there’s an ache every time I think about seeing her in intensive care on a respirator. There’s anger every time I think of her trapped in faulty equipment. There’s fear that I could be in that position myself.

Melanie

I’ve been quite lucky in that regard; I haven’t had too many bad medical experiences. My general practitioner will mention my weight, but she has also said that she doesn’t think that everybody is meant to be thin, and she has heard of HAES before. My major problem with her is that she doesn’t have extra-large blood pressure cuffs.

When I was younger, she would put me on diets or give me diet pills, but that was before I knew better. The doctor that I had before her put me on this meal replacement cookie diet when I was around 12. I look at pictures of myself back then and I want to give him a shake. Sure, I was bigger than my classmates, but I was not fat.

I had surgery a few years ago and not one of the doctors mentioned my weight. I’m currently dealing with torn cartilage in my knee and, again, nobody has mentioned weight. Either they are afraid of me, heh, or here in Canada doctors aren’t as obesity-obsessed as other places. Who knows. I hope that my luck continues to hold out. Reading other people’s stories has my guard up, so I’m ready to have this discussion with doctors.

Trigger warning: Discussion of weight, eating disorders, health and weight loss.

Yesterday, we heard from seven women who shared their experiences with the social determinants of health (SDH) and how it has affected their self-care. For the final three questions, I ask them to describe their relationship to Health at Every Size^® (HAES) and for their suggestions on how we, as a community, can address the social determinants of health. What’s awesome is that their answers sound a lot like the suggestions made by Dr. Dennis Raphael and Dr. Stephen Bezruchka, the two SDH experts with decades of research in this field.

Question 4: Do you consider yourself to be “practicing HAES”? If so, what does that look like in your life? If not, how has HAES been insufficient at meeting your needs?

Kendra

I used to think I was practicing HAES, but I am not so sure anymore. I find that I am not necessarily at my healthiest. I know that my weight is taking a toll on my body. I am still curvy, but I am finding that when my own weight goes down my joints and polycystic ovary syndrome (PCOS) symptoms go down. So I am really conflicted.

Lorenzee

I consider myself to be practicing HAES. I find that with me, balance is key — everything in moderation. I don’t drive, so I walk and take public transportation everywhere. Still, I wish I had more enjoyable movement in my life. I used to go clubbing a lot, but at over 40 I feel like it’s time for something new.

Lisa

I do my best to practice HAES. There are times when I have to let go of it, though. I’m gluten free to help with joint pain/inflammation, and when I get really broke, I end up eating cheap, processed wheat products to get by. And when I get really busy with work, or I have to travel long distances for art fairs, my activity level plummets.

Rene

I think that doing the best you can with the resources available to you at any given time is part of HAES. Seeing health and healthy choices as a continuum, rather than a right or wrong situation, is what differentiates HAES from the weight-loss paradigm. I’m reminding myself of that a lot lately, like when I seek out healthy behaviors and treatment for health conditions that my body weight might change as a side effect. I’m currently examining ways to control my PCOS better, and it’s looking like all of the options that I haven’t tried yet typically lead to weight loss, often significant weight loss. I’m struggling to integrate that with my HAES mindset.

Sonia

Yes, I have been practicing HAES since 2010. I’m not saying it has been easy or that I got it perfectly. I’ve been working on different aspects of myself ever since.

Since I have struggled with eating disorders before. It’s been a long way. So far I have manged my self-image and understood my hunger signals. Still, I struggle with diet mentality and with joyful movement mainly because exercise was my way of purging.

I do, however, enjoy exercise. I don’t have a problem with motivation, but with obsession on performance. I tend to overdo stuff and I burn out. It has been more difficult ever since I got Hodgkins last year. I’ve lost a good deal of physical fitness since then. I can’t seem to take it easy and I overdo my routines. I’m giving myself a break on that. Also, I’m focusing on learning how to nurture myself without concerning to excess about the “perfect” meal. Which rationally I know its bullshit, but from time to time I tend to get engage in a diet mentality, I know I eventually will get it, but I think I need professional support to achieve it. And that is where money gets in the way.

Melanie

I would say yes. I have made an effort to eat food that makes me feel good, to add in more fruits and vegetables, to try new things. I can’t exercise like I used to due to a knee injury, but I do the best I can. I think that HAES should incorporate doing the best you can with what you have while trying to enjoy yourself. I’m not going to participate in movement that I don’t like and I’m not going to eat food that I don’t like for the sake of “health.”

Mey

For me, it’s a mixed bag. Oftentimes, I’ll eat plenty of good fruits and vegetables and other food that makes me feel good, and I’ll be fairly active and get a good amount of exercise, but other times, not so much. When my depression flares up, though, I don’t do as well, and I’m less active and less mindful about the foods that I eat.

Question Five: The SDH have both social and economic origins. If you could direct a group of activists to fight the SDH in a way that would have a positive impact on yourself and/or others you know who struggle with the SDH, what would you recommend? If you have multiple suggestions, please give some indication as to priority or “bang for the buck” in your view.

Lisa

The most important thing for me is something many activists are already focusing on:  being treated fairly, by medical and fitness professionals, would really make a huge difference.

Lorenzee

My answer would take too long. The short version would be to make healthy habits more affordable and sustainable. I budget myself well enough to get by, but I work like a dog to do it and forego certain things like owning a vehicle, etc. Things I want to partake in either aren’t available in my area or are too expensive to maintain long term. Plus, who has time?

Here in Massachusetts, the Governor installed a program that allows doctors to write a prescription that would give obese patients at high risk a considerable discount to use the local bike share program, called New Balance Hubway, to get around. However, the Hubway bikes are only rated to 260 pounds and you must sign a legal contract that you won’t put more weight than that on the bikes — anything happens to you on that bike and you’re on your own. My current focus of ire are the carnival barkers who talk over fat people and oversimplify the issues while stealthily being backed by industries set to profit off public fears.

Sonia

I agree with Lisa, the first thing would be to pressure the healthcare system to educate about weight prejudice. Second, I would urge them to pressure the government to stop the new legislation in my country that will penalize the patient for their illness.

Rene

To add to what the others have said, I’d encourage more work toward changing the way our food production system is currently incentivized. The agricultural subsidies are just a start (to be clear, I don’t want to take those subsidies away from farmers completely, just shift the focus and perhaps make those subsidies only available to individual farmers and not corporations). At a more local level, I love the programs that allow SNAP recipients to purchase produce at farmer’s markets. Let’s use those agriculture subsidy dollars to pay farmers to set up markets in food deserts. Let’s make fresh foods and whole foods cheaper than processed foods. I’d love to see more options for quick meals for people who spend a lot of time working or using public transit or in school or whatever. Let’s put home economics back in schools so that people have the opportunity to learn the skills they need to cook from scratch. I could go on and on, but there’s a start. Oh, and finally, involve the people you’re trying to help in the planning and implementation of the solutions. Not in a patronizing, “you’re here as the token poor person on the committee” way, either.

Final question: If you were Benevolent Dictator of your nation for an hour, what changes would you make to improve the SDH situation for yourself and others?

Kendra

Education! And pay equality. lol

Sonia

I agree, if I had an army on my side I would dismantle the corruption in the Mexican government, confiscate their assets gained with dirty money, and see that those assets covered some of the main financial problems in Mexico, so we can have better social and economic conditions that would make it easier to achieve a better health.

1. Better social and economic conditions for Mexicans
2. A food and agricultural policy that provides support to local farmers, and better exportation and importation policies
3. A truly universal public health system that provided people full health coverage.
4. Involvement of the private sector, but not just as “promoters of health”; rigorous regulations on toxic wastes, and true ecological engagement, along with better working conditions for employees

Rene

Public transit. It benefits people’s economic situation in that they can get to and from their jobs without the expense of a car. It reduces stress from commuting, it helps the environment, and when using public transit people typically are more active by walking/wheeling to the transit stop. What we did for roads with the interstate system in the US we now need to do with public transit. And by making public transit cleaner, more efficient, and more accessible, we reduce the stigma of utilizing that service. When it’s not just a service for the poor but a service for everyone, we’re doing something right.

Melanie

More time. We spend so much time working and commuting. I really don’t blame anyone who doesn’t want to leave work to start chopping vegetables for cooking or to go to the gym for two hours.

Kendra

I would also say pay a parent to stay at home for at least the first four to five years of a child’s life. And three to four weeks of paid vacation per year.

Lisa

I can’t think of anything that hasn’t already been said in these comments. I definitely second improving public transit, and less time working. I know Europeans think the American work week is barbaric.