Smart Things About Fatness: JanuaRant 2019

In January, 2019, one of my amazing, lovely, smart friends posted a month-long JanuaRant™ about diet/exercise culture and fat stigma.  J is the best kind of advocate, articulate, witty, and level-headed.  I loved her posts, they made me think, and I feel they're worth sharing.  This is an anthology of all 31 of her posts, because I think they're important, and I want to be able to revisit them, as well as give her a place where they're all compiled online for posterity.  Highlights are mine, noting bits I found particularly moving or identified with particularly strongly.

1/01: Seems like January is a good time for an extended rant about diet/exercise culture and fat stigma.

Hide me for the month if you don't want to hear about it, but I'd encourage you to at least think about what I'm saying here, because it's a real public health issue and a real social justice issue, and I don't think it gets enough attention. There's a ton of misinformation out there and a ton of predators looking to make money off people's shame. You probably have a lot of both in your feed right now.

Here's the basic mainstream story we get told about weight:
  • There is a morally correct body size.
  • People who behave correctly will correct the size of their bodies. Therefore, people whose bodies are the incorrect size are not behaving correctly.
  • Any punishment that accrues to people who refuse to behave correctly is appropriate, because it's important to society that we enforce correct body size.
This is a long chain with a lot of very weak links, most of which are never questioned by most people. The tl;dr is: this story is wrong wrongity wrong. Don't believe me? OK, that's cool, because I'm going to prove it.

1/02: I do want to say, I don't have any issue with anyone changing their behavior for any reason or no reason.

Want to dye your hair or get a tattoo or have boob surgery or drink your own pee or sleep in a hyperbaric chamber? Great! The problem is that misinformation about body size and dieting is foisted on us from every angle, especially by predatory companies trying to separate people from their money and doctors driven by their own biases. So if you don't like the size or shape of your body, and you want to try to change it, I completely support your efforts to do so. Or if you want to change your behavior to try to get healthier, that's fantastic too! I just want to counter all the BS. I want you to be able to make behavioral choices based on facts.

Most of what I want to change is how people, especially people who aren't in larger bodies, think about those who are in larger bodies. January is a nonstop shamefest and I think that's gross. I'm probably going to screw up a lot with this project, sorry. Please correct me if you catch something.

1/03: Why does it bother some people to see a fat person?

Taking the health question out of it, because that's just a smokescreen, the truth is some people just don't LIKE to look at fat people. Or very skinny people. Or ugly people (whatever that means). Or people who are dressed or otherwise presented in a way that doesn't align with our ideas about attractiveness.

Looking at the bigger picture of conventional beauty standards, why do we feel like the people around us are obligated to adhere to those standards? Another person's appearance has zero effect on me. Their behavior, sure, but their appearance? No. We need to stop shaming people for the way they look, whether it's something they can control or not.

Other people are not NPCs, and their purpose is not to decorate your world. You don't get to say what they should look like. Keep your eyes on your own paper.

1/04: So, ARE fat people unhealthier because they're fat?

The truth is, we don't really know. A lot of scientists think not. Think about it: how would you know that weight gain caused an adverse health outcome? How would you know that the outcome wasn't caused by an underlying behavior that also caused the gain, or by a third factor outside the person's control? Or that the gain wasn't an early symptom of the illness?

I hate to say it, because I love science, but scientists have biases too, and sometimes they also have external motivations for showing that higher weight causes illness. So sometimes their studies are designed to back up a particular idea, or their conclusions aren't quite supported by their results, and then secondary sources like health websites write about their studies and skew them even further. Next time you see a claim like this, drill down into it, and see what it's really based on. Don't just assume it's true because it aligns with the story we've been fed all our lives.

1/05: It's true that high weight is associated with certain adverse health markers, yes. But step back from your assumptions for a minute.

For example:
  • People with higher weights tend to have higher blood pressure. We've assumed this is a bad thing by itself, but big people with high blood pressure are healthier than small people with high blood pressure. Maybe they just need higher blood pressure to pump blood through larger bodies. High BP isn't a poor health outcome BY ITSELF. Nobody dies of high blood pressure. (Also, fun fact, if the blood pressure cuff is too small, it will give an incorrectly high reading. Guess who's most likely to be measured with a cuff that's too small?)
  • Fat people have bad heart health compared to thinner people. But, fat people are also more likely to have weight cycled -- lost and regained large amounts of weight -- because of greater pressures on them to diet. Fat people who haven't weight cycled don't have the same heart problems that those who have weight cycled do. Some people who study this stuff think that *none* of the heart risk associated with high weight is caused by weight itself.
  • Higher weight is associated with a lot of other harmful factors, too. Like poverty, for example. The stress of living under weight stigma, including poor medical care. Disordered eating behaviors. A lot of things have been shown to contribute to poor health outcomes.
So why do we automatically assume that a fat person is sick because they're fat? We believe fatness is a moral failing, so all our biases point in the direction of blaming the fat person. Once you start seeing those biases, you'll see them in almost everything that's written or said about obesity.

1/06: Does weight loss cure illness?

This is a good one. First of all, if someone loses an appreciable amount of weight and keeps it off, and at the same time their illness gets better, did the weight loss cause the health improvement? Or vice versa? Or did a lifestyle change, or surgery, or some unknown other factor cause both? What assumption do you think a doctor or scientist who studies "obesity" is going to make? A lot of the people who do this kind of study are directors at diet clinics, incidentally.

Second, in order to even begin to study this properly, you'd have to have a large population of people who had lost an appreciable amount of weight and kept it off in the long term. Good luck with that.

1/07:  Arbitrary Correlation

Say a patient experiences a change in two pieces of data about their body, at roughly the same time. Their doctor is thrilled! Both these data changes are correlated with a decrease in ill health! The doctor decides, arbitrarily, that the change in factor A caused the change in factor B, and tells all their patients to change their factor A numbers. The doctor is unable to provide any reliable way to change factor A, but insists nonetheless, discussing this factor at every single visit and blaming each patient's failure to change factor A not just for factor B, but also for factors C, D, and E. The patients are noncompliant and probably lazy.

It's baffling, right?

1/08: If a person comes to the doctor with a health complaint, it's reasonable to expect the doctor to address the health complaint ITSELF. Not to focus on some other factor that may or may not be causing or contributing to the health complaint.

For example, if a person has joint issues, you'd want the doctor to directly address the joint issues, like with physical therapy. Perhaps the doctor could address the complaint with lifestyle suggestions that have been shown to help. (Lifestyle suggestions like this might also, incidentally, cause weight loss, but that shouldn't be the purpose of them.) Then follow-up visits would assess any changes in the original complaint to determine the effectiveness of the treatment.

Is that so much to ask?

1/09: How do people come to be fat, anyway?

Short answer: nobody really knows.

Certainly there's a genetic component. There seems to be a component related to the gut microbiome. Some people gain a lot of weight when they change their behaviors, start eating too much or stop working out as much as they were. Some people gain weight after a trauma, like a sexual assault. Some people gain weight when they get an illness, or when they start taking a medication, or when they have their thyroid taken out. Some people gain weight when they have a baby. Some people gain weight when nothing seems to be changing except their age. Some people just start out fat and stay that way; we really can't put responsibility on a 3 year old kid for their BMI, that's for sure.

Then again, some people eat a lot (or eat a lot of "bad" foods), and never work out, and stay thin. Some people get sick or take meds or have a baby and stay the same weight, or gain weight and then lose it without even trying when the instigator is no longer present.

It seems pretty clear that we shouldn't just assume that someone is fat because of some poor choice they made.

1/10: Is it possible to lose weight intentionally, through behavioral changes?

You can do the research yourself; I'm limited by a lack of scientific background and a lack of access to some of these papers. But the reviews seem to indicate success rates around 5%.

And how do they define "success" in these studies, anyway? Sometimes it's a pretty low bar. It varies from study to study, but it might be something like losing 10% of your body weight and keeping it off for a year. So if a person who weighs 300 lbs gets down to 270 and stays there for a year, that's success. But where are they in two years? Five years? Forty years? The studies don't usually watch past a year or two.

(Ten years down the line, that unusually "successful" 270 lb person walks into a new doctor's office. Is that person treated like an "after" picture, a success story? Or is that person badgered about their weight just as much as they were at 300 lbs?)

It's not impossible to lose weight intentionally. It's very unlikely, but it's not impossible.

1/11: So, let's say a person likes the 5% chance of losing weight on purpose and wants to try it. Why not?

Yes, there's a chance of losing weight and keeping it off. There's also a chance of something going wrong.
  • Around half of people who lose weight on a diet will gain back more than they lost. If you're trying to lose weight, that's a problem right there. But beyond that, it's a problem because weight cycling causes health problems.
  • Since dieting is fundamentally a system of ignoring the body's eating and activity cues, it can lead to full-blown eating disorders. Depending on how severely you diet, you are 5 to 18 times more likely to get an eating disorder than a person who didn't diet. A peer-reviewed study found that "35% of 'normal dieters' progress to pathological dieting. Of those, 20-25% progress to partial or full syndrome eating disorders". I don't think we can know how the causation works here, but we do know this: dieting IS a disordered eating behavior.
  • Dieting can cause a loss of muscle mass (and that's not just the skeletal muscles that you see, it's organ muscles too), loss of bone density, lowered metabolic rate, malnutrition, GI disturbance, headaches, insomnia, and all kinds of other nasty stuff.
And that's just the direct physiological effects! Other effects tomorrow!

1/12: So, what about the non-physiological effects of dieting?

If we're going to make this about health, we have to talk about social and emotional health as well as physical health. First of all, because that in turn affects physical health, but also because social and emotional health MATTERS, by itself! Possibly it matters even more than physical health.
  • When a person is ignoring physical hunger cues, their brain is going to keep focusing on those cues until the need is met. This is bottom-of-the-pyramid survival instinct stuff. That means they're going to have less focus for anything else. Even apart from the lack of energy the brain is getting, the dieter is going to feel fuzzier and less able to accomplish tasks that aren't related to eating.
  • Also, many of our social customs center around eating and drinking. Dieters may avoid social gatherings to avoid being exposed to forbidden foods or having to find workarounds that fit within their guidelines. Some people stop eating dinners with their families. Others keep doing these social rituals, but struggle with the competing pressures of sticking to the diet and eating with everyone else. I don't know why humans are like this, but I'm pretty sure all cultures gather around food and drink this way, so it's got to be something we're designed for. Which means there's going to be a cost when we opt out.
  • Here's a negative side effect of dieting: all the money spent! Americans spend more than $60 billion a year trying to lose weight. Do they get their money's worth?
  • Dieting also sets the dieter up for shame and self-loathing. We know that diets usually fail; the body's drive to eat a certain way and weigh a certain amount is just too strong. And when a diet fails, where does the blame fall? It usually falls on the dieter. They eat, as they are viscerally driven to, and as they eat they feel shame. They enjoy the food (food has been shown to be much, much more pleasurable to a person who's been food restricted), and feel the shame at the same time. The shame gets all mixed in with the pleasure of eating. Does that seem healthy to you? Because that's what dieting is.
1/13: Side topic: the Minnesota Starvation Experiment

Late in WWII, a group of conscientious objectors volunteered for an experiment in starvation. The idea was: people in Europe are starving, and we need to figure out what that means for their health and how best to help them recover once food becomes more readily available. The ethics of this study were, let's say, pretty yikes-y, but the good news is that we learned a lot about food restriction. Thirty-six men had their caloric intake reduced to 1560 calories per day for 24 weeks.

Think about that: 1560 calories a day was considered a STARVATION DIET. There were huge impacts on these men, sometimes for YEARS following. Typical modern weight loss diets recommend 1500 calories, sometimes 1200 or even as little as 800 calories per day. These men were disabled by this diet. They lost a lot of weight, but couldn't see their own weight loss in the mirror. They were irritable, apathetic, and obsessed with food. One of them chopped off three of his fingers with an axe, and didn't know if he had done it accidentally or on purpose. On 1560 calories per day, for less than six months.

This is a really interesting experiment, and you should definitely google it if you want to learn more. Food restriction is not good for us, folks. It's not to be encouraged.

1/14: Who gets diagnosed?

A 22 year old woman walks into her doctor's office. She doesn't want to be there, but her mother has dragged her, because she's obviously ill. She presents with:
  • weight loss
  • severe, obsessive food restriction
  • excessive exercise
  • extreme fear of being fat and preoccupation with her body size
  • amenorrhea (no menstrual period)
  • other signs of malnutrition, such as hair loss, fainting, and low blood counts
  • social isolation
Yikes! She totally has anorexia nervosa. Let's get her some help.

Wait! Actually, no. Her BMI is in or above the "normal" range. Well, good for her! She is taking steps to reduce her weight, just like we told her to (again and again and again), and it's working!

- - - - -

One of the diagnostic criteria for anorexia nervosa is being "underweight". It's possible to get diagnosed with atypical anorexia nervosa, which is exactly the same but without the BMI factor. But by the time people get this diagnosis, they tend to have been sick longer and lost more weight than people newly diagnosed with AN, and so, unsurprisingly, they're sicker. I do wonder how many people are walking around with AAN and never get diagnosed at all. Isn't this more or less how we expect fat people to behave? Isn't that what makes a "good fatty"?

1/15: Let's talk about the ladies, in particular.

“A culture fixated on female thinness is not an obsession about female beauty, but an obsession about female obedience. Dieting is the most potent political sedative in women's history; a quietly mad population is a tractable one.” ― Naomi Wolf, The Beauty Myth (yeah, I know, but it's still a good quote)

Look, I'm not an educated feminist, and I'm not gatekeeping feminism either (you do you!). But it's certainly something to think about: what are the broader effects of the pervasive preoccupation American women have with what they are eating and how their bodies look?

How much time and energy are we spending fighting our own bodies (our hair, our skin, our SELVES!), and what else could we be fighting instead?

What are we telling ourselves about our own WORTH based on the level of our compliance with beauty standards, and do those messages make us accept less than we deserve in other areas?

1/16: Does it matter WHY someone is restricting their food?

Perhaps I've convinced you that restricting food for the purpose of weight loss is not a best practice. "But I'M not trying to lose weight," says the voice in the back. "I'M doing it for WELLNESS."

I'll say, for the sake of clarity, that I have food restrictions. I had near-daily headaches for several years after the birth of my kid, until I found, through a miserable process of flailing, a set of food restrictions that actually mostly got rid of them. (This was a last resort after trying every medical intervention short of Botox, which as it turns out is really expensive and not usually covered by insurance. Also scary.) I don't drink tea or coffee or soda, I don't use alcohol or cannabis, and I don't eat cheese, potatoes, or peppers. This is a regimen that sucks. It doesn't feel good. It feels restrictive. It makes it hard to find food to eat at restaurants, and it makes social gatherings challenging. I am a pain in the butt to feed! Sometimes I eat the foods on the list, and sometimes (especially with cheese) that means I have a bad headache that no meds will touch for 3 days. That's my reality. I know that my restrictions have bad effects, and I am (usually) choosing those bad effects over the bad effects of eating the foods.

My partner has life-threatening food allergies, and that has social consequences. There are some restaurants he cannot walk into without becoming ill. No, he can't just have a drink or some french fries while everyone else at the business meeting has lunch. That's a problematic restriction, but he is, fortunately, committed to it.

We all have ways of eating that physically work better for us than others. Maybe you have more energy when you have protein with breakfast. Maybe cutting out carbs makes you lose your everloving mind by 3pm, or maybe carbs with lunch makes you feel like sludge by 3pm. Maybe you have to eat before bed or else you wake up nauseated, I don't know. Those aren't *moral* judgments, though. Protein-breakfast person can have waffles with the kids on Sunday morning and not feel guilt about knowing they're going to feel crummy later. The crummy feeling is its own consequence; it doesn't need a side consequence of shame to go with.

Nutrition is important, and knowing what's in your food is great. Read labels! But food ingredients aren't dirty or impure or shameful, and eating them doesn't make YOU dirty or impure or shameful.

*** Food ingredients aren't dirty or impure or shameful, and eating them doesn't make YOU dirty or impure or shameful. ***

If you're restricting, obsessing, experiencing a restrict-binge-shame cycle, then it may not matter why you're doing it. The same negative consequences accrue whether you're trying to lose weight or not. If you're sure that the benefits to your health are outweighing the negatives, then by all means, stick to it. But there's no need for shame; restriction is freaking hard! The health consequences are enough without the shame.

N.B.: OCD can manifest this way. Please honor this serious condition if you think you have it. It's no joke.

1/17: So, just to sum-up partway through here:
  • Being fat doesn't make a person ugly, and even if it did that's really none of your business;
  • Being fat doesn't necessarily make someone sick;
  • Losing weight doesn't usually make sick people well;
  • It's very unlikely to lose weight on purpose anyway; and
  • The effort to lose weight is much, much more likely to cause negative effects than it is to cause weight loss.
Still with me?

1/18: Do fat people owe us, society, their good health?

Perhaps some people are fat in part because of unhealthy eating habits. Let's assume that's true, for the moment. Do fat people owe us, society, their good health? Do thin people owe us their good health?

Do we judge a fat person who's eating ice cream in public, because they're responsible for rising healthcare costs?

Do we judge a serious runner who's been told not to run for 4 weeks so they can get over an injury, but they start back after 2 weeks, because they're responsible for rising healthcare costs? Or do we smile and roll our eyes and admire their drive?

Do we judge a person having a melanoma removed, because they're responsible for rising healthcare costs for not wearing enough sunscreen? Or are we just glad it got caught in time, and cross our fingers for their future good health?

Why is it that we assume the fat person is unhealthy and making themselves more unhealthy, despite having absolutely no information about their actual health? Why is it that we assume a fat person owes us, personally, every effort they can make to be more healthy? How healthy are your thin friends' behaviors -- do they work out regularly, eschew beer and office donuts, take their vitamins every day, get 7-8 hours of sleep per night? Do they owe you those behaviors? Do thin strangers owe you those behaviors? Why is it that people out enjoying the nightlife late at night, drinking, probably wearing unhealthy shoes and damaging their hearing, aren't getting the stink eye for causing healthcare costs to rise?

This isn't about rising healthcare costs, folks. That just doesn't ring true.


Take a moment to imagine a fat woman in a movie theater lobby, walking away from the counter with a bucket of popcorn and a big soda.

Now imagine a thin woman with the same items.

Think about these two women for a minute before you read the next part.

Deep down, or maybe right on the surface, did you have different feelings about these two women? Did you make assumptions about who they might be with, or how they might be feeling, or what kind of people they were?

Funny, isn't it? I mean, not FUNNY. We have been trained to make certain assumptions; we have trained each other to make them. We can start to train ourselves out of them, but only if we start by recognizing them.

This implicit bias test is best known for testing black/white bias, but did you know there's a test for fat/thin as well? It's really hard to measure implicit biases; this seems to be one of the best ways to do it. (Incidentally, according to this testing, implicit biases based on sexuality and race have decreased over time, but those based on body weight are actually getting a little bit worse.) It might be worth a few minutes of your time.

1/20: What does it feel like to live as a fat person in a fat phobic culture?

Well, to start with, there's discrimination. The fatter you are, the more likely you are to have experienced some kind of discrimination for your weight, and it's a lot worse for women than it is for men. Job discrimination on the basis of body size is legal everywhere in the US except for Michigan and a few cities, like San Francisco. There's also discrimination at school, at the doctor (more on that later), and really any kind of public accommodation. Anywhere you have to rely on someone to work with you or do something for you, they're probably less likely to give you what you need the bigger you are.

The whole physical world is set up for smaller bodies. Furniture, cars, offices, clothing, public transport, everything. Walking around the world while fat is a constant reminder that you're not welcome in many spaces. And plenty of fellow humans are happy to remind you of that, should you ever forget.

There's a ton of research showing that it's generally harmful to live under stigma and prejudice. It means living in a constant state of hyper-vigilance, which means the body is on high alert and pumping out stress hormones. We know that this is directly bad for health: hypertension, heart disease, respiratory disease, glucose intolerance, and more days spent sick in bed. It's also indirectly bad for health: it causes depression and psychological distress, and it causes unhealthy behaviors like smoking. In fact, weight discrimination *itself* causes higher mortality, when you control for physical and psychological risk factors. It actually kills people.

So, we have to ask ourselves: do we ACTUALLY care about the health of fat people? Because if we do, the thing to do is DECREASE fat stigma.

1/21: Fat stigma and discrimination is a funny thing, compared to other forms of discrimination.

Fat stigma and discrimination is a funny thing, compared to other forms of discrimination. It actually seems to be worse for morbidity and mortality than other types of prejudice (even when controlling for physical factors). There might be a few reasons for this:
  • Weight discrimination is more likely than other types of discrimination to come from the people who should be your support system -- parents, partners, friends, and so forth. That's discrimination that hurts more because it comes from loved ones, and it also removes a well of comfort that victims should be able to draw from to protect themselves from fat phobia.
  • Because we're taught that fat people got that way by making poor choices, there's a sense of shame and self-loathing that goes along with the discrimination. This removes even the well of comfort that people should be able to draw from within themselves, and it discourages people from fighting back against any unfairness they encounter, or from joining with others like them to fight.
  • Under this extraordinary stress, the brain will compel behaviors that can make the body even larger: eating more, eating more calorie-dense foods, binge eating, and avoidance of physical activity (because it has become a source of discrimination, and also because this stress causes depression). We know that discrimination is worse the larger you are; thus, the vicious cycle.
  • And remember, fat phobia has actually been getting *worse* over recent decades, unlike other forms of prejudice.
It's really an incredibly cruel system we've set up for each other, isn't it?

1/22: Is fat acceptance "glorifying obesity"?

What kind of results do we see when we support fat people with body acceptance strategies? The "glorifying obesity" crowd would predict that a body acceptance therapy program would cause weight gain, right? They're assuming the only things keeping people from gaining weight are the fear, hatred, and shame of being fat. Well, that's not what we see.

What we actually see is: less depression, less anxiety, and less disordered eating. Oh, and also a little bit of weight loss, incidentally, even when that's not a goal of the therapy. People move more and eat healthier. People end up feeling better in every way, and those benefits last at follow-up months later.

Do people really think shame motivates weight loss? Because... there's a lot of fat shaming out there. I mean, like, a LOT. There is a movement now for body acceptance or liberation, but that's relatively new and still pretty small compared to the other side. If shaming people causes them to lose weight, why are there so many big people around? Why, as weight discrimination has gotten *worse*, have weights risen at the same time?

We need to stop pretending that we're using fat stigma to help fat people. That's not the goal of fat shaming, it doesn't help fat people, it doesn't make people lose weight, and it's cruel. If we want to help fat people -- and, actually, everyone, since fat phobia causes disordered eating and movement in people of all sizes -- the way to do it is to accept people's bodies exactly the way they are.


Buckle up, this is a long one.

If you've never been fat, you might not know what a nightmare the medical system is for fat people. Honestly, this one topic could easily be an entire month of ranting, so I'll just try to hit the high points.
  • Med students don't see fat people in textbooks or in gross anatomy class (there's a weight limit on donated cadavers). They might study "obesity", but outside that context, everyone is apparently thin. So fat people only appear in their education in the context of their fatness being a problem.
  • Standard teaching, it seems, is contrary to the scientific evidence that I ranted about at the beginning of the month. Most med students don't get much in the way of education about nutrition at all. So they just hear what the rest of us hear, except they hear it from other medical professionals, who are supposed to be teaching them, and so they take it as fact.
  • About half of doctors will explicitly admit that they have negative views of obese patients, and will apply a variety of adjectives to them which are, honestly, too horrifying to list here. Virtually all doctors hold implicit biases against fat patients. The problem is worse among younger doctors, which is consistent with findings that fat phobia has generally gotten worse over the past few decades. (By the way, anti-fat bias is also worse among male doctors than female doctors.)
  • Nobody I called wants to tell me what the weight limits on their exam tables are. I suspect they don't know, and don't care. One office told me only that their tables can accommodate any patient they take on, but also said they didn't have a weight limit on what patients they take on. I'm guessing based on terrible online research that most standard exam tables max out at 500 lbs, with some at 600 lbs. That sounds like a lot, but really it's not that much. If you're tall and 550 lbs, you're still likely walking around and having a pretty normal life. So... do doctors turn patients away for being too big for their equipment? Do they take on 400 lbs patients but fire them when they hit 500 lbs? Do they take on heavier patients not realizing or caring that the equipment could be unsafe for them?
  • And what about the rest of the equipment? Are the stirrups wide and sturdy enough? Are there gowns big enough to cover a larger body? Do they have larger speculums on hand (yup, that's a thing)? Are there blood-pressure cuffs large enough to get an accurate reading?
  • Research studies are mostly done on people with "normal" BMI. That sometimes means the dosing for bigger patients is just... an educated guess. Sometimes they guess wrong. For example, contraceptives are more likely to fail for bigger people, because the doses aren't designed for them.
  • Here's an interesting little tidbit. Fat patients are more likely to die if they get cancer, for a number of reasons. Just 7 years ago, the American Society of Clinical Oncology did a study and released some new guidelines on how to give chemo to fat people. They found that about 40% of fat people were being under-dosed -- not given enough chemo. Chemo is dosed based on body weight, and doctors would do the math and see the number and go, "Whoa! That's too much!" and they would adjust it down based on some cockamamie equation so that the math came out looking better to them. Just because that number looked so big, they figured the patient would have too many side effects. (Interestingly, fat patients actually tolerate full proper doses of chemo better than thin patients do.) How long was this going on before these new guidelines? How many fat people died of cancer because nobody bothered to figure out if full doses were actually ok for them? How many doctors are still using the old, bogus calculations for dosing fat people? I'm hoping none, but based on my experience of doctors and how well they keep up with current research... well. Maybe oncologists are better about that. I hope.
  • Doctors bullying patients for being fat is a VERY big problem. I'll just leave it at that.
  • Going to the doctor can be a miserable experience for fat people. Most -- predictably, reasonably -- don't want to go back. They avoid preventive screenings and delay making appointments for symptoms that pop up. That means when they do go in, they're sicker.
  • The first thing many doctors think about when they see a fat patient is their weight, regardless of what the patient came in for. Back pain? Must be your weight. Knee pain? Weight. Heart issues? Weight. Weight loss? Good for you! So they don't look further. They don't run the tests or prescribe the treatments that they would if the patient were thin. That means the true underlying disease or injury goes untreated for longer, and perhaps until they die from it.
I honestly don't know what we can do about this from outside the system. Certainly we can encourage patients to advocate for themselves ("How would you treat a thin person with this problem? Let's try that."), but I hate to put the entire burden on the group that's essentially being victimized here. It's tempting for thinner people to want to boycott doctors who aren't treating fat people well, but doesn't that just leave fewer appointments with the better doctors, appointments fat people really need? Maybe thin people could offer to accompany their fat loved ones to medical appointments and advocate on their behalf, using scientific evidence. It's horrible to say, but fat phobic doctors are more likely to listen to such an argument from a thin person than a fat one.

I don't know. It sure is a horrible mess, though.

1/24: You know what the placebo effect is, but what's the nocebo effect?

If you give a group of people a sugar pill and you tell them it might have side effects, some of them will actually get those side effects. Like actually, physiologically, have health problems, because you told them they might. This is a real thing; it's not controversial.

How many times have you heard that being fat will make someone sick? How many times do you think fat people have heard this, including from health professionals? And on the other side, how prevalent are the messages I've been pushing lately, about the looseness of the connections between size and illness?

How could this NOT be making people sick?

1/25: Can we talk about the words we use to describe BMI ranges?

Etymologically, the word "obese" means, more or less, "ate too much". I guess that's how one becomes fat, apparently.

The word "overweight" clearly means having too much weight. I mean, what's the "over" in "overweight"? Over WHAT, exactly? Not over average, certainly; average BMI in the US is well into the "overweight" range. Perhaps it's over the average weight at some point in the past. But then again, how many of us are over the average height from some point in the past? The average American height gained about 2" over the last century.

I'm not sure the word "normal" is especially appropriate for the next category down, either, just based on what I remember a normal curve is. This category tops out at a BMI of 25, which is about the 30th percentile for Americans.

The BMI categories were supposedly based on patterns of health outcomes, although we know there are a lot of factors that contribute to those (also, I find it interesting that those supposed naturally-occurring distinctions lie precisely at BMI's of 25.00 and 30.00) (also also, almost the entire panel that made those categories was from the weight-loss industry). But who actually uses these charts and these category names?

I went to the doctor recently, and the visit summary they gave me had my BMI printed prominently, in large print, near the top of the first page. No, my visit had nothing to do with my BMI. No, my size has nothing to do with what I went in for. (Incidentally, my BMI is in the "normal" range.) What is the purpose of automatically calculating BMI for the doctor? Can they not see the size of the body that's directly in front of them? Do they not have immediate electronic access to a wealth of information about me that's actually directly pertinent to my health? (Why not prominently print my race or my height, which are both associated with my propensity for certain illnesses?) Most importantly, what is the effect on care of pointing out to a doctor that their patient's BMI is in the "overweight" or "obese" range?

Surely we can come up with better terms than these, something neutral like roman numerals, or at the very least be a little more careful about how we use them and how often we use them. Every time a person uses a word like "obese", they're anchoring to all those old, incorrect, harmful ideas about obesity. I'd wager that most of the time these terms are used, they're in relation to a person whose BMI isn't even all that relevant. BMI really doesn't measure much, after all; there's no facility to factor in things like muscle mass or bone mass. So why are we mentioning it so much?

1/26: Who profits from guilt and shame?
  • Diet doctors or anyone who sells their services to tell you how to lose weight
  • Anyone who sells diet books or other materials
  • Companies who sell diet food, including any food marketed as “guilt-free” or “healthy” or any of those dog whistles
  • Companies who market their foods as a “guilty pleasure” or “naughty” or “decadent”. That’s just capitalizing on diet culture and fat stigma, so it’s really not much better than selling diet food.
  • Gyms! Now, I’m all in favor of gyms. But I suspect their business model would look a lot different if they couldn’t depend on some percentage of members not using their membership. And I further suspect that this phenomenon is based at least partly on the whole shame/guilt system. A lot of gyms lean heavily on the "melt the pounds off" message.
Now, I'm a good American; ain't nothing wrong with hustling to pay your bills. All I'm saying here is that we need to be more aware of the messages around us and the financial motivations that could be behind them. Look at the ads. Look at the food packaging. Look at who designed and wrote up that study about how to lose weight, or the benefits of losing weight; read the paper and consider whether the conclusions are valid. Consider the messenger, and consider the pervasiveness of the message. Armor yourself against the misinformation.

1/27: Things That Actually Make Fat People Sick, a Partial List:
  • malnutrition and other health problems caused by dieting
  • weight cycling caused by chronic dieting
  • poverty due to weight discrimination in hiring
  • depression and general stress due to fat stigma
  • avoidance of physical exercise due to stigma
  • delay in seeking medical care due to past mistreatment by doctors
  • doctors' misattributing symptoms to weight rather than seeking other possible causes
  • the nocebo effect
  • the same thing that made them fat, e.g., trauma
Please feel free to add others in the comments.

1/28: Allyship Ideas: Is your speech supporting fat stigma?

(Disclaimer: I'm not a model ally. I've read some stuff, I'm doing some work on myself, that's all. I'm just going to give some starter ideas for what to do moving forward, mostly for smaller-bodied people. Please chime in if you have related ideas.)
  • Don't comment on changes in people's bodies. When you compliment someone's weight loss, they now know that you (a) notice their weight, and (b) consider a lower weight to be more valuable. Actually, everyone that hears you say this now knows this about you. How do you think it feels to be around someone like this, for a person who's larger or who has gained weight?
  • Actually, don't comment on people's bodies at all. Don't talk about how much you'd like to have someone else's body because they're thinner. Don't talk about how much more attractive one person is because they're thinner than another. Saying, "Wow, I'd kill to have HER body!" is exactly the same as saying, "Wow, I'm sure glad I don't have YOUR body!"
  • Don't talk about changes in your own body size or shape as though your weight and your worth are in inverse proportion.
  • And if you have kids or you're ever around kids, DEFINITELY keep your mouth shut on this stuff while you're around them.
I know you have the thoughts; I have the thoughts too. We all have the thoughts. It's the water we're swimming in. It's ok. Have them inside your head, or discuss them with your therapist. Talk about them with a friend who's also working on unlearning this. But don't say them out loud like they are normal and healthy. That makes you part of the problem.

1/29: Allyship Ideas: Notice furniture.

Look around your work environment. Look around all the other environments you're in. Are they spaces that larger-bodied people can feel comfortable in? Do they feel welcome there? Or does it feel like a space that's not made for them?

Do the chairs have arms? Do ALL the chairs have arms, or is there perhaps a bench or two off to the side? Does the furniture seem sturdy enough to sit on? I was at a lovely wedding reception once with folding chairs, and my chair collapsed under me. It was embarrassing but mostly just silly, because I wasn't particularly big at the time. But how would that feel to a larger person? Do the chairs you see seem like they would support 300 pounds? 400 pounds? Imagine one straight-sized adult with another on their lap; does the chair seem likely to collapse?

Do you have any standing to advocate for changes in the furniture where it's not up to snuff? Does your work have a waiting room or reception area with sitting furniture, or a conference room for outside meetings, or chairs for clients to use at people's desks? Are you planning a wedding and in a position to demand at least some chairs that can hold larger bodies? If you notice a change to more accessible furniture in a space, make sure to thank the people responsible.

1/30:  Allyship Ideas: Where do you buy your clothes? What sizes do they carry?

This might seem shallow to you, but not being able to find decent clothes to wear -- attractive, stylish, affordable, well-made, properly-fitting clothes -- is a very real part of living under weight stigma. How much of your waking life do you spend wearing clothes? What if you hated them? I had a job as a kid that involved a very ugly, ill-fitted polyester uniform. Having to wear that the whole time I was at work colored my entire experience of that job.

Isn't it odd that most stores don't carry above about a women's size 14? Given that the average dress size for American women is about a 16-18. I drew a curve for you, although I have no idea what the standard deviation in dress sizes is or if the distribution is symmetrical. The point is, if it's a normal distribution, then there are as many women wearing size 22 as there are size 12. And as many wearing size 28 as size 6. (Size 28 is the largest size carried by Lane Bryant.)

What's the reason for the unavailability of larger clothes? I mean, it's not because of the amount of fabric involved; you could easily price your clothes higher overall. Plus sized women are used to paying out the nose. It isn't because plus sized women aren't a valuable market; ask a plus sized woman why she doesn't buy more clothes and she'll probably tell you it's because there just aren't that many to buy, and most of them are awful. Retailers are leaving money on the table -- because it's FAT money, and they don't want it. They don't want big women in their stores, and they don't want big women wearing their brand.

When you buy clothes, are you giving your money to companies that support fat stigma? Are you in a position to advocate for more size inclusiveness at those retailers? Can you encourage companies that carry plus sizes online to carry them in their brick-and-mortar stores?

1/31:  JanuaRant™ Allyship Ideas: See messages.

  • Notice marketing messages for what they are
  • Pay attention to how people (including you) talk about food and eating and exercise
  • Pay attention to how people (including you) talk about their bodies and others' bodies
  • Notice fat phobic messages in your and your kids' media, and counter-program your kids (and yourself!)
  • Speak up when someone uses a fallacy like equating high weight with ill health, laziness, undesirability, etc.
  • Refuse to tolerate insults based on body size, even if you really don't like the person being insulted

Be part of the solution. You don't have to be perfect at it. Just move in that direction.

Thanks for the month, guys. Epilogue tomorrow.

2/1:  JanuaRant™: Epilogue

Turns out January isn't that long a month, and there's a lot I didn't have a chance to rant about. Thanks for still reading! Here are a few things I didn't talk about but I still think are interesting and ripe for the ranting.
Weight-loss surgery: amazing? terrifying? predatory? miraculous? It's hard to find long-term data on this, and most of the data seems to be coming from people with a monetary interest. I will say this: body autonomy has to be the most important thing here. Surgery (unlike dieting) does often result in weight loss, which by itself is going to help people, because that's going to reduce the impact of fat stigma on their lives. It helps some people in other ways, too. I'm not going to tell anyone they should or shouldn't make a choice that's going to help them, even if it means taking a physical risk, because that's their choice to make. As long as they have all the information they need to make an informed decision. But this is NOT a solution to the broader problem of weight stigma.
"The Biggest Loser" (on indefinite hiatus) - This show is disgusting, and I hope it never comes back. How could we ever think this was ok? How was this a show that could get on the air? How is this not a gross breach of basic human ethics? This is an EATING DISORDER COMPETITION.
Maybe take another look at "Survivor", while you're at it.
For God's sake people, think of the kids here. Adults can make their own choices for themselves without supporting a culture that demonizes children for high BMI. Can we PLEASE not screw up a whole other generation? Can we break this cycle?
Here's a hard question: how do we support a friend who's changing their behavior in an effort to lose weight? We know shaming them is a bad idea. We don't want to alienate them, because we love them and we care about their mental and physical health. I think bringing up their weight is probably a bad idea, but what's the best way to respond if they bring it up? Can we steer the conversation to how they're feeling and coping, and away from their weight? Very tricky.
There's a lot of intersectionality at play here. Living under any kind of stigma is going to make you more likely to be fat, and that's another layer of stigma, and those stigmas create discrimination that's going to make you poor, which is itself stigmatized, etc. The fatter you get, the more discrimination you experience. Women and people of color experience harsher weight discrimination than privileged people of the same size. It's all just a big lasagna of lazy thinking and cruel behavior.
There are lots of ways to be an ally that I didn't get into -- generally, just look around and try to imagine what the space or culture you're in would feel like to someone heavier than you. (Whatever size you are, people heavier than you have it worse.)
We know how to eat. We always have, somewhere in there. If you have a history of dieting or the restrict-crave-binge-shame cycle, or even just a history of living in a world that tells us there are virtuous foods and evil foods, maybe you would like to try to get back to your body. Maybe you would like to get back in touch with what your body wants and what makes you feel good, physically and otherwise. Maybe you'd like to get back to eating with pleasure and without shame mixed in. I really think you can! I don't pretend to be an expert on any of this, but the book "Intuitive Eating" has helped a lot of people. There's also a website with a forum you can join for free. It's not a quick fix, usually, and it's not necessarily easy or simple. But it's better than the norm, that's for sure.

OK, now go rant!