Coming Out

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I am officially coming out as fat today. I’ve been thinking about doing this for a while now. This concept might seem laughable to some of you. How can someone come out as something that everyone can plainly see? Take one look at me and my size and there is no question that I am fat, but up until fairly recently, I had eschewed the title of “fat,” something that I never wanted to claim to be.

I would describe myself with euphemisms: chubby, chunky, curvy, plus size. I would try to shrink myself in public, taking up as little space as possible lest someone feel like my body imposed on them. I would keep my gaze down as I passed strangers on the street, a way of showing my own shame and embarrassment for my body. I would dress in loose, baggy clothes so no one would be forced to see my belly rolls. If I went to the beach, I would be sure to wear a cover-up the entire time unless I decided to be brave and go for a swim. Then I would sprint into the water so that bystanders would not need to be assailed by the vision of a fat woman in a bathing suit.

All of this was an attempt not to take up space in the world, to show that I, as a fat person, was aware of my horrible shortcomings and was not okay with being in this body. The world that we live in confirmed these feelings often. Microaggressions would come in the form of friends discussing another friend’s weight gain or loss, family members commenting on what I was or was not eating, and doctors suggesting changing my diet without asking me what my diet looked like in the first place.

Like any “good fatty,” from a young age I would engage in different weight loss attempts to try to shrink myself and be “healthy.” My first earnest weight loss attempt was in my senior year of high school. I had made up my mind that I would finally lose the weight that had plagued me throughout my childhood and adolescence and be thin by the time I started college in the fall. Then I could start my new adult life in a socially acceptable body and everything would be perfect. I dutifully dieted, restricting all the foods that I loved, instead living on fat-free cottage cheese, vegetables, and sadness.

My body began to shrink and everyone noticed. I got compliments, invitations to parties, acceptance. My doctor was so impressed that he told me to “keep going” and “get skinny.” Meanwhile, I had lost my period, become completely obsessed with eating as little as possible, and was a grumpy, exhausted mess. At my worst, I was exercising twice a day to try to break the plateau. I was downing sugar-free candies to prevent myself from snacking between meals. (P.S. Fun fact about those candies: They are wicked laxatives!) I would loathe going out to eat with my friends and family, as I would be faced with all the foods I no longer allowed myself to have. Food and weight were all that I could think about.

When I went off to college in the fall, the wheels fell off the proverbial wagon, and I gained back all the weight I had lost and then some. The weight loss/gain cycle continued throughout college and into my 20s as I tried diet after diet, thinking that this time it will stick. But inevitably, the weight would creep back up, and I would feel humiliated and ashamed.

Little did I know then that my experience was not unique. In an analysis of 31 long-term diet studies, researchers concluded that while individuals can expect to initially lose 5% to 10% of their weight regardless of which diet or “lifestyle change” they choose, the weight inevitably comes back, with at least one-third to two-thirds of people regaining even more weight than they had lost in the first place. Another study that looked at the effectiveness of traditional dietary and exercise interventions for weight loss determined that while there is not much long-term follow-up data in the effectiveness of these interventions, “the data that do exist suggest almost complete relapse after 3-5 years.” And those 3-5% of dieters who do manage to keep the weight off for more than 5 years spend all of their time and energy trying to stay that way, often by using disordered eating and exercise behaviors.

I remember reading an article in the New York Times about nine years ago that focused on the National Weight Control Registry (WCR), a research study that follows individuals who have lost at least 30 pounds and have kept it off for at least a year. The article featured a husband and wife who had lost over one hundred pounds each and had been on the WCR for five years. In order to maintain their weight, the couple engaged in a rigid regimen of diet and exercise. Both of them not only exercised for a minimum of two hours per day, they also weighed and measured every morsel of food they ate, logging it into a food diary. They severely limited not only their calories, but the types of calories they were eating (e.g., low carb, no desserts). The wife herself said, “It’s pretty easy to get angry with the amount of work and dedication it takes to keep this weight off,” but the alternative (i.e., gaining the weight back) was not an acceptable outcome for her.

Part of the reason I made the decision to become a registered dietitian was the hope that I could finally crack the code of weight loss. I figured, well, if I learn about all the aspects of nutrition, I will be able to lose weight, keep it off, and help others to do so, too. Before entering the nutrition program, I had dieted down to a lower weight and thus was obsessively thinking about food and my body. Interestingly, by the time I had completed my dietetic program, internship, and Master of Science in nutrition, I had again gained back all of the weight I had lost. Of course, I was quite unhappy with this development but still believed that I could figure out my weight dilemma eventually.

My first dietetic job was at an eating disorder center where I was a registered dietitian working with residential patients. It was around this time that things started to shift slightly for me. I saw how the patients were treated differently based on their body size. For instance, those patients in larger bodies, regardless if they had been admitted for restriction or not, were put on “weight maintenance” meal plans to prevent them from becoming “too fat,” while those patients in smaller bodies were encouraged to eat more to restore their weights to a “healthy weight.”

Basically, we were prescribing behaviors to one group of patients (restriction for those in larger bodies) that were considered disordered in the other group of patients. This double standard did not sit well with me, but I adhered to the guidelines at the center. At the same time, I was still fixated on shrinking my own body, terribly self-conscious of being a fat dietitian in a field known for a very specific type of person: white, female, thin. I thought to myself, “How will any of these patients take me seriously when they see my body?” I dieted once again during this period of time, and with my own wedding day approaching, I got even more obsessed about the number on the scale.

It wasn’t until after the wedding (and subsequent weight regain) that I finally had enough. This wasn’t working for me anymore, and it wasn’t for lack of trying. I had hit diet rock bottom and knew there had to be a better way. So when I learned of Health at Every Size® (HAES) and Intuitive Eating (IE) at a talk given by a colleague, I was so ready to hear the message that there was a way to live a happier and healthier life, a life where food is not the focus and where I could be free of the chains of dieting.

I delved into all of the HAES, body positive, and intuitive eating material I could find online and in various books. I attended workshops and lectures and even spent three weeks at a HAES/IE retreat. I started listening to podcasts, connecting with other HAES and IE practitioners, and before I knew it, my mindset had shifted significantly. HAES and IE spoke to me like no other paradigms or approaches, and once I learned that they are also both backed by scientific research, I was a convert.

During this time, of course I gained some weight after years of losing and gaining (in addition to having a baby), with my body finally landing in the “obese” range, at least for now. It is difficult to be in a larger body for many reasons. Doctor appointments have become more fraught as I brace myself for the weight lecture. Luckily I was able to find a weight-neutral doctor who knows not to talk to me about weight loss, but if I ever need to see a specialist, I know that inevitably my weight will come into the discussion.

Being in a larger body makes it harder to shop for clothes, fit in some spaces, and feel “normal” amongst my mostly slim friends and family. I never had to think before, “Will I fit in this seat?” But now these are things I need to consider. Being a “small-mid fat,” I want to acknowledge that I have much more privilege than those who identify as “large-fat,” “super-fat,” or “infinifat.” The hatred, mistreatment, and oftentimes abuse these individuals deal with on a daily basis make me simultaneously so angry and so sad.

Our diet-obsessed, fatphobic culture makes sure to remind me and other fat people that we are lazy, gross, sloppy gluttons who could be thin if we just tried hard enough and put down the bonbons. The overwhelming majority of people believe that weight is controllable and that if fat people just ate less and exercised more, they could be thin. Most people also believe that the health conditions that are often associated with larger body sizes (such as heart disease and diabetes) are directly caused by weight, even though there are thin people who develop these conditions, too.

While obviously what we eat and how much we move can affect our health, they are a very small part of the picture of overall health and wellness. Access to healthcare, socioeconomic status, oppression, and weight stigma have even greater impacts on our health than just diet and exercise. And just because someone does all of the “right” and “healthy” things does not guarantee that they will never become ill. Society would have us believe that the pursuit of health is a moral imperative and totally within our reach if we just try hard enough. But in the wise words of fat activist Ragen Chastain, “health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed.”

Otherwise open-minded, liberal people who believe in equality and respect for those of different races, ethnicities, sexual orientations, religions, abilities, and gender identities do not consider body size diversity as something that also needs to be respected and protected. This world is not built for larger people, and existing in it can be torturous at times.

In addition to all of this, I still have a great deal of internalized fatphobia that I am constantly trying to counteract with body acceptance. I have had to come to terms that I will never likely be in a smaller body and that this is not the end of the world. At the same time, nearly everyone in my life lives and breathes the same diet culture air we live in, so it’s rare that I am not faced with some fatphobia, diet talk, or weight stigma. It’s like I’m swimming against the current of diet culture nearly 24-7, and sometimes I just want to give up and go with the flow or jump out of the water entirely. But knowing what I know about the lies of diet culture and how miserable my life was when I pursued thinness, I can’t go back.

So I am coming out as fat today to reclaim this word that has been used to taunt me and millions of other people but should honestly be just a neutral descriptor. I am a fat, fair-skinned, red-headed registered dietitian, wife, daughter, sister, friend, and mother. I am all of these things. And I am no longer going to stay in the body shame closet.

Praising Adele’s Weight Loss Is Fatphobic

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The following is a guest blog written by “Sarah,” a nurse practitioner in the Boston area, who strongly believes in utilizing Health at Every Size (HAES) and anti-diet approaches in both her personal and professional lives. She has been Joanne’s patient for about six years and is in recovery from an eating disorder.

It is no secret that our current society is obsessed with physical appearance. The perceived attractiveness of a person very much determines how they are valued, respected, and treated. This is especially true in regard to women, and to an even further extent, celebrity women. 

At this point, I am sure most of you have come across recent media stories of renowned singer Adele’s dramatic weight loss. After an Instagram post from Adele of herself in a form-fitting dress, with a caption giving a mention of her birthday and a shout-out to the first responders in the midst of the COVID-19 pandemic, comments swarmed in that had nothing to do with what she actually wrote. Now there were some comments that highlighted the fact that we should be praising Adele for her immense talent and not her appearance. Five or ten years ago, some of these comments would probably not have existed, and therefore that does highlight the progress we have made in rejecting diet culture and in the public knowledge of this movement. However, the majority of the comments praised her new, thinner, more “acceptable” body. 

Now I want to make it clear that I know absolutely nothing about Adele as a human, including her diet or exercise regimen. It is truly none of my or anyone else’s business what Adele decides to do or not to do in regard to her body. Even as someone who fully believes in HAES and is very anti-diet, if Adele did intentionally seek a smaller body, I can’t say that I blame her. Our world is a hostile place for those of us living in marginalized bodies. If you are fat, disabled, trans, poor, non-white, or any iteration of these, you are subjected to discrimination and othering. Therefore, it is no wonder why one would want to attempt to fit into a more socially respected body. 

I would normally say that it is unfair to assume anything about Adele’s means of attaining this new look, but in recent articles, she does discuss a particular diet of a VERY scary low number of calories (*trigger warning) and a rigidly structured exercise plan. Again, it is no one’s business how Adele decides to treat her body, but by the DSM standard, there is no question that she would be diagnosed with an eating disorder. I recognize that this is more of a systems issue, and those who mean well by praising her new body are operating under a fat-phobic structure. While eating disorder behaviors are considered concerning when the individual is thin, these same behaviors are encouraged for those who are in larger bodies. It is what we are taught and how we operate as a culture; it is no wonder that full recovery from eating disorders is so challenging (and oftentimes unachievable).

Now let’s get down to the real issue and meaning behind Adele’s weight loss (which really has not much to do with her at all). Body autonomy is part of the HAES movement, and I fully stand behind this for Adele or anyone else. It is the mere fact that a single picture can prompt so many comments (positive or negative) about one’s body that is the core issue here. 

The focus by others on a changing body, in a positive or negative way, often keeps people from recovering fully. If we lived in a world where a body was just a body regardless of how large or small it became, this would not even be a topic of conversation. Although it is an inevitable fact that bodies fluctuate for various reasons throughout the lifespan, we cannot seem to accept this as a society. Naomi Wolf stated: “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.” Diet culture and fatphobia are the prime examples of this. We are taught that our worth depends on other people’s evaluation of us and that how our body looks to others matters more than how it feels to us. Especially as women, we are taught that making others happy is more important than making ourselves happy and that the most important thing is that others will like and approve of us, and therefore it is no wonder that we constantly rely on external validation to prove our worth.

Being fat and/or gaining weight is seen as the ultimate failure, and there is countless evidence of this belief expressed throughout history. We see and hear examples of this in our everyday lives, whether we recognize it or not. It is more common knowledge these days that “diets don’t work,” but we have yet to make significant progress in the idea that one’s body does not determine their worth. That is not to discredit all of the amazing progress that the HAES community has made, and as someone in a straight-size body, I cannot speak to the true experience of someone living in a larger, marginalized body. However, as a woman living in constant recovery from an eating disorder, I can say that the fear of weight gain has held me back in so many ways throughout this journey. Fatphobia truly affects everybody (whether they realize it or not) but is much more pervasive for women. 

I now know that these are reactive thoughts stemming from decades of diet culture brainwashing and the instinctual need to belong as a human. These messages have become even louder throughout the COVID-19 pandemic. Not only are we separated from many of our in-person support systems, dealing with real threats to our health and vitality, but we are relatively stuck at home with our thoughts. Although I do truly believe sitting and ruminating in these thoughts and fears can lead to growth in so many ways, it is also extremely triggering. We have less access physically and maybe financially to certain foods, and this can be triggering in itself.

To add to this, those who suffer from eating disorders and also live in larger bodies are especially vulnerable given the extreme fatphobia that knows no boundaries. There have been countless news articles claiming that people living in larger bodies are more susceptible to COVID-19. Not only is this untrue, but it is incredible healthism and just another example of diet culture profiting from our fears. Attempting to change one’s body size in the hopes of health and immortality has never worked in the past and scientifically never will. It is disappointing that these messages of blame and shame are being touted instead of compassion, inclusivity, and actual scientific facts, especially during this time. 

So how do we begin to change as a culture? By recognizing that beliefs and facts are not the same. By rejecting diet culture and recognizing that our body size or health status has nothing to do with our worth as humans and by treating others with respect and dignity just because they exist. As the wise Ragen Chastain said best: “Health is not an obligation, barometer of worthiness, or entirely within our control,” and this could not be more relevant in our current climate.

Emotional Eating in Quarantine

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Despite the major life disruption that the coronavirus quarantine has been for us personally, Jonah and I are lucky enough to be able to still work, as we are telehealth providers. While all of my patients are struggling in different ways with quarantine, one theme keeps on popping up consistently: “I feel like my emotional eating is out of control.”

Many of my patients are working on becoming intuitive eaters, and the current pandemic is making it extremely difficult for them to heal their relationship with their bodies and food. Living in these strange times is like nothing we have ever experienced before – being confined to our homes, socially distancing, and the near constant underlying fear of illness are exhausting and emotionally draining.

Some of my patients are working on the front lines of the corona crisis, taking care of patients who are severely ill. Some of my patients have lost loved ones to the virus. Others are struggling with the loneliness of isolation. In short, the past couple of months have been really, really rough. And the fact that there is no definite end point for this pandemic, that this state of limbo could continue for months on end, leaves many of us feeling hopeless and trapped.  

So when my patients tell me that they are emotionally eating, I am not at all surprised. Emotional eating in times of stress and uncertainty is normal and, honestly, to be expected. From the time that we are born, food is a source of nourishment and comfort. Food is a basic human need. From the very beginning, whether we start out nursing or bottle feeding, drinking breast milk or formula (or both), food is necessary for survival. It is designed to make us feel satiated and safe. Food is one way that our caregivers take care of us when we are babies, providing comfort when the feeling of hunger arises. This is all to say that turning to food for comfort is a completely normal thing for humans to do – it is programmed in our DNA. And feelings of comfort and safety are paramount to developing love and attachment.

The phrase “emotional eating” has been around for many years, and it always seems to be presented as a negative thing. Many of my patients characterize themselves as emotional eaters and wish that they could stop. In most cases, these patients feel as though they have “no control” around food, that they will overeat on certain comfort foods, and they inevitably feel shame after they do this. Of course, many of these patients are consumed with fears around gaining weight and feel that by engaging in emotional eating, they are likely to become larger.

To me, “emotional eating” is a phrase that was created by diet culture because at the root of it is fat phobia. Our culture is a completely fat phobic one, and one of the underlying themes is that engaging in emotional eating is a dangerous habit; if one emotionally eats regularly, they will gain weight, become fat and be unhealthy, unattractive, and unlovable. Emotional eating is seen as problematic by diet culture, and those who engage in it are deemed weak-willed and less than.

In my work, what I have found is that the amount that a patient engages in “emotional eating” is almost directly proportional to the amount of restriction (both mental and physical) in which they also engage. In other words, my patients who feel like they are emotional eaters and cannot control themselves around food are often the ones who are the most restrictive with their intake.

If you think about it, it makes sense on a biological level. Our early ancestors were often subjected to famine and food scarcity, and in order to survive during those times, their sole focus became about finding food. It is one of our most basic survival mechanisms, and it is deep within our genetic code. When we are deprived of food (whether it be deprivation imposed on us by others/circumstance or self-imposed), our primal brain is designed to focus solely on procuring food. And not just any food, mind you, but food that is calorically dense and will give us quick and lasting energy, specifically foods that are high in carbohydrates and fat. Is it any wonder that many of our “comfort foods” are often comprised mainly of carbs and fat? It is our ancient genetic code’s way of keeping us alive.

This is all to say that when we are in times of stress, anxiety and fear (like during this pandemic), it makes perfect sense that we might turn to food for comfort more often. This behavior in and of itself is not problematic; it is one of the many ways that humans cope during difficult times. Add on top of that feelings of deprivation around food (with many grocery stores running out of supplies and access to restaurants reduced), and it is no wonder that we have food on the brain more often as well. The most important thing we can do right now is not to judge ourselves for “emotionally eating” during this tough time, but to have some compassion for ourselves. We are all just trying to take care of ourselves in the best way we know how.

Stop Complimenting Weight Loss

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On the surface, complimenting someone’s weight loss seems like a benign and positive affirmation, but there are a number of reasons why doing so is problematic.

First and foremost, unless we have been told by the individual that their weight loss was intentional, we really have no clue as to why someone is losing weight. It could be due to illness, grief, or depression. It could also be as a result of an eating disorder (ED). Many of my patients say that comments about their weight loss when they were in the throes of their eating disorder fueled the disorder and made them feel like they had to keep up their disordered behaviors in order to keep their body “in check.” This goes double for patients with anorexia who are in larger bodies. These individuals often go undiagnosed with an ED because their weight loss is seen as a positive thing, never mind that they are engaging in extreme restriction and over-exercise to achieve this loss.

While I was never formally diagnosed with an ED, I myself remember when I was a teenager and engaged in very disordered eating and exercise habits and ended up losing a significant amount of weight in a short period of time. Despite the fact that I had lost my period, had very little energy, avoided going out to eat for fear of having to eat “junk” food, and overall felt awful and obsessive, I got compliment after compliment from family, friends, and even from my doctor. I even remember my doctor saying to me, “I don’t care what you are doing to lose the weight, just keep doing it!” I cringe just thinking about it!

Another reason to stop complimenting weight loss? It inherently implies that there was something wrong with the person’s body before they lost the weight. Think about it – do we ever comment on someone gaining weight in a positive light? Nope. These weight loss compliments also imply that being smaller or skinnier is better than being larger. The truth of the matter is that bodies come in all shapes and sizes, and they all deserve respect. Placing smaller bodies on a pedestal reinforces the idea that people in larger bodies are less than. This is weight stigma, and it has been shown to negatively affect us not only psychologically, but physically as well. Furthermore, since we know that 95-98% of intentional weight loss attempts result in weight regain, the silence when someone regains the weight they lost can be deafening.

Finally, and possibly the most important reason, is to stop modeling this behavior for our children. Little ones are like sponges, and from a young age, they are acutely aware of our society’s dislike of fat people. One study found that children aged 6 to 11 hold considerable negative attitudes towards their heavier peers, being more likely to describe these “overweight” peers as “mean, stupid or dirty” than average-weight peers. Other studies found that “nearly a third of children age 5 to 6 choose an ideal body size that is thinner than their current perceived size” and that “by age 6, children are aware of dieting and may have tried it”. When we compliment another’s weight loss, we are telling our kids that to be smaller is better and that being fat is a bad thing.

What can we do instead? Don’t comment on another person’s body. Full stop. If you feel compelled to give a compliment, try complimenting the person’s kindness, humor, intelligence, or other attributes not related to body shape or size.

“Sometimes I want to binge so bad.”

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A guy two months removed from spinal fusion surgery has no business moving a 45-pound plate. For that reason, in the late spring of 2014, I introduced myself to a new personal trainer at my gym and asked him to please put away the plate that another member had left on a machine so that I could use the equipment.

Typically, I shy away from new trainers, who tend to pitch themselves to virtually every member they meet in an effort to build their client rosters. As a former trainer myself, I get it, but I also do not like being pressured. This trainer was different though, and once I saw that he was not going to push me for a sale, I began talking with him on a regular basis. That hey-can-you-please-put-this-weight-away interaction turned out to mark the beginning of what has evolved into a friendship of sorts.

In the five years since, we have chatted about superficial matters, such as the rise and fall of the Celtics, as well as issues of more substance, like marriage and fatherhood. Despite the connection we have developed and my opinion that he is generally an excellent trainer, I have never referred my patients to him because of one factor that makes it ethically impossible for me to do so: He unintentionally encourages disordered eating.

Food and eating behaviors are common topics of conversation during his training sessions. Calories, cheat days, tracking apps, Halo Top, junk food, clean eating, intermittent fasting, and willpower are just some of the buzz words and trendy features of diet culture that I frequently hear him and his clients discuss.

My patients and I sometimes talk about these topics too, but the substance of our conversations is entirely different. Whereas I work towards dismantling diet culture and helping my patients understand the harm that comes from relating to food in such a way, this trainer sees these as positives. He tracks his calories, fasts, and weighs himself regularly, and he cites his own weight loss from the past year as evidence that his behaviors are the secrets to success that his clients should replicate.

Last week, one of his clients texted him to say he was going to be a half hour late. With an unexpected chunk of free time on his hands, the trainer came over and struck up a conversation with me while I was stretching. “Do you help people lose weight?” he asked. No, I do not, and I gave him my elevator speech explanation as to why.

His response somewhat surprised me. He told me how difficult weight loss was for him, how exhausting it is to track everything he eats, and how he just cannot keep up the behaviors. “Sometimes I want to binge so bad,” he conceded. The restriction is unmaintainable, he regains the 15 pounds he lost, then resolves to become lean again, reengages in his previous diet behaviors, again loses 15 pounds, and the cycle repeats.

In the last five years, I have overheard literally hundreds of conversations he has had with his clients regarding nutrition, many of which have referenced his own eating behaviors, but never have I witnessed him disclose his struggles and concerns as he did last week when none of his clients were around to hear about them.

So, I told him about the Ancel Keys starvation study and how binge behaviors were commonplace among the subjects once the dietary restrictions placed upon them were lifted. In their excellent book, Beyond a Shadow of a Diet, Judith Matz and Ellen Frankel explain the following:

“What these men [the study’s subjects] experienced as a result of their semi-starvation is typical of feelings and behaviors exhibited by dieters. When the men entered the refeeding portion of the study, the food restrictions were lifted. Free to eat what they wanted, the men engaged in binge eating for weeks yet continued to feel ravenous. They overate frequently, sometimes to the point of becoming ill, yet they continued to feel intense hunger. The men quickly regained the lost weight as fat. Most of the subjects lost the muscle tone they enjoyed before the experiment began, and some of the men added more pounds than their pre-diet weight. Only after weight was restored did the men’s energy and emotional stability return.”

Modern day dieting, I pointed out to the trainer, is really just self-imposed starvation, and it is completely understandable that dieters respond just like the study’s subjects. It is not a matter of willpower, but rather one of biological mechanisms, honed through evolution, that resist weight loss and encourage weight gain in order to help our species survive famines and other times of food scarcity.

Soon enough, our day’s conversation came to a close. He had to get ready to train his client, and it was time for me to head home and prepare for my own day’s work. Just before we went our separate ways, he told me that his clients have no idea how hard it is for him to try to maintain his eating behaviors, and we agreed that we never really know what someone else is dealing with behind the scenes.

Our parting sentiment is also the key takeaway from this blog. Said differently, consider the words of one of our most experienced and knowledgeable colleagues, Dr. Deb Burgard, who once said, “In almost 40 years of treating eating issues, I have found that when someone sits down across from me, I have no idea what they are going to tell me they are doing with food.”

In this trainer’s case, while many of his clients see him as a role model and look to him for nutrition advice, they do not realize that he is struggling and that the behaviors they seek to emulate are actually signs of disordered eating.

The Kids Are Alright

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Weight Watchers, I won’t call you by your new convenient moniker “WW” designed to try to fool the public that you aren’t all about the weight. You might try to kid yourself into thinking that you are just about “wellness” and that the goal of weight loss is just a byproduct of a “healthy lifestyle change.” Nope. It’s just the same crap in a slightly different package. Any way you slice it, the only thing you care about is your bottom line, not helping your customers get healthy. If you really understood health, you would realize that a lifetime of weight cycling, weight stigma, and self-loathing are far more damaging than just staying fat. 

Weight Watchers continues to spread the lie that intentional weight loss is attainable if you just try hard enough. And if you fail at maintaining your weight loss, you, not the diet, are to blame. Bull. If your program worked, you’d be out of business. Even your former financial director Richard Samber stated as much in an interview, explaining that repeat customers are “where your business comes from.”

Where is the evidence that Weight Watchers “works” anyways? The company is famously close-lipped around their long-term success rates. In fact, they cannot demonstrate that anyone, save for a measly tiny percentage of dieters, can keep off the weight they lose for more than five years. And those who do manage to keep the weight off often use disordered eating and exercise behaviors to do so.

Intentional weight loss endeavors, whether they are through Weight Watchers or any other diet or “lifestyle change,” fail 90-95% of the time. Yet our medical community continues to push weight loss on fat patients, telling them that they are at risk of death if they don’t lose the weight. For myself and many other fat people, going to the doctor can be an anxiety-inducing experience, as we are often met with weight stigma and advice to stop eating so much (even if that’s not what’s going on). Many fat people I know just avoid going to the doctor altogether to avoid this weight shaming. Is that health-promoting behavior? I don’t think so.

The notion that weight loss is achievable and maintainable is one of those common beliefs that is put forth by diet culture. Diet culture tells us that being fat is inherently unhealthy and unappealing, that those of us who cannot lose weight are lazy, inept, unintelligent individuals who just aren’t trying hard enough. Diet culture glosses over all of the research that shows how and why our bodies fight like hell against losing weight. Diet culture ignores the facts that repeated dieting and yo-yoing is actually much more physically harmful than just maintaining a higher weight and that shaming fat individuals is not helping anyone but is taking a toll on all of our health and well-being.

Weight Watchers’ latest endeavor, launching an app that targets children aged 8-17, makes my blood boil. In the iconic words of John McEnroe, you cannot be serious, Weight Watchers. Never mind all of the eating disorders that this app will help to create and/or encourage; this app contributes to the weight stigma that plagues our society. It reinforces the idea that being fat is a bad thing and that it must be avoided at all costs. It fosters a feeling of shame in heavier kids, a feeling of being “less than.” 

As a chubby (not fat) child, I was repeatedly told by my pediatrician and my family that my body was wrong. These messages and the messages I got from diet culture led me to develop disordered beliefs around food, exercise, and my body. It wasn’t until I found Health at Every Size that I finally figured out that my body is not to blame. My body doesn’t need to change. Our weight-shaming culture needs to change. And I am honestly scared for the legions of kids and teenagers who are exposed to this toxic culture.

Weight Watchers’ app will teach kids that they cannot trust their own bodies, that their own bodies are damaged or ill-equipped to tell them what and how much they need to eat. This app will create lifelong struggles for these kids, who likely will have a disordered relationship with food and their bodies for the rest of their lives. I cannot even wrap my mind around the amount of psychological and physical damage this program will cause. 

I don’t know if it’s the fact that I have a daughter myself now that this is striking such a chord with me. I fear for her. I don’t ever want her to feel like she needs to make herself smaller to be loved, accepted, or healthy. I don’t want her to spend her life trying to change her body and fear its appetites. I want her to be confident in her body, to trust that it will tell her what it needs, and that her weight is not the measure of her worth. 

So, Weight Watchers, I hope this program fails and you disappear into the ether sooner than later. 

Macy’s

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This month, Macy’s found themselves in hot water for selling plates, made by Pourtions, that many people criticized for encouraging eating disorders and fat shaming.

One of the plates, for example, features three concentric circles, the smallest of which is labeled “skinny jeans,” while the middle one reads “favorite jeans,” and on the largest of the three circles is emblazoned “mom jeans,” insinuating that the bigger the portion, the larger the pants size.

According to Huffington Post, Mary Cassidy, Pourtions’ president, explained, “Pourtions is intended to support healthy eating and drinking. Everyone who has appreciated Pourtions knows that it can be tough sometimes to be as mindful and moderate in our eating and drinking as we’d like, but that a gentle reminder can make a big difference. That was all we ever meant to encourage.”

Her company’s intentions do matter, for if they had purposely intended harm, then this would be a very different matter, but the impact remains the same whether their actions were malicious or an attempt at humor that missed the mark.

“These expectations can actually kill someone, and I know someone it has,” read a tweet from one responder, who elaborated that the plates spread a “toxic message, promoting even greater women beauty standards and dangerous health habits.”

Eating disorders are serious business. They can wreak havoc on one’s health, family, career, and life in general. And yes, they can be fatal. Additionally, they are more common than many people realize.

“As we all know, pressure to be thin leads to dieting, which can lead to a variety of problems, including eating disorders,” I wrote in the April 2016 issue of Boston Baseball. “These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would fill section 41,” which is a large section in the bleachers behind the Red Sox bullpen.

One does not even have to have a diagnosed eating disorder to be suffering the effects of diet culture and weight stigma. We see plenty of disordered eating which can be comprised of a constellation of symptoms, such as a strong good/bad food dichotomy or feelings of guilt and virtue associated with eating behaviors, that does not meet the diagnostic criteria for a specific eating disorder but can be just as disruptive and dangerous.

When we work with people recovering from eating disorders and disordered eating, we help them to uncouple judgment from their eating behaviors, and part of this work entails exploring where they learned such judgment in the first place.

The judgments implied by the Pourtions plates are so blatant that they are self-explanatory, but sometimes the message is more subtle. For example, Trader Joe’s has a line of “reduced guilt” products, such as their low-fat mac and cheese, which implies increased guilt for its full-fat counterpart. One might argue that the “reduced guilt” tag is a tongue-in-cheek marketing gimmick and is not to be taken to heart. Perhaps, but messages like these – whether in your face or toned down – are so commonplace that they are insidious.

Honoring internal eating cues is difficult to do in a society with pervasive messages that our bodies are not to be trusted. We have 100-calorie snack packs, for example, that people often utilize in an attempt to limit their consumption via an external control – in this case, the pre-portioned quantity – but the implication is that 100 calories is the correct amount to consume, that it should be enough food. In some cases, it will be, but 100 calories is an arbitrary amount of energy, and chances are low that it will just so happen to match up with someone’s hunger/fullness cues. If someone gets to the bottom of the bag and yet they are still hungry, the dissonance between their body saying, “Hey, I need more food,” and society saying, “Hey, you have already eaten enough,” is confusing and stressful.

The small print on food labels reads, “Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs,” but time and time again, I have patients who believe they should be consuming 2,000 daily calories because food labels imply that this is the standard amount for an adult human. They then have difficulty making sense of their bodies asking for more food than that and feel tempted to restrict in an effort to match the label.

While I am not advocating for the abolition of food labels or snack packs, we have to consider the gap between impact and intent and realize that these tools might not actually be as helpful in reality as they seemed in their creators’ imaginations.

To Macy’s credit, they took the feedback they received to heart; seemingly realized that despite the humorous intent of the Pourtions products, the reality is that the plates are offensive and send harmful and dangerous messages; and consequently stopped selling them.

Walking While Jacketed

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The Needham police stopped me while I was out for a walk yesterday morning. Reportedly, someone had called them to express, umm, “concern” that I was pushing an empty stroller. But the stroller was not empty, as the officer quickly realized when I introduced him to our infant daughter.

Even if the stroller had been empty, that is not a crime. Maybe I was returning home from dropping my baby off at daycare, or on my way to pick her up from visiting with a family member. Perhaps I was going to use the stroller to transport groceries home from the supermarket.

After I asked the officer exactly what the caller said, he made mention of the heavy winter jacket I was wearing, suggesting that my wardrobe choice raised suspicion. Some people run warm, some people run cold like me, but neither one of these characteristics is illegal either.

Before I get to the elements of this incident with which I take issue, let me first state what my problems are not:

My problems are not with the police department, and I am glad they responded to the call. What if I had actually been up to no good and they declined to pursue a tip that could have prevented a crime?

My problems are not with the responding officer. He was respectful throughout our encounter, and while he was understandably guarded at the outset, he became super friendly once he saw our daughter.

My problems are not with somebody keeping an eye on the neighborhood. “See something, say something” is an important call to action. Even in a relatively safe town like Needham, crimes still do occur, and we have to look out for each other and help the police to protect us.

My first problem is that what constitutes suspicion needs to be set at a higher threshold than what was exhibited yesterday. All the caller saw was a guy, a stroller, and their own prejudices.

My second problem is that not everybody gets treated the same by first responders, so when somebody ponders calling the police, they have to consider not just what crimes their call might prevent, but also what crimes their call might cause. As a white guy, I can see a police officer approaching me and feel confident that whatever transpires during our imminent encounter, I am likely going to be treated fairly and that my safety is probably not in danger. If I had dark skin, I would be less optimistic. We do not have to watch the news for very long before we see examples of seemingly-benign calls to the police resulting in murders of minorities.

My third problem – and the reason I am writing about this in a nutrition blog – is that this incident is emblematic of a broader issue in our town: We judge each other for our looks. Some of my fellow Needhamites have given me a hard time for my appearance as far back as elementary school, when my chosen attire and hair style were out of step with the hip childrens’ fashions of the day. While I am not equating picking on a kid on the playground for his hair and clothes with calling the police on an adult for his jacket, I am saying that they exist on the same bullying continuum and that they are both symptomatic of an intolerance/phobia/disrespect of people who are different than oneself.

This latter point is what most frustrated and disappointed me about yesterday morning. All these years later, from the 1980s Broadmeadow playground to 2019 in my own neighborhood, the message is the same: Look different in this town at your own peril. Despite all of the changes that Needham has undergone over the past few decades, the pressure to conform remains fully intact.

Nobody should be surprised then that so many of our patients are working to overcome eating disorders, many of which – but certainly not all – were triggered by a desire to escape weight-based stigma, shaming, and bullying and to become a member of a more socially accepted group. No wonder then that some of our patients with restrictive disorders are reluctant to weight restore; after having a taste of thin privilege, surrendering it and returning to the crosshairs of stigma is a difficult proposition. Similarly, it is understandable that patients of all ages have a hard time giving up their fantasies of becoming thin, which is a necessary step in healing their disordered relationships with food.

A small fraction of our readers take umbrage at our occasional discussion of politics and societal issues, but most people seem to understand that if we are truly going to help our patients with their nutrition, we have to do more than address the nitty-gritty of food and eating behaviors. We have to advocate not just for greater tolerance of questionable fashion choices, but also for serious issues of equality. We have to fight for size acceptance.

Dietetics Within the Health at Every Size (HAES) Framework

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Following is an edited transcript of the presentation I gave at the Weight Stigma in Healthcare Settings conference at Massachusetts General Hospital (MGH) on October 18, 2018. The video of my actual presentation is available here.

I have been an MGH patient for a long time. Over the years, I have had three back surgeries here, and the staff has always been amazing. That includes my surgeon, the physical therapists, occupational therapists, nurses, and everybody who helped me during my hospitalizations. Because of the high level of care that I have received here, I feel particularly grateful to have the opportunity to talk with you today. Certainly, this 15-minute talk does not even out everything I have received over the years in terms of give and take, but it feels like a step in the right direction.

My first surgery was over 20 years ago when I was an undergrad at Tufts University, after a preseason physical for the tennis team ultimately revealed a tumor on my spine. After I recovered from the operation and graduated with a double major in mathematics and English, I worked across the river from here as an operations research analyst for the Department of Transportation.

The DOT was a fine place to work, but I realized the field of transportation was not for me. After a period of trying to figure out what I wanted to do with my career, I decided to go back to school to study nutrition at the University of Massachusetts Amherst. Once I completed my degree and my internship over at Beth Israel Deaconess Medical Center, I finally became a registered dietitian, and to be honest, I thought I was going to be amazing. The way I saw it, the basis of nutrition is biology, biology is essentially chemistry, chemistry boils down to physics, and physics is really just math. And who has a math degree? Me. Plus, with my experience in research analysis, and my background in athletics and having worked on the side as a personal trainer, I thought I had all the education and background I needed to be a great dietitian. Calories in and calories out, the Krebs cycle, grams, medical nutrition therapy, energy metabolism, what have you. If they had taught it to me, I had learned it and learned it well, so I thought I was going to be a star.

My initial patients thought I was great, too. They came to me primarily looking to lose weight or to change their body composition, and the vast majority of them did. They were thrilled with their results, some of them called me a “guru,” and they referred their friends.

Everything seemed great, but then I began to notice a pattern. In almost all cases, the initial weight loss plateaued and began to reverse. Maybe it took months, maybe it took years, but the results were almost always the same. My patients looked to me for the answers. After all, I was the one who helped them to lose the weight in the first place. But really, I had no answers. Based on my training, what I was doing should have been working, so what was the problem?

I remember how nervous my patients would be when they got on the scale or on the table for a body composition analysis, but what they did not know was that I was right there with them, as I experienced a really intense internal anxiety, praying that the numbers would be to their liking because if they were not, I was at a loss. Despite the high opinion of myself that I initially had, I began to realize the truth, which was that I kind of sucked at being a dietitian. I got into dietetics because I wanted to help people, and I realized that I was doing nothing of the sort. I felt like a fraud because, honestly, I was. I thought I had all the answers, my patients thought I had all the answers, but the truth was that I had very few of them.

Right around the time that I was experiencing this professional crisis of sorts, questioning everything that I was doing, my wife, who is also a dietitian, was attending a peer supervision group at MEDA, the Multi-Service Eating Disorders Association, so I decided to tag along. We would go around and share our most challenging cases with the group in order to learn from each other and get support that would enable us to better help our patients. When I mentioned that I was consistently seeing weight regain in my patients and I did not know what to do about it, the group leader told me that in approximately 95% of cases, people regain the weight they lose, and in about 60% of cases, people end up heavier than when they started.

My initial reaction was essentially, “Come on, there is no way that is true. If that were true, they would have taught us that in school.” So, I began asking around to other seasoned dietitians I respected, and to my surprise, they confirmed the same. Still, I was skeptical, so they pointed me towards research and articles to back up what they were saying.

For example, according to the New York Times, “After two days of testimony from leading obesity specialists, the panel said it had found no good evidence that any currently popular methods of ‘voluntary’ weight loss had much chance for long-term success. In fact, what evidence the panel could find suggested that 90 to 95 percent of dieters regain all or most of their hard-lost pounds within five years.”

Despite what they taught us in school about calories in and calories out, eat less and exercise more, and all of that, it turned out that nobody had demonstrated that they knew how to create long-term weight loss in more than a small fraction of the people who hope to achieve it. Clearly, I still had a lot to learn.

So, I began talking with more colleagues and doing the reading that they suggested, works like Beyond a Shadow of a Diet, Intuitive Eating, and Health at Every Size. My wife and I became members of ASDAH, the Association for Size Diversity and Health, and networked with colleagues all over the planet who had all come to realize that focusing on weight does not work and were instead utilizing a weight-neutral approach to care with greater success.

Knowing what my wife and I now knew, we wanted to adopt a weight-neutral approach to care, too, and maybe you are thinking to yourself that you have some interest in doing the same – maybe that is what brought you here today – but you probably realize just as we did that it is not that easy to shift gears.

Our professions demand that we further our education, hence continuing education requirements, but when new information makes us realize that we have not been helping people as we thought we were, that can be tough. One of the hardest parts for me was coming to terms with my mistakes and working through the guilt that I felt for having taken patients down a path that turned out to be less helpful than I had expected.

Beyond that, changing approaches risks losing our established patient pool, which risks our livelihoods. Our bills do not suddenly stop coming while we regroup and build up a new practice; the reality is that we all have to keep earning a living.

In a healthcare culture that is very weight focused, announcing that we are taking a weight-neutral approach not only risks losing patients, but also referral sources, our professional credibility, and maybe even our job.

For senior clinicians, including those in managerial roles, change is not easy for them either. Grants, book deals, and clinics can revolve around a given approach and professional identity built up over years and years, and changing direction can risk all of that.

My wife and I are privileged and lucky, in that circumstances and opportunity came together and we had the freedom to change, because certainly not everybody does.

Now that we have changed approaches, we find a weight-neutral approach to nutrition to be so much more helpful and beneficial than a weight-focused approach. Trying to foster long-term weight loss is generally a fruitless task, but by taking a Health at Every Size (HAES) approach, we can bypass that and go directly at whatever someone’s health concerns are.

As examples, if someone has high cholesterol, high blood pressure, or glycemic control issues, we can use medical nutrition therapy to treat these conditions directly, as opposed to attempting to use weight loss as an intermediary.

As another example, if someone is trying to improve athletic performance, we can focus directly on nutrition interventions to improve their performance, rather than hoping that weight loss will bring about increased strength, speed, endurance, or flexibility, when really it might just bring about a nutrient deficiency or an eating disorder.

A fatphobic model is particularly problematic when working with eating disorders, some of which are brought about by concerns about weight and body size in the first place. Trying to tell someone with anorexia that we will help them regain some weight – but not too much weight – reinforces weight stigma and actually colludes with the eating disorder voice, thereby hindering recovery. An approach that incorporates size acceptance, which HAES does, sets the stage for better outcomes.

Now, don’t get me wrong, being weight-neutral, as we are, is different than being anti-weight loss. If someone, through the course of behavior change, happens to lose weight as a side effect and they are happy about that, great, no problem. It’s just that the weight loss is not our goal, nor is it the focus of our work.

When we think of weight bias and the inherent issues with weight-centered care, we often think of the impact on people at the larger end of the spectrum, but the truth is that weight stigma in healthcare hurts thin people, too.

This quote is from a dietitian in Oregon. “I think there are a good number of people at the lower end of the weight spectrum who have undiagnosed sleep apnea. have a friend who was exhausted for years, did lots and lots of testing, and yet because she was thin, they never tested for sleep apnea. And sure enough, that’s what it was…five years later.”

An Australian colleague says, “I know of thin and active people, including a close friend and my physio who weren’t tested for cholesterol, diabetes, hypertension etc. because it was assumed they wouldn’t have an issue when they actually did have very high cholesterol, hypertension, or diabetes.”

According to a therapist practicing in California, “I have also had many clients tell me that because their bodies looked ‘healthy’ their providers would say, ‘Whatever you are doing, keep it up!’ even though they were throwing up, abusing laxatives, compulsively exercising, etc. To a one they talked about how utterly lonely they felt, and how it confirmed that the world did not care about what was really going on with them as long as they just kept up appearances.”

As a thin person myself, I have had doctors make incorrect assumptions about my eating habits because of my size. Whereas fat patients of mine tell me stories about how their doctors give them unsolicited nutrition advice, things like “lay off the bread basket” without even first inquiring about their bread consumption, doctors will bring up nutrition to me only to very quickly stop themselves, citing not my profession, but rather my frame, assuming that I must already be eating as they would have suggested because I am thin.

After my first back surgery, my neurologist cautioned me to “stay skinny,” telling me that if I ever thought about slacking off in terms of physical activity, to remember this conversation I was having with him. I certainly do remember that conversation, as it triggered an exercise addiction that took me over a decade to resolve. All those years, I went to him for follow-up, and he and other doctors missed blatant red flags that I had a problem because the attitude was “You’re thin, so whatever you are doing, keep it up.”

Even though I love my PCP, he is reluctant to order lab work because he sees a thin guy in front of him and tells me “I have zero concerns,” whereas I think of my family history, there are certain markers I want to be keeping tabs on, so every year we go through the same song and dance as we renegotiate what to test.

Professionally, I have had patients assume I know the secrets to getting and staying thin because I am thin myself. This is a huge issue in personal training, too, where our bodies are seen as advertisements for our services. Not only does this create a barrier, in which people who would make awesome dietitians and trainers are wary of entering the field for fear they will not be taken seriously since they do not look the part, but the presence of size-based bias in the room is a hurdle that can hinder care, conjure up false expectations, and mislead patients regarding expertise or lack thereof.

In truth, my size is mainly the product of genetics, privilege, and luck. Despite the overconfidence that I had when I finished nutrition school, the truth is that I still have a lot to learn, and I certainly have no secrets, except for maybe one, which I will share with you now: Some of my colleagues who are much bigger than me, the ones who have trouble getting patients, or referrals, or even jobs – because who wants to see the fat dietitian, obviously they do not practice what they preach, right? That’s the garbage that some people say? – Well, the truth is, the secret is, that these colleagues might be a lot bigger than me, but they are also way better clinicians than me even though I am thin.

He Said, She Said: MEDA Conference Takeaways

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He Said

Today’s society is talking more and more about the idea of privilege. We often hear about white privilege, male privilege, and straight privilege, but people less commonly discuss another form that directly impacts our nutrition work: thin privilege.

My thin privilege became obvious to me four years ago when I went to the doctor about back problems. In early 2016, I wrote a blog reflecting on how different my healthcare experience was than that of many of my larger patients who go to their doctors about similar woes. Not only did I receive evidence-based medicine instead of a directive to lose weight, but some of my doctors even made assumptions (incorrect assumptions, at that) about my diet based on my size. That is thin privilege.

While I was already aware of some aspects of my privilege, the most powerful talk that I attended at the Multi-Service Eating Disorders Association (MEDA) national conference helped me to understand that my thin privilege includes elements I had never before considered. Caitlin Martin-Wagar, an eating disorder clinician and doctoral student in counseling psychology, gave a presentation in which she listed several examples of thin privilege, some of which you may not have previously considered either:

  • Chairs and airplane seats fit thin bodies.
  • Thin bodies are represented in all forms of media.
  • Thin people are never the punchline in sitcoms because of their body size.
  • When thin people go to the doctor, their health concerns are generally taken more seriously.
  • Thin people can buy dolls of similar build for their children.
  • Thinness connotes good morals and positive characteristics.
  • Thin people have an easier time shopping for clothing.
  • Thin people do not have to represent all people of their size.
  • In comparison to larger individuals, thin people receive less unsolicited health/dietary advice or veiled concerns about their health.
  • Employers pay thin people more.
  • Thin people face less scrutiny while eating in public.
  • As a thin person myself, I can write this blog without receiving accusations of being self-serving.

In order to escape weight stigma and in hopes of enjoying the same privileges as thin individuals, some people embark on weight loss endeavors that are most likely to make them heavier in the long run and worsen their health. If we are serious about wanting to help people improve their health, then we have to change our society so that people of all sizes enjoy the same privileges.

Ms. Martin-Wagar offered us professionals some tips regarding how we can combat weight bias within healthcare, but she also shared some ideas for how all of us can challenge thin privilege:

  • Read and learn about the relationship – and lack of relationship – between weight and health (which you can do on our Weight Loss FAQ page).
  • Consider the barriers and challenges of living with a larger body size.
  • Learn from larger-bodied friends about their experiences.
  • Do not make comments about people’s body sizes, shapes, or weight.
  • Be aware of weight bias veiled as concern.
  • Call out injustices as you witness them.

We do not live in a zero-sum game in which treating larger people better means treating thinner people worse. Rather, we can and must work to establish a society in which thin privilege is no privilege at all, just the same rights and respect enjoyed equally by people of all sizes.

 

She Said

This year’s MEDA conference had a number of interesting and informative talks given by experts in the field of eating disorders (ED). Throughout the day, I was heartened to see that the ED treatment community is starting to embrace the principles of Health at Every Size® (HAES) and Size Acceptance. But despite this positive movement, unfortunately what stood out to me this year was that we still have a long way to go in the ED treatment community when it comes to helping those in larger bodies who are suffering from an ED.  

Ragen Chastain, the author of the blog “Dances With Fat” and renowned speaker and advocate for HAES and Size Acceptance, was the keynote speaker on the second day of the conference. Her talk centered on the idea that given the culture that we live in (i.e., one that is fatphobic, diet-minded, and generally not welcoming to people in larger bodies), those who are living in larger bodies and struggling with ED can find it nearly impossible to fully recover as everything in our society tells them that being thin is the most important thing. Ragen’s talk hit the nail on the head, and it was interesting to see many of my colleagues in the audience nodding their heads in agreement with her points. At the end, Ragen received a well-earned standing ovation, and it seemed like everyone in the room was on the same page.

Well, not everyone, it seems. During the Q&A session after her talk, Ragen received a question from one of the ED practitioners in the room. This woman started out by saying that she agreed with everything Ragen had just spoken about, but she had an anecdotal experience that made her question some of Ragen’s points. She went on to explain that her “morbidly obese” brother had struggled with his weight for years, and it had gotten to such a dire point that a number of years ago he had gastric bypass surgery. As a result of this surgery, she contended, her brother’s weight went down and all of his troubling health conditions cleared up almost instantly. She went on to say that while she knows that some gastric bypass patients regain the weight due to “cheating” on their prescribed diets, there are those who maintain their losses and “good health.”

This woman’s sentiments went over like a lead balloon, and there were audible gasps from the audience. Ever the consummate professional, Ragen adeptly navigated this uncomfortable situation. She explained that while there are always some outliers who do well with stomach amputation, there are many more who suffer from complications from the surgery, such as lifelong issues with malabsorption, deficiencies, future surgeries to correct structural problems resulting from the original surgery, and even death. In fact, Ragen went on to say that fatphobia is at the root of the weight loss surgery industry because the medical professionals who advocate for these surgeries view fat people as less valuable; that it is better to risk a fat person’s life by having them get the surgery than letting them stay fat. In other words, the weight loss surgery industry is essentially telling fat people that their lives are not as valuable as those of thin individuals and that it is better to be thin and sick or even dead rather than fat.

While I would hope that this woman was the only one at the conference who held positive beliefs around weight loss surgery, I am not foolish enough to think so. Yes, the ED treatment community is getting better about not pathologizing certain body sizes and understanding that EDs can occur in people of all body sizes. But the fact still remains that we all live in this toxic diet culture that constantly tells us that fat is undesirable and unhealthy, that the pursuit of weight loss by any means is admirable, and that thin bodies are superior to fat bodies.  When you have been marinating in this culture for your whole life, it can be hard to realize your own bias around fat people. My hope is that Ragen’s talk changed some minds that day at the MEDA conference and made people think more about how their own fatphobia contributes to diet culture and undermines recovery for patients with ED.