My Fat Knee

Posted on by

About a month ago, I hyperextended my right knee while lying in bed. As a result of this (and a history of knee problems that I’ve had for the past decade or so), I had a very bad flare-up of osteoarthritis. I wish that I could say that I had injured myself doing something much more fun or exciting, but I guess when you are in your 40s, this stuff starts happening to you. Interestingly, aside from the initial sharp pain and chronic aching that ensued for several weeks, I noticed that I had some other feelings as well. The usual feelings of sadness and frustration were present of course, but there was something else too: panic.

When I tried to think about why I might be feeling panic in this situation, I had to wade through a lot of things: history, past trauma, hurt, and fear. Since I have always been in a fat body (although at times it has been straight size through restriction and overexercise), I have had a troubled relationship with medical professionals. Starting from a very young age, I became aware that my larger body was something problematic and to be feared. I have very early memories of feeling ashamed of my body whenever I would be weighed at the pediatrician’s office. I remember my pediatrician warning my mother about my weight percentile on my growth charts, and in turn she would turn her concern into “let’s fix this” mode, keeping an eye on my eating and monitoring my portions. I remember being weighed in my kindergarten class, and everyone’s weights were listed next to their names on the chalkboard, so everyone knew where they “ranked” in body size. I was the heaviest girl, of course.

As I got older, my fraught relationship with medical professionals continued. When I entered my late teens, I switched over from my childhood pediatrician to a family physician who was also a family friend. At one point, I believe he treated at least four of my five nuclear family members. And every year, I would dread going to see him as I knew that my weight would be brought up as an issue.  Of course, there were a few years when I had lost weight that I looked forward to going to the doctor as I knew that I would receive praise and encouragement to keep going (never mind that what I was doing to lose the weight could qualify as an eating disorder). But even occasional weight loss didn’t stop me from feeling anxiety when going to the doctor. Because I knew that my body was still “wrong.”

When I found Health at Every Size (HAES), I felt like I could finally breathe for the first time. At last, here was a paradigm that welcomed my body and encouraged me to take good care of it, no matter what size I was. I stopped my periods of dieting and worked on improving my relationship with food and my body. I found a physician who is weight-inclusive and treats me as a whole entity, not just my weight. I learned how to advocate for myself in medical situations when my weight would be brought up as an issue. I have helped countless patients navigate their own troubled waters of medical weight stigma. I have been in therapy for many years and continue to work on these issues as they arise.

But despite all of this work I have done and continue to do, most medical situations result in that pit-in-my-stomach feeling. I flash back to the decades where I was taught that my ailments or injuries were due to my weight and that feeling of shame and embarrassment that would wash over my face when a doctor would give me the “weight lecture.” All of those years of hearing that my fat body was to blame for almost anything negative occurring to it sunk in deep and etched into my brain. So whenever I have a medical situation, whether it is slightly elevated cholesterol in my lipid panel, a knee injury, or sleep issues, my knee-jerk reaction is to brace for the inevitable “weight lecture.” Never mind that I have found the unicorn of PCPs who not only understands and practices through a HAES lens, but also lives in a larger body herself which makes her even more empathetic. I know that my PCP’s office is a safe space and that my fat body will be treated with care and respect.

And even with all of this knowledge, the past trauma that I have received around my body in medical settings is still present. It makes me sad and also makes me incredibly angry. I think about all of my patients who have been through similar experiences with their healthcare providers. I think about the fact that I hold a lot of privilege (being small-medium fat, white, cis gender, heterosexual, able-bodied, financially stable, etc.) and that those who don’t hold those privileges are treated as less than at best and are downright abused at worst in these medical settings.

It is really enough to make me feel very cynical and jaded about the medical profession as a whole, and as a result, I am hesitant to seek out medical care. But despite this, I know that the only way things are going to change in our medical system is if enough of us stand up and refuse to be treated this way. The more patients that I can help to advocate for themselves in medical settings, the more doctors I can try to educate about the harms of weight stigma, and the more that I can speak up in moments of witnessed weight stigma (along with racism, homophobia, and a plethora of other abuses), the more I feel I can somehow make a difference, even if it is just for one person.

Credibility

Posted on by

The Academy of Nutrition and Dietetics (AND) recently issued a draft of their updated clinical practice guidelines regarding medical nutrition therapy interventions for what they term “adult overweight and obesity treatment.” The very last point in their draft recommendations reads, “For adults with overweight or obesity, it is suggested that RDNs [registered dietitian nutritionists] or international equivalents not use a Health at Every Size® or Non-Diet approach to improve BMI [body mass index] and other cardiometabolic outcomes or quality of life.”

As you can imagine, the Health at Every Size (HAES) community is pushing back against the AND’s draft recommendations. The Association for Size Diversity and Health (ASDAH) published an open letter to the AND as well as one to the HAES community outlining the ways in which the AND’s position is problematic.

(Before continuing, I want to highlight that the latter publication makes reference to white supremacy and how it factors into the picture, which I can imagine might trigger some head-scratching from those unfamiliar with the history of diet culture. If you want to learn more about this topic, consider checking out Fearing the Black Body – which, to be candid, I have not yet read myself, so I am calling attention to it based solely on its excellent reputation – or the first chapter of Anti-Diet.)

While I do not always agree with ASDAH and we do not speak for each other, I completely support the sentiments conveyed in their response letters. Similarly, I agree with Ragen Chastain’s response, which goes into more detail than ASDAH’s letters. Rather than reiterate their same points, I want to take a step back and look at one of the dynamics at play in this situation and in healthcare in general: credibility.

Back when I was in school for nutrition and looking ahead to my career, I wanted to become a universally respected expert, which is one of the reasons why I worked so hard in school. Then I began my dietetic internship and quickly began to sense that my expectations might be unrealistic. While all of my clinical preceptors placed a great deal of emphasis on note writing, or charting, each of them differed in how they wrote them, yet each felt strongly that their way was best and the others were wrong. One preceptor would praise me for utilizing a writing style for which another preceptor would chastise me. With my superiors giving me contradictory guidance, I felt confused and a bit paralyzed. There was no winning, no way in which I could make everybody happy, for what they each wanted from me was mutually exclusive.

Once I began practicing, the theme continued. Each time I changed how I practiced, some patients and colleagues applauded my shift while others thought I was making a mistake. Forget striving for universal respect, as there is no such thing. Credibility is subjective, and the truth is that every practitioner, no matter their approach, level of success, or reverence, is still seen by many as a quack.

This dynamic is not unique to dietetics; it shows up in other branches of healthcare as well. Reflecting upon issues I was having with my back in late 2013 and early 2014, I remember meeting with six surgeons – all of whom were highly regarded – and receiving five different opinions regarding what type of surgery I should have. One of them went so far as to say that if one of his interns had recommended the procedure that his colleague had suggested for me, he would have given the intern a failing mark.

Just as I had to weigh the pros and cons of the surgical options and choose the one I felt was the best for me, practitioners and patients also must decide which approach to healthcare is the one for them while understanding that large groups of people will always think their decision is wrong no matter what they choose.

When I first discovered HAES, I was skeptical since it contradicted much of what I had learned up to that point. Additionally, I did not want to believe it because it posed a threat to the weight-focused care I was providing at the time. On a deeper level, admitting HAES had validity also meant having to face the harm I had inadvertently done to my patients. Nobody who chooses a career in a helping profession wants to admit that they instead brought about hurt. Perhaps the folks at the AND – an organization that reinforces diet culture and weight stigma – are feeling similar resistance now, hence their criticism of HAES, or perhaps they are critical of HAES simply because it is not the approach that they choose to practice themselves.

“As long as you’re healthy . . .”

Posted on by

“Health.” It’s a simple one-syllable word with a deceptively simple definition: “the state of being free from illness or injury.” What I have come to realize over the decade-plus that I have been practicing nutrition therapy as a registered dietitian is that health means many different things to different people. Health is not black or white, but a million shades of gray. But the wellness industry (diet culture’s shapeshifted cousin) would have us believe that health is not only easy to define and simple to identify, but also easy to achieve, if we just try hard enough. Well, sorry, it’s not that simple.

When I was a preteen, I remember feeling like my body was wrong, too big, taking up too much space. My mother and I would go to my pediatrician appointments, where my doctor would hem and haw about my weight. I had always trended on the 95th percentile on growth charts, and every year my pediatrician would comment on it in a concerned way. My mom would echo these concerns at home, gently reminding me that my doctor was worried for my health. When I would cry to my mom about being in a larger body than my peers, she would always come back to this statement: “You are a beautiful girl. We could make some changes to how you eat and exercise. I just want you to be healthy.”

“I just want you to be healthy.” These words ring in my ears as they have been spoken to me in different iterations throughout my life. From concerned college friends after I had gained a significant amount of weight during my freshman year (post diet, of course): “We are just worried about your health.” From my first adult PCP when I was 22 years old: “We just want to make sure you are healthy.” From my mom when I announced that I would be going on a low-carb diet at age 25: “as long as you’re healthy!”

Everyone seemed to say that my health was the most important thing and that being healthy meant being in a “healthy-looking” body. When I actively engaged in dieting, restricting, tracking every morsel, weighing myself multiple times a day, exercising even when I didn’t feel like it or was sick or injured, eschewing lunch outings with friends, losing my period – during these times, everyone marveled at how “healthy” I was. “It’s so nice to see that you are finally taking care of yourself!” my family would crow. “Keep going, get healthy!” my doctor cheered. Little did they know the personal hell I was living in. But at least I “looked” healthy. Or at least my body fit the social norm for what we collectively believe is healthy, i.e., it was no longer considered fat. But inevitably as the weight would come back on, the concerns for my health would resurface.

When I finally gave up on dieting and learned about Health at Every Size® and intuitive eating, I was ready to hear the message. At last, I didn’t need to micromanage my intake and output. I didn’t need to obsessively count and weigh and measure. I didn’t have to give lunch outings with friends a second thought. It was like a freedom I hadn’t felt since I was a child, before I was told that I had a body that was “wrong.” I began to realize that health is not one-size-fits-all and that it looks different for different people. With individuals who have chronic illnesses such as celiac disease or cystic fibrosis or those with physical disabilities such as paralysis or amputation, they would never be able to achieve a state of being “free from illness or injury.” How about the millions of people who deal with depression or anxiety? Are they unable to achieve health as well?

I feel that we need to change our beliefs and expectations around health. In my opinion, health is a multifaceted amorphous concept that is not always attainable. It is also something that changes during our lifespan for a multitude of reasons. Even if we engage in all of the “health-promoting behaviors” we have been told to do, there is no guarantee that we will be healthy. In addition, there is no moral requirement for us to engage in these behaviors. As the wise Ragen Chastain so eloquently states: “Health is not an obligation, a barometer of worthiness, completely within our control, or guaranteed.”

The wellness industry loves to prey on our fears of illness and death. It purports to give us the answers to living longer, healthier lives. All we need to do is buy their program, supplement, or detox, and we can unlock the secret to immortality. It’s a brilliant marketing scheme that swindles millions upon millions of people every year. What if we decided to care more about our mental health and wellbeing? What if we made healthcare accessible to everyone? What if we eradicated weight stigma from the medical field? What if we decided that health doesn’t look the same on every body and that this is okay? My guess is the wellness industry would lose billions of dollars. Worrying about and obsessing over our “health” is most definitely not good for us. I wonder when our society will figure this out.

Weight Stigma in Healthcare Harms Us All

Posted on by

The following is a guest blog written by Deirdre, who has given us permission to use her real name.

All my life, I’ve been sick. I can remember being five years old and waking up in the morning sobbing because my eyes were swollen shut, I could not breathe, I was always tired, and had severe skin conditions and rashes all the time. I had to go on nasal sprays, steroids, oral allergy medicines, and eye drops almost year-round from that age. Around the age of 14, I started to present with vomiting up bile every single solitary morning before proceeding with my day. Despite complaining to doctors all my life about all these things, I was ALWAYS considered healthy. The number one indicator for doctors? I was thin. I always had a “healthy” BMI, and all my bloodwork looked good, so nobody ever took me seriously.

Fast forward another decade. At this point, my body was so inflamed from consuming gluten – a protein which I later found out I was severely allergic to all along – that I had gained a significant amount of weight. I was 24 years old at this point, vomiting and having diarrhea after every single meal, suffering with mental illness (depression and anxiety, some from trauma but also largely because I *never* felt well and had no choice but to press on), smoking cigarettes constantly to suppress my appetite, abusing Adderall to suppress my appetite, exercising excessively (3-5 mile runs, 10 on weekends, and 2-hour workouts daily). Doctors still would not listen to me.

When I was thin, my health complaints were ignored because I was thin. When I was big, my health complaints were ignored because I was big. This is how weight stigma harms people of all sizes. When doctors are trained to view the BMI as such a strong indicator of our health, they tend to miss out on treating the whole patient and the concerns they are actually presenting. In this way, fatphobia continues to dominate our medical fields in the most insidious ways, regardless of a patient’s size.

When I was younger, I felt like my only sustainable solution was to put restrictions on my eating. I felt like I needed to do everything in my power to just not really eat. The only thing that ever felt good to me was mint chocolate chip ice cream. It was the one food that never made me sick. I ate a pint of it nightly, then would feel guilty, throw up the next morning involuntarily, feel good about that because I was disordered in my eating habits by then, and the cycle of “weight management” continued to wreak havoc on my life and destroy my gut health, self-esteem, and brain chemistry.

At 25, I was accepted to my dream graduate school for my health degree, and thus I was always in Boston. This meant finally seeking out primary care at Fenway Health and getting a fat-positive, conscious, and compassionate doctor for the first time in my life. Dr. Karen Kelly literally saved my life, as I know I would have attempted suicide that year if I had not met her. I was at my wit’s end.

Karen’s team allowed me to face away from the scale when they took my weight. I told Karen all the symptoms I’ve always had. She referred me to an incredible gastroenterologist who finally listened to me and tested me for a bunch of autoimmune gastroenterological diseases.

Notice that only now, because I finally was seeing a fat-positive doctor, was my weight looked past in order for me to receive the care I truly needed. My current health care team, including Karen, is amazing. It is a shame that all the doctors I ever saw prior assumed that being thin meant I was healthy. That mentality destroys a doctor’s ability to see clearly, and my chronic autoimmune disease was completely missed for 25 years as a result. If my celiac disease had been caught sooner, it could have meant avoiding severe damage to my organs, and possibly even reduced my chances of long-term health implications. Now I have to live with whatever damage has been done.

More and more public health research is finally showing that fat people can be healthier than thin people. More and more people are catching on that the BMI as a marker of health is a limited, archaic, outdated, weak, inaccurate, and frankly incredibly lazy way to approach medicine. It is a way for doctors to not do their jobs. All doctors should first and foremost be researchers and scientists listening, looking, and hypothesizing with open minds. I am almost the heaviest I have ever been now, yet my cholesterol, blood pressure, oxygen, etc., are all fantastic.

The concept of weight management is a barbaric and inhumane way for any doctor to practice. One hundred years from now, we will look back at the ways we tried to force mutilation on humans through diets and bariatric surgeries and see the oppressive reality of that kind of hatred of fatness. Doctors that focus on “weight management” and miss what is really going on need to start being held accountable – sued and fired by their patients.

I think that numbers are detrimental, and so is excessive monitoring of size and shape. We came here to live in these sacks of skin as vessels for our non-physical selves, our souls, and nothing more. The BMI is bullshit and was invented by an astronomer in the 1800s who only used white Anglo-Saxon males in his sample size. BMI does not account for muscle mass, bone density, or genetics. It does not leave room for all the boobs and butts and hips our bodies create to cushion us or to grow or feed our babies.

Someday I will have chapters in a book titled “the BMI is racist,” and “the BMI is sexist.” Once I am a doctor or nurse practitioner, I will create a new tool for epidemiologists to test that will actually be inclusive of all sexes, genders, races, etc., without poisoning our minds with self-doubt and self-mutilation.

If I had unbiased doctors all my life, I may have been diagnosed with celiac disease much earlier on and could have potentially saved myself from having cancer or infertility someday. I hope to live a long life and to have children and grandchildren, and I hope to leave them in a world with less weight stigma and more active listening, especially in the field of medicine.

Coming Out

Posted on by

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

Posted on by

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.

The Natural Purple Pill?

Posted on by

At this year’s Cardiometabolic Health Congress, a cardiologist I will call “Dr. Q” began his nutrition presentation with a factoid: 90% of cardiologists reported zero or minimal nutrition education, yet 95% of them felt it was their personal responsibility to discuss it. Meanwhile, 61% of the public thinks that doctors are “very credible” sources of nutrition information.

In other words, we have doctors who do not know what they are talking about talking about it anyway, and patients are listening and trusting them because they are doctors.

He called blueberries “the natural purple pill” and cited research showing that 93,600 women who were studied over 18 years and who consumed three servings of blueberries per week throughout the study had a 34% reduced risk of a myocardial infarction. He then flashed a slide listing the dozens of known chemical compounds in blueberries, asked how we know which nutrient or combination of nutrients is responsible for the benefits, and answered his own question with, “I don’t think any of that really matters,” intimating that the bottom line is that blueberries offer health benefits.

But the underlying mechanism absolutely does matter. He assumed a causal relationship between at least one of the chemical compounds and reduced risk of heart attack, but the relationship between blueberry intake and heart attack risk could also be correlation. For example, the real factor at play might not be some minute compound, but rather money.

Relative to other fruits, blueberries are incredibly expensive. According to data I obtained from Peapod.com, blueberries cost $0.44-$0.64/oz. (depending on the size of the container purchased), which exceeds apples, grapes, melons, strawberries, and all other fruits I examined except for pomegranate seeds ($0.63/oz.) and raspberries ($0.56/oz.)

Could it be that the women in the study who could afford to eat blueberries three times a week also had other financial advantages that enabled them to take better care of themselves, such as the ability to absorb higher insurance costs for office visits and testing, health club memberships, time off from work or no work at all, massages, and psychotherapy?

On the flip side, you know who is probably not splurging on blueberries or able to engage so extensively in taking care of their health? Those working multiple jobs just to get by, those living paycheck to paycheck, those suffering from food scarcity, those relying upon the Thrifty Food Plan, and those who need to make $3.33 stretch enough to buy multiple items to feed their entire family instead of blowing it on a small container of “purple pills.”

“Whether measured by income, formal education, or job status, there is a socioeconomic gradient to health,” Bacon and Aphramor write in Body Respect. “And the greater the inequality in society, the steeper the gradient. The United States has the greatest inequality of all wealthy nations – and the greatest health disparities.”

This is what I was getting at last year when I wrote about nutrition and politics. We talk about the concept of intersectionality and how various layers of oppression aggregate. The further one’s identity lies from that of the pinnacle of privilege – a thin, white, heterosexual, educated, wealthy, American-born, Christian male – the more the individual is subject to oppression.

It might not just be that one’s economic situation makes regularly consuming blueberries unrealistic and limits their access to health care, but that in addition to fretting about cash flow, that person might also have to worry about suffering a hate crime or having their rights stripped away. Even if someone does not fall victim to such misfortune, remember that stress itself is associated with cardiovascular disease, so the very threat itself is problematic.

Assuming that the reduced risk of heart attack was due to a few weekly handfuls of berries without considering the greater context is ridiculous and exemplifies the problems inherent in viewing nutrition solely as a hard science. Anybody who has extensively studied the field should know to consider social, cultural, and other factors, which makes me wonder: When Dr. Q told us that 90% of cardiologists reported zero or minimal nutrition education and yet 95% of them felt it was their personal responsibility to discuss it, was he describing himself?

Dietetics Within the Health at Every Size (HAES) Framework

Posted on by

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.

“Just tell me what to eat”

Posted on by

We have no idea what we are doing. As new and first-time parents, Joanne and I are overwhelmed with questions that outnumber our answers. Last weekend, we went out to dinner, just the two of us, and we commiserated regarding our uncertainties, unsolved dilemmas, and seemingly unpredictable behavior and sleep patterns.

“Someone can surely help us with this,” I said, referring to professional help. An expert with advanced education and certifications must exist who has all of the answers, someone who can take control, simplify the picture, and teach us the right way to parent. I paused, realizing the significance of what I was about to say next, and then continued, “I just want someone to tell me what to eat.”

One of my favorite nutrition authors, Alan Levinovitz, is actually a professor of religion, but he has taken to writing about food and eating behavior because he recognizes how themes of spirituality, including fear and a longing for control, are incorporated into how many of us relate to food.

“It’s terrifying to live in a place where the causes of diseases like Alzheimer’s, autism, or ADHD, or the causes of weight gain, are mysterious,” Professor Levinovitz says. “So what we do is come up with certain causes for the things that we fear. If we’re trying to avoid things that we fear, why would we invent a world full of toxins that don’t really exist? Again, it’s about control. After all, if there are things that we’re scared of, then at least we know what to avoid. If there is a sacred diet, and if there are foods that are really taboo, yeah, it’s scary, but it’s also empowering, because we can readily identify culinary good and evil, and then we have a path that we can follow that’s salvific.”

And who can blame someone for wanting black and white food rules, a clear and crisp portion prescription, and a list of what to eat and foods to avoid? When we feel desperate and overwhelmed, we just want someone to come along who says they have the answer, the simple solution to our complex problems, and they will tell us what to do. Is that not exactly how I was feeling in the restaurant?

Similarly, who would possibly want to hear that no singular right answer exists, that what constitutes “right” is debatable, and that the situation is complex with several moving parts, some of which are not fully understood or within our power to manipulate? Who wants to be told that no set of rules or rigid structure is likely to produce long-term success, that even the most seasoned experts have gaps in their knowledge and experience? Don’t talk to me about guidelines and trial and error; my daughter is crying, and I need the answer now.

The good news, both for us and for the patients who come into my office, lean back in their chairs, cross their arms, and command, “Just tell me what to eat,” is that help and support are available, even if they are not the sharp and definitive solutions for which we pine. Joanne and I are privileged to have a pediatrician, experienced family members, and other infancy professionals who are all just a text away. While they do not have all of the answers either, we can collaborate and walk the road together.

Similarly, because of nutrition’s complexities, Joanne and I cannot just tell someone what to eat, but we are able to work with our patients to examine the factors that are influencing their eating and then formulate strategies for improvement. Other practitioners can similarly lend a hand. Therapists, for example, can be tremendously helpful for deeper issues that are getting played out through eating behaviors. Answers may be neither immediate or obvious, but together we can figure out a way to move forward.

He Said, She Said: MEDA Conference Takeaways

Posted on by

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.