Sunday, October 23, 2011

Healthy At Every Size?

Read first, then decide.

Today I saw a 12 yr old girl, I’ll call Gabrielle, whose weight was off the charts. She was referred by her doctor, supported by her concerned parents. And here's what I told her, because I believe it to be true.

Her place on the weight chart is likely the right place—for her. Since the age of 2 yrs she has paralleled this curve at just above the 95th percentile, (in spite of being only 5 ft tall, much shorter than average), resulting in a very high BMI. She is an active, healthy girl—more active than most thin girls and boys I see, with no apparent suggestion of health issues. She eats well—appropriate portions, as I'd expect for her need, a healthy balance of foods, including those I'd call "junk" food, and she eats the same when she is alone and when with others. In other words, she’s got a healthy relationship with food. Most importantly, she feels good about herself, and the last thing I wanted to do was add mental health issues to any perceived, but non-existent risk of physical health issues.

Gabrielle is one of several patients I’ve seen recently, fitting this description. Some individuals are larger than average size, some smaller, kids and adults, males and females. And we should not assume that’s a problem, as several bloggers are sharp to point out. Health At Every Size, The Fat Nutritionist and others enlighten those who don’t know better, who don’t ever question their assumptions, that large people can be healthy, fit, and in fact happy.

End of story? 

Not quite. The key word is can be. While we cannot and should not assume that an individual’s weight is causing them medical or emotional problems, there are overweight individuals who are not healthy or comfortable at their size, for whom weight loss may help. I question the belief that striving to lose weight, in all cases, is bad. And I am not talking fad diets, mind you.

I am not simply projecting here. I speak on behalf of the patients I have seen over my 25 years of practice. Just as we cannot assume that they’re distressed at their current weight, we cannot assume they are very comfortable or healthy at their state of health and size either.

There are kids, and adults, like Gabrielle described above—always large, but healthy and fit. Many are self-accepting, many self-loathing, perhaps due to society’s discrimination and learned messages they need to unlearn. And I do my best in my sessions to convey this very message, that they are just fine as they are—their eating, their activity and their weight. I am not addressing these “Gabrielles” in the remainder of this post.

Rather, I am speaking about those for whom obesity, or the degree of obesity they are living with, is not their norm, the men and women who have gained weight outside of their comfortable and usual weight range. This includes individuals struggling with compulsive overeating, as well as those without any emotional baggage. It applies to those who no longer take time to meet their needs for exercise, or who might have suffered an injury, which forced a decrease in activity, without adjusting their food intake. I’m describing those who don’t know how to prepare a healthy meal as well as those who eat many meals out, juggling the modern life of working and parenting, soccer practices and carpooling. And those who minimally eat throughout the day, only to eat excessively at the end of the day.

I am not judging them, merely conveying what I hear from them day in and day out. They put off travel because airplane seats feel too tight, and European cars fail to accommodate their size. They want to be off the medications they now take daily, for hypertension, high cholesterol and joint pain. They want to be free of their sleep apnea and their heartburn. 

Sure, there are plenty of normal weight people, thin even, who also develop such conditions (count me in—thin with high blood pressure). But as a population, increased weight increases the odds of developing such conditions. The damage to their knees may be already done, but it is easier to move a body with a lower mass versus carrying surplus weight, particularly when you’ve got pain.

I’m not picking on the obese. If you read any of my posts you’d clearly see my philosophy. Similarly, I do not believe there can be health at every size at the low end of the spectrum. While not all slim individuals have eating disorders, (some are naturally thin, always were and always will be) I can tell you that a low body weight that contributes to loss of menstrual periods, low body temperature, a very low pulse, distorted thoughts and preoccupation with food similarly would benefit from a change in weight. 

And if you think these individuals are immune to society’s judgment, think again. There is equally little sensitivity to those struggling with weight issues on this side of the spectrum. Yes, sometimes the very people who preach size acceptance are all too quick to dismiss, insult and disregard the opinions and insights of someone who is thin, simply because they are thin.

A rabbi friend once said jokingly “Anyone who is more religious than me, is a fanatic. Anyone less religious, a heretic.” Sometimes that’s how I think we all behave around the issue of weight. It’s fine if you are my size, but thinner or fatter we accuse of needing to change and have a difficult time accepting.

Ultimately, the primary focus should not be on losing weight. Yes, even for those who truly care to lose weight, for whom a high BMI was not the norm. Rather, they need to address their behaviors and experience tangible benefits—a sense of accomplishment, having set a realistic goal and achieved it; better sleep; better endurance; better concentration; less irritability by honoring their body’s need for fuel; and a better relationship with food. As these changes occur, weight loss also follows.         
Where do you fit in all of this?

Does your activity need to be addressed? Are you even at a healthy enough place to be exercising? What modest goal can you set that you’ll be able to achieve?

Do you allow yourself to eat when you need to? Or do you push this to the limits, thinking you are too fat to be eating? Everyone, 
regardless of her size, needs and deserves to eat throughout the day.

Do you give yourself permission to eat foods you enjoy? Do you even remember what those foods are? Or are you so stuck following everyone else’s rules (including your own), absorbed from years of dieting and denying yourself?

Yes, allow yourself to eat whatever you’d like—no single food makes a person fat. And have it when your body needs it—when you are hungry, any time you are hungry. But learn to have just as much as you need (do read through the many older posts that address this topic).

In fairness, the palpable anger I feel from those who blog about fat acceptance is understandable. They have been mistreated by our society, including those that should know better, such as the medical community. They include those, like Gabrielle, for whom weight loss may be inappropriate. They are repeatedly told to change, when change is truly not necessary.

But let’s not over generalize. There are also those overweight individuals who would like nothing more than to be accepted for who they are but have medical conditions that may be assisted with weight loss. And they deserve to be supported on their journey to a healthier place.


  1. If that's what you get from the FA movement, I'm not sure you're reading them correctly. HAES *is* about moving around, not being afraid to exercise and take care of yourself, despite people who (ironically enough) both criticize heavy people for being heavy, then mock them when they go outside and try to engage in activity that is reserved for thinner folks. I think you will find most FA bloggers encourage their readers to be active within the limits that their health and conditions (if they have medical conditions) allow them to be. The anger comes from the assumption that if you are larger, of course it is because you never do anything active at all.

  2. Lori, I like your post and that you try to cover a range of viewpoints.

    Clearly, both you and the HAES movement agree on the basic points: that one should love one's body for what it is and can do and nurture oneself through healthy habits. Where you disagree is not on content but on the lens through which you view this content.

    In your post it seems that you categorize people as: large BUT healthy (the 'Gabrielles'), large AND unhealthy, thin AND healthy, and thin BUT unhealthy. Your focus is still on the body size part of the label. What I believe Health at Every Size is trying to point out is that body size is not part of the focus at all. Health has nothing to do with body size; health has everything to do with healthy habits.

    You say that "as a population, increased weight increases the odds of developing such conditions." But that does not mean that weight is a sufficient or even component *cause* of poor health. If a person increases his/her healthy habits, happens to also lose weight, and sees a positive change in his/her health, what caused it? Can we truly say it was weight loss, or was it, in fact, healthy habits?

    Wouldn't it make more sense to say healthy habits (as well as other social and genetic factors that are not under discussion right now) are behind health? Wouldn't this explain why there are people of every size who experience good health, and people of every size who experience poor health?

  3. In practical terms, most of the fat acceptance advocates I've heard from differ from you in two aspects.

    First, they completely reject using guilt and obligation to pressure people into being healthy, instead relying on freedom and the inherent desirability of health. That makes more sense to me, because I like feeling healthy and when I focus on what I imagine owing other people instead of what makes me feel good, I make worse choices.

    Second, they think that people who want help with issues such as controlling compulsive overeating, needing to relearn how to exercise after an injury, finding ways to plan their day so they can enjoy whole foods, learning how to follow hunger cues (instead of veering between being painfully hungry and painfully overstuffed), should get that help without having weight loss as a specific goal. The reasoning behind that is that the health benefits of increased strength and stamina and better nutrition can accumulate without weight loss, and in the long run, attempts at long-term weight loss almost always fail. This makes sense to me, because all of my attempts at dieting have failed (including plenty of attempts that would undoubtedly meet your standard of moderate and sensible dieting), and when I try to get a workout routine going without worrying about weight loss, I stick to it longer and become healthier.

  4. Lori, Good post, but I have to also agree with the commenters above.

    For me, the bottom line is health (if that's what you want, of course). The fact is, 95% of us aren't going to reach and maintain that elusive, so-called "correct" weight, no matter how hard we try. Not to mention the fact that most of the strategies designed to make fat people slimmer are more often than not unhealthy, either psychologically or physically--and often both.

    So why are we still trying to help people get healthier by prescribing weight loss, when it's almost impossible, may not even be all that helpful and is quite possibly deleterious to their health? Learning mindful eating, understanding and overcoming disordered eating, and engaging in physical activity to the best of one's abilities--these are all laudable, doable things that we know improve health. Why not start with these strategies and see where they take us? Probably on the road to much better health.

    I am convinced that we are actually on the same wavelength. I seriously doubt that you ever counsel people to just "go on a diet". I'm sure you suggest dietary modifications to help control diabetes, for instance, or therapy to deal with eating disorders but do you really use weight loss on its own as a way to improve health?

  5. Nowhere in this post, or anywhere in my blog, do I encourage weight loss just because of an absolute number--please reread this post if you think otherwise, starting with the first paragraph case study!

    I respectfully disagree about the problems with losing weight--if you are not in the "Gabrielle" category. For instance, for someone who has been gaining weight who previously and healthily maintained their weight, the weight gain is a potential marker to be addressed. Sure, rule out organic causes (hypothyroidism and other endocrine issues) first. But gaining from your normal place is a flag for behaviors that may need to be modified, both to feel well and to maintain one's physical health.

  6. Of course I know that you don't suggest weight loss for weight loss's sake! That's why I said "I seriously doubt...". I also said that I think we are on the same wavelength. Clearly, it's very easy to be misunderstood on the Internet.

    As for your example of someone who suddenly gains weight, this is obviously a situation that requires attention. I have actually been in exactly the opposite situation: I suddenly started losing weight with absolutely no effort (I only lose weight if I am constantly hungry) and I knew right away that something was very wrong. I was diagnosed as hyperthryroid, went on medication and went straight back up to my "normal" weight. My weight is so stable (within a 5 pound range) that now, when I drop below this range for any reason, I actually get frightened that something is wrong with me.

    Clearly, weight loss or gain can sometimes be the symptom of a physical or psychological problem. When the underlying problem is dealt with, a change in weight may result. The attitude I have trouble with is the one that attributes all problems to excess weight. I'm sure we agree that our society's habit of blaming every problem on weight is not making anyone healthier.

    Nothing I have read of yours leads me to believe in any way, shape or form that you belong to the diet world. Unfortunately, this is the Internet, where misunderstandings abound. I hope this response clears things up a bit.