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Immanuel Can —

August 16, 2010
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Today I will be discussing the issue of whether having making unhealthy choices is “immoral,” which may make some people uncomfortable to read. I am not attempting to shame anyone, especially since I would be included in the shamed group. I’m trying to explore a concept often embraced, but rarely discussed, in Fat Acceptance.

Ya know how our parents tell us when we’re little that we can be anything if we just put our minds to it? As adults, we know it’s a lie. There is no end to the vocations I would never be qualified for, regardless of a single-hearted pursuit.

My genetic endowment and environmental upbringing pretty much prevent me from joining any sort of professional sport short of curling.

But that doesn’t stop me from playing on the company softball team and thinking I’m the Mark McGuire to Mutual of Omaha’s Sammy Sosa in Accounting.

Or, to quote the ever excellent Avett Brothers, “Ain’t it like most people, I’m not different/We love to talk on things we don’t know about.”

And that’s what I’m going to attempt today… a philosophical dissection of an oft-used phrase in Fat Acceptance: health is not a moral imperative. For the sake of simplicity, I’ll refer to this as the Mantra.

I’m not sure why I’ve been thinking about this lately, but I have used it before myself to deflect criticism of people who have an unhealthy lifestyle which can lead to weight gain: eating too much and not exercising.

I’ve always interpreted the Mantra to mean that nobody is under any moral obligation to engage in healthful practices or abstain from unhealthful practices. I believe this is true in the same way that nobody is under any moral obligation to wear seatbelts in cars or helmets in motorcycles or be compliant with their meds.

Is it it a good idea to wear seatbelts or helmet, or be compliant with your meds? Sure. But are you acting immorally if you don’t? I don’t think so.

But then I started to think about it some more.

Maybe there are circumstances under which it would be immoral to intentionally endanger your life. The strongest case to be made is for parents. As a parent, my moral obligation extends to my family, and so when I choose to act in a way that increases then health risks in my life, then my decision is no longer an act with isolated consequences.

I have often used the example of a job I had working with mentally retarded/developmentally disabled adults in order to illustrate a point regarding the judgments of others against fat people. I worked for a company that helped MRDD adults start their own businesses if they were too high functioning for sheltered workshops (basically, assembly lines for easy-to-assemble products), but not yet ready for competitive employment (McDonalds).

The businesses they began were small, simple ones, like recycling cans or toner cartridges, or supplying simple vending machines in office buildings. The man I worked with, Jim (name changed obviously), wanted to start a greeting card company, and it was my job to help him.

Jim was in his early 40s and had a traumatic brain injury (TBI) that severely impaired his ability to move and communicate. He used an electric wheelchair, as he was paralyzed from the waist down, and from the waist up had minimal motor control. He could not speak, but instead used a computer that had both preprogrammed buttons (for eat, drink, sleep) and a QWERTY keyboard.

Jim was responsible for his TBI because when he was 21 he went out with his friends and while drinking and driving had a horrible crash that forever altered his life. It also forever altered the life of his newborn daughter, who would only know her father as a man confined to a wheelchair and a keyboard by is own irresponsible actions.

Is drinking and driving immoral? Yes. Does the immorality of drinking and driving increase with the added knowledge of a child at home? I believe so, yes.

Yet, I myself have received a DWI when I was young and foolish and a single father. When I did not have custody of my son, I was the typical 23-year-old running around, getting drunk and, in several instances, getting behind the wheel. I received my first, and only, DWI when I thought my friends had abandoned me at a club and, living about an hour away, figured (in my inebriated state) that my only option was to drive home.

I was pulled over swerving down the highway doing 105.

Even without the obvious endangerment to others, if I had magically only been risking my own life, I believe this would still be an immoral act, both in endangering my own life and risking a future for my son that could have easily been swapped with Jim’s.

I no longer drink (unless there’s a wedding with an open bar, then V and I flip for DD status) because I recognized that my behavior was out of control. I now engage in safer, slightly more responsible recreational activities that do not pose the same grave threat to my life, my family’s life or to strangers around me.

Now, I know some people may be cringing between the drunk driving/unhealthy lifestyle analogy, but I believe I am consistent in my Fat Acceptance views: it is lifestyle, not weight, that determines health.

I believe that being fat is not a health risk, but I do believe that if you rarely eat fruits and vegetables (as I have spent MUCH of my life guilty of) and avoid exercise (as I have spent MUCH of my life doing), then you increase your risk for all those metabolic diseases that are typically ascribed to weight alone.

I believe that engaging in unhealthy behavior — in the absence of a legitimate reason for engaging in that behavior — is self-destructive and that self-destructive behavior can be immoral (again, depending on the circumstances).

For example, if you are impoverished and in order to make ends meet, you have to purchase cheap, highly processed, unhealthy foods in order to meet your basic caloric requirements for survival, then this unhealthy behavior is not immoral, since your choices are limited by your economic circumstance.

If you can’t exercise because some physical condition makes it painful or uncomfortable to do so, then this unhealthy behavior is not immoral, since your choices are limited by your physical circumstance.

While researching this subject, I came across Immanuel Kant’s description of the categorical imperative, which is based on three formulations:

  • Act only according to that maxim whereby you can at the same time will that it should become a universal law without contradiction.
  • Act in such a way that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end.
  • Therefore, every rational being must so act as if he were through his maxim always a legislating member in the universal kingdom of ends.

An example given by Kant is that lying under any circumstance would be forbidden since if lying became universally acceptable, then it would be no longer possible to believe anyone and language would be rendered useless.

Benjamin Constant challenged Kant’s construct by explaining that under these laws, a circumstance which could arise where a murdered asks you where to find his next victim and by not lying, you essentially condemn the victim.

Constant basically draws a clear distinction between a moral imperative and a hypothetical imperative. While a moral imperative is universal and unbending, a hypothetical imperative depends upon the circumstances.

Which brings us back to health.

Health is not a moral imperative, but it is a hypothetical imperative. If you have the means and ability to choose health, but do not choose it, then your self-destructive behavior may be labeled immoral.

But here’s the kicker: the only person who can label your behavior as immoral is yourself.

Nobody else knows the truth of the circumstances surrounding your health choices. They can infer certain things, but even if you explain all of the financial, physical, emotional, psychological reasons for making the choices you do, they will still have a vastly incomplete picture compared to your own knowledge of the situation.

And so, whether health is a moral imperative or a hypothetical imperative is a moot point entirely.

The fact is that my morality is none of your business.

The ultimate list of moral imperatives, especially in the Judeo-Christian culture of the United States, is the Ten Commandments. Among those commandments is the one forbidding adultery (but not fornication, oddly enough). Jesus takes it a step further and says that not only is adultery forbidden, but so is lust.

Therefore if lust and adultery are on in the same, then abstaining from lust is a moral imperative (and as far as I know, there aren’t any hypothetical circumstances under which adultery or lust can be justified). And if society wants to begin passing judgment on our success or failure at adhering to moral imperatives, then those who choose unhealthy lifestyles will have no trouble turning the tables.

And finally, health choices cannot be gleaned simply from the size and shape of a person. We all know thin people who do nothing but eat crap and play video games. The current environment encourages society to assume that all fat people are making unhealthy choices and that all thin people do not. So the moral imperative, even if justifiably applied, is not fairly applied across the board.

The same attention to the morality of strangers is not directed at thin people, only the fat. Therefore, attempting to ascribe moral value to a person based on their health choices, which is in turn based on their body size and shape, is would be akin to ascribing moral value to a person based on whether they steal cars, which is in turn based on their race or skin color.

In conclusion, it seems to me that saying “Health is not a moral imperative” is an oversimplification of the concepts underlying it. It would be more accurate (but probably less effective) to say “Health is a hypothetical imperative, which is none of your damned business.”

UPDATE

Read my response to all the comments here [not the link I use in the comments].

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49 Comments leave one →
  1. dufmanno permalink
    August 16, 2010 10:40 am

    Agreed. There are always going to be personality types who enjoy a good crusade though. They like to start conversations with the question “you know what your problem is?”

    • August 16, 2010 2:45 pm

      dufmanno,
      And I find that, usually, those people have zero problems of their own to work on. 😉

      Peace,
      Shannon

  2. Patricia permalink
    August 16, 2010 1:39 pm

    Interesting concepts. Very compelling read Atchka, love how you’re constantly pushing the envelope in FA. Thanks a bunch from this fearless fatty.

    • August 16, 2010 2:54 pm

      Thanks Patricia, I appreciate it. And welcome.

      I don’t think of it as pushing the envelope so much as not taking our beliefs for granted. I’ve seen the phrase used so much, but I hadn’t given it much thought until over the weekend. I think morality is pretty sticky territory and it is more important to point out that my morality is my business than it is to point out whether my actions are or aren’t immoral.

      Peace,
      Shannon

  3. August 16, 2010 2:13 pm

    I like your line, but it just doesn’t have the same ring as “Health is not a moral imperative”.

    I agree with your basic premise, but I do not think bringing Immanuel Kant into the discussion with most health trolls is going to have an impact. By saying that health is not a moral imperative, you can cut off all the “your body is a temple” arguments by clearly stating that you are not buying that particular temple.

    • August 16, 2010 2:56 pm

      You’re right and I think that the line itself is useful in shutting down moralistic arguments for sure. If the person is intelligent enough, they will push the premise and then you can rely on a deeper discussion of moral values, rather than a simplistic mantra.

      And, if all else fails, you can make them watch this.

      Peace,
      Shannon

  4. CollieMom01 permalink
    August 16, 2010 3:13 pm

    I’ve been sitting with this article all day long, and I am still unsure how to respond. While I agree, in theory, that any behavior may be considered immoral to some, I disagree with your hypothesis that morality is decided on an individual basis; i.e., “my morality is none of your business”, and I guess I disagree with this because as a society, we may all decide individually what we think is moral or immoral, but as with most democratic societies, the majority ultimately rules. So I guess there are two different types of morality–personal morality and societal morality, and they may not always be in complete agreement. Viewing fatness as a moral failing allows those with this opinion to feel just a little bit superior–as is important when assessing judgement to the failings of others. I mean, if you’re not going to get anything out of calling others immoral, than what’s the point? But I do not feel my fatness is immoral. And I wouldn’t think so even if I never ate another green bean or did a squat thrust or moved my fatness off my comfy couch. Am I somehow more worthy and less immoral because I choose to exercise a few times a week, or eat a salad once in awhile? Do we now begin the journey onto the slippery slope of judging what’s a “good fattie” and a “bad fattie”? If I had children, would my bad behavior be considered immoral strictly due to the fact that I am a parent?? If I don’t have children but engage in sketchy behavior that doesn’t hurt anyone else, is that considered immoral? I think I disagree with the idea that driving while drunk is somehow more immoral if I have children than if I don’t. I mean, if someone is injured or killed due to my negligence, even though I had no intent, is that immoral? How is it more immoral if I kill someone AND I have children than if I am a single person with an alcohol problem who’s taken an innocent life? I think that might be where personal immorality and societal immorality meet. Don’t get me wrong; I totally agree that being a parent requires more responsibility than any other “job” on the planet, and every decision one makes should be well thought out and weighed against what this behavior may mean to the future of my loved ones. Real life rarely allows such introspection, however. And deeming something or someone immoral is a pretty heavy (no pun intended) judgement. I don’t consider my parents immoral because they both smoked, and thus, probably shortened their lives–they may have shortened the lives of myself and my siblings as well, as I lived with second hand smoke for 20 years. So what is morality, anyway?? Lots to think about with this essay, and again, I feel like I’m grasping at words trying to respond to this very interesting and multi-layered piece. Thanks for making me think–I’m still not sure I’m finished, but if I think of more to add, I’ll be back. 😀

  5. August 16, 2010 5:00 pm

    atchka –

    I love it when people get thoughtful and introspective, so of course I enjoyed this post on many levels.

    You caught onto something that I hadn’t noticed in the use of the phrase “health is not a moral imperative.” But I recognize the sentiment.

    I tend to focus more on bodily autonomy…the idea that if someone insists on believing that health or weight is a choice, then it’s my choice to make.

    As a disabled person, when I hear people railing about how us fatties should take “personal responsibility” and “not be a burden”…all I think about how silly and short sighted those people are being.

    Humans are mortal creatures. We are ALL eventually going to get old and then get sick. At best the act of taking on “healthy behaviors” will stop us from becoming unhealthy in the short run.

    And, yes, it’s very fatalistic to look at things that way, but being chronically ill means I’ve had to face up to my mortality. It is MY RIGHT to make choice about my health and quality of life because I’m the one that has to live with those choices.

    Trying to say my choices are a “costly burden” or that they’re “immoral” is not only insulting, it’s also dehumanizing. I simply won’t put up with it.

    But, really, my bigger objection is about people making a moral judgment based on appearance. You can’t tell who does or doesn’t participate in healthy behaviors based on weight (or BMI).

    I object to the mythology that weight equates unhealthy behavior. I agree with you that “it is lifestyle, not weight, that determines health.” And no one can SEE lifestyle.

    Anyhow…loved your post. Made me think and you know I like it when my brain matter twinkles.

  6. Sam Knox permalink
    August 16, 2010 6:01 pm

    Constant’s criticism of the categorical imperative is flawed in this way: None of Kant’s formulations require that I answer the murderer’s question, only that, if I answer it, I should answer it truthfully.

    Also, in general, you’re making a mountain out of a molehill. Every behavior has third-party effects. Focusing on the morality of obesity does little more than take up space in a blog. Saying that “my morality is none of your business” is absurd on its face. If your morality included, for example, sacrificing virgins, then it would certainly be the business of others.

    Finally, I was surprised that you would actually say that obesity is the result of “eating to much and exercising too little.” This view has been thoroughly discredited.

    Obesity is the result of a metabolic disorder that causes over-eating, and the process begins when calories that should be used for energy are stored as fat, thus depriving the cells of the energy they need. In other words, people don’t get fat because they overeat, they overeat because they’re getting fat. (Exercise plays no part in the equation; it burns calories, but it also makes us hungry.)

  7. Fat Academic permalink
    August 17, 2010 4:09 am

    As a total aside from the morality (or lack therof) of a healthy lifestyle, I thought I would tell you what my old church used to teach about the Thou shalt not commit adultery thing. They told us all that as soon as you had intercourse with someone you were ‘married in the eyes of god’ as back in the old days, it was sex that marked a couple as being married, not a legal ceremony. So if you have slept with someone, you are married to them. If you then go and sleep with someone else, you are committing adultery. Regardless if you are legally married to the first partner or not. It was this sort of teaching that had me marry an abusive man at age 19 (thankfully I escaped relatively in one piece a few years later). I don’t attend church anymore and no longer subject myself to that sort of ‘teaching’ but though I would let you know some of the stuff that church goers are told ; )

    Sorry for the derail!

  8. August 17, 2010 7:28 am

    I take issue with your use of Kantian ethical theory. While discussions of ethics often begin with Kant, his theory is by no means the end-all-be-all of All Ethical Theory. You might come to a different conclusion (or not) if you delve into Meta-Ethics, for example. As it is, you are starting with the presupposition that matters of “health” are things which can be moralized in the first place.

    As I see it, the main problem with arguing that Health is a Moral Requirement is not so much that it’s no one else’s business, but rather that terms like “healthy” and “unhealthy” are Subjective and Relative terms, without solid, static definitions. E.g., the prevailing wisdom says that it is “healthier” to eat whole wheat bread. Except that I have Celiac’s disease and ANY kind of wheat is unhealthy for me. The same prevailing wisdom says that it is “healthy” to walk for 30 minutes every day. Except that I have a genetic degenerative muscular neuropathy in my legs and muscular fatigue actually hastens the degenerative process.

    The problem is more that the culture in which we live arbitrarily ascribes moral attributes to deeply personal behaviors and abilities which it believes to be “healthy” or “unhealthy” where no such morality exists in the first place. Everyone is different. Not everyone is capable of becoming an ultra-marathon runner, nor is anyone under any sort of moral obligation to try to become one. And neither is the ultra-marathon runner morally superior (in ANY way) to the non-ultra-marathon runner.

  9. August 17, 2010 11:20 am

    This is SUCH an interesting post. I know I’m going to be thinking about it for days! Thank you, Atchka. And I agree, you *are* pushing the envelope–which is a great thing. We should always question our mantras and how they’re received by others.

    I think the whole point is that morality isn’t objective and means nothing without context (and I don’t mean just what you can see!). And I like the distinction between consequences unique to the individual or her circumstances, and moral consequences to society.

  10. August 17, 2010 12:04 pm

    I’m not up on my philosophy, so I could be totally threadjacking. If so, I apologize. Given that, my first thought on reading this is it doesn’t make sense to discuss this merely in terms of fat and food/exercise choices. If we go with the idea that “[i]f you have the means and ability to choose health, but do not choose it, then your self-destructive behavior may be labeled immoral,” there are situations in which your decisions CAN be labeled immoral by an outside observer (unlike food/exercise choices, which CTJen pointed out).

    For example, smoking. You can make the choice not to smoke; if you do smoke, however, you are making an easily observable immoral choice. My mother smokes, and since she has kids, her choice is especially immoral.

    But then what about driving (or riding in) a car? According to the NHTSA, 26,689 vehicle drivers/passengers died in motor vehicle accidents in the U.S. in 2008. In many areas, you can make the CHOICE not to drive; whether or not you cause the accident doesn’t matter, because you can’t control the behavior of others and at the very least you’re putting yourself at risk. Driving (for those with the choice not to), therefore, would be considered an immoral act. My point is, any avoidable, risky behavior could be considered immoral, and, seeing as how we don’t live in a danger-free world, in order to not willfully engage in “self-destructive” behavior, you’d have to do almost nothing.

  11. KellyK permalink
    August 17, 2010 3:16 pm

    Lots of interesting and thought-provoking stuff.

    I think the distinction between personal morality and societal morality is an important one. There’s a big difference between what you might call “wrong” in an abstract sense and which portions of “right and wrong” can be imposed on other people.

    The best part of the post, I think, is this:

    But here’s the kicker: the only person who can label your behavior as immoral is yourself.

    Nobody else knows the truth of the circumstances surrounding your health choices. They can infer certain things, but even if you explain all of the financial, physical, emotional, psychological reasons for making the choices you do, they will still have a vastly incomplete picture compared to your own knowledge of the situation.

    The thing that makes this really complicated is that each choice isn’t made in a vacuum, and that *every* action has both pros and cons morally and health-wise. From a strict nutrition perspective, no dessert is probably “better” than dessert on any given day, but if it’s at the cost of a mentally healthy attitude around food, maybe not so much.

    As another example, one might assume that it’s the moral choice for a parent to quit smoking. But if nicotine withdrawal makes them incredibly irritable, and they’re solely responsible for their young children, there are harmful possibilities either way. Do you risk scarring the kid for life while you’re trying to quit or wait til they’re older and better able to understand what you’re going through? And how many attempts will it take? (Not that living with a parent going through nicotine withdrawal is automatically going to be a traumatic and life-altering experience, but the possibility is there, especially if the situation isn’t exactly stable or optimal to begin with.)

    I also think it’s important to be *really* wary of assigning different morality to parents because it feeds into a martyrdom concept where the only important thing is their kids. I think that can devalue parents as people in their own right and encourage a lot of neurotic perfectionism (I *must* do everything exactly right ALL THE TIME or I will RUIN my kid’s LIFE!)

    While parents’ decisions affect a lot more than just them, that’s true of most people. Anybody’s death leaves a hole in the lives of their families and friends. A much bigger hole in the life of their child usually, sure, especially because it affects whether the child is well taken care of. But I don’t think it’s so dramatically different as to put parents’ morality in a totally different class.

  12. Rich permalink
    August 23, 2010 1:45 am

    Interesting thoughts, but one dangerous flaw: being overweight IS a health risk, independently of exercise habits or composition of diet. Especially for women, who are at higher risk of breast cancer and endometrial cancer from excess peripheral estrogen conversion in adipose tissue. Not to mention obstructive sleep apnea, osteoarthritis, etc. that are directly related to physical aspects of being big. And lastly, we should mention the big guns: diabetes and heart disease, both of which are associated with obesity even when exercise habits and composition of diet are controlled for. By perpetuating the myth that obesity per se has no heath risks, you are really doing your readers a disservice.

    • August 23, 2010 5:29 am

      “By perpetuating the myth that obesity per se has no heath risks, you are really doing your readers a disservice.”

      The first problem here is that you’ve made an assumption about our message. You assumed that we don’t ever talk about the possible links between weight and health. You assumed that we haven’t spent any time looking into the research.

      I started writing this really long post trying to address all the points you presented…but then I started to wonder if you read anything past this one post before accusing us of perpetrating a myth.

      Are you interested in hearing an alternative version of the points you presented? Or are you just here to add your voice to the idea that “people in Fat Acceptance are ruining the world with their lies?”

      So, here’s what I propose. You give me some links to research articles that back up your points and I will present my case, also including links to research articles that back up my points. If you are really interested in this subject, I am totally willing to give you a clear case for my position based on the research I’ve spent the last year accumulating.

      That way, I don’t have to feel like I’ve just trying to convince someone who’s already made up their mind. We would instead be having a debate that we’re both invested in.

    • August 23, 2010 6:30 am

      A drive-by troll, a week after the fact! Wow!

      I would also add to Elizebeth’s fair-play response: included in your scholarly and scientific evidence, Rich, I would like to see a study that demonstrates a diet/lifestyle change/what-have-you that is successful 5 years out for at least, say, 5% of participants. (Not too much to ask, right?) If I’m going to jump back on the “diet-and-exercise” wheel, I’d like to know that it’ll work this time (as opposed to all of those other times that didn’t because, well, diets don’t work.)

    • August 23, 2010 8:37 am

      Rich,
      Welcome and I appreciate your dissent. However, if you’re going to make claims about the health impacts of obesity, please provide research like Elizebeth said. For example, I’ve read a lot about the correlation between diabetes and heart disease, but I have yet to read anything that says that exercise habits and diet have nothing to do with diabetes. Healthy exercise and diet are the most successful means of treating diabetes we have, so how it could be unassociated is unclear. Of the items you mentioned, only sleep apnea has been shown to be caused by obesity itself, as opposed to simply being correlated.

      Finally, we support a Health at Every Size approached to health here, which focusing on improving diet and exercise regardless of weight lost since, as marchioness mentions, the failure rate of dieting is both well-documented and widely accepted. Therefore a person who is already obese has few options to improve his/her health. By promoting HAES, we provide an option, one supported by a wide variety of obesity specialists.

      If you would like to have a discussion about the health implications of obesity, we’d love to join you. Just be sure to back up your claims so that we know where you’re coming from.

      Peace,
      Shannon

      • Rich permalink
        August 25, 2010 1:42 am

        Chill folks, we’re on the same side! Shannon, I think I must have poorly explained what I was trying to say — which is that Obesity is independently a risk factor for dozens of diseases, even if the obese person eats lots of vegetables and is in great cardiovascular shape. I certainly didn’t mean to imply that being in great cardiovascular shape, even in the absence of weight loss, was not extremely beneficial. Many studies have proven that.

        But, many studies have also proven what I said (and not just for obstructive sleep apnea). I already gave the example of increased incidence of endometrial and breast cancer in obese women, the mechanism of which is well known and directly caused by the increased size and number of adipose cells. Osteoarthritis is the direct result of increased stress on the joints because of increased weight (although, risk for osteoporosis actually decreases with obese persons). Increased adipose tissue also leads to a prothrombotic state, which makes DVTs and pulmonary emboli more likely. Increased fat vacuoles in the liver lead to NAFLD (non alcoholic fatty liver disease) which can progress to cirrhosis. Too much adipose tissue also directly leads to insulin resistance, which is why the vast majority of type II diabetics are obese. The list is so incredibly long that it almost makes no sense to keep typing, when a quick trip to uptodate.com or some other medical resource will list them all for you. The New England Journal has an obesity article in practically every issue these days – there’s a reason obesity is considered a public health crisis and 300,000 deaths are attributed to it each year in the US. But, if you insist on my providing some source, read this article:

        Shoelson SE, Herrero L, Naaz A (May 2007). “Obesity, inflammation, and insulin resistance”. Gastroenterology 132 (6): 2169–80

        That’s a pretty good explanation for a few of my points.

        Marchioness, my original post never mentioned anything about whether diet/exercise work, but if you want to discuss that, we certainly can. I share your frustration that only a tiny fraction of those who lose weight keep it off. That certainly doesn’t prove that diet/exercise don’t work! What it proves is that the diet/exercise most people are doing doesn’t work. What works is a permanent lifestyle change of strict calorie counting – for the rest of your life. People who do that loose the weight and keep it off.

        But tying it back to the original argument… for people who are unsuccessful at keeping the weight off, of course they should still exercise, since it will lower their risk of cardiovascular disease considerably, even without weight loss. On the other hand, I’m not sure I would ever recommend that someone give up trying to lose weight, when obesity is such a huge health hazard.

        • August 25, 2010 9:26 am

          Rich,
          You’re leaving out a key piece of the puzzle in the correlated studies you mention (and again, they are studies that show correlation, not causation). For instance, you mention osteoarthritis as caused by the stress that extra weight puts on the joints. You say this as though the cause has been settled and everyone knows that obesity causes arthritis. But recently there have been studies linking arthritis and leptin, in which one of the researchers says “‘We were completely surprised to find that mice that became extremely obese had no arthritis if their bodies didn’t have leptin,’ said Farshid Guilak, Ph.D., director of orthopaedic research in the Duke Department of Surgery. ‘Although there was some earlier evidence that leptin might be involved in the arthritis disease process, we didn’t think that there would be no arthritis at all.'”

          There are also studies linking leptin to both CVD and inflammation. Check out this article on how certain proteins associated with inflammation can predict future weight gain.

          The point is that obesity is an extremely complicated, extremely inter-woven condition that we just don’t understand with the degree of certainty that the media claims. Obesity is a risk factor for many diseases, but so is height (although whether being tall or short is more of a risk factor for health is still up for debate).

          I disagree that the high failure rate of dieting means we should promote lifestyle change as a means of weight loss instead. 95% of weight loss attempts fail INCLUDES lifestyle change and especially includes “strict calorie counting.” So saying that you would never recommend that someone give up on trying to lose weight, in spite of this fact, means that we’re not exactly on the same side. You believe that the presence of adipose tissue itself is a threat, while we, generally (can’t speak for everyone), believe that lifestyle is the threat and adipose can be a symptom.

          Thank you for following up. I love a good debate.

          Peace,
          Shannon

          • Rich permalink
            August 25, 2010 5:05 pm

            Thank you for the fascinating link about osteoarthritis. It definitely calls into question my statement that osteoarthritis in the obese is caused solely by increased mechanical stress. However, read carefully:
            “If you are obese, there are benefits to losing weight in terms of arthritis. For example, if you are obese and lose just 10 pounds, pain decreases significantly. Pain modulation is another clue it might be a chemical or systemic metabolic effect, rather than just a mechanical effect of less weight on the joints.”

            This actually suggests it might not be due to mechanical stress, but is still probably due to increased adipose tissue (which supports my more general point). Also, what’s true in mouse studies doesn’t always correlate for humans. Without actually reading the study in question, I can already think of a weakness in it: Mice are much smaller, while composed of tissue (bones/cartilage) of the same general density/composition as we are. That’s why a mouse can fall proportionally much greater distances without being significantly injured. By that same logic, 200 pounds of fat resting on my knee joints should cause a lot more erosion than an extra 100 grams of fat on a mouse’s knee joints. You see my point… Since obese humans, as your article points out, get osteoarthritis in their wrists (which aren’t load-bearing), this suggests it isn’t completely due to physical stress.

    • August 25, 2010 8:46 am

      Is anyone arguing that there is no *correlation* between obesity and healthy problems?

    • August 26, 2010 4:49 am

      Between your two comments there are so many points that I really don’t have the time to hit them all. So I’ll try to focus in on a couple things.

      What do you think is the absolute risk of each of the conditions you’ve listed? Meaning, within the population of overweight/obese – what is the actual rate of incidence?

      Because a lot of things in life are risky. Like driving in a car. Or having a cocktail. The thing that makes it so were not terrified all the time is the context of how risky those thing actually are.

      All over the place you’ll find statistics saying that 60% of the US population is overweight and 80% of diabetics are overweight. But, to put those numbers in context, only 7-10% of the us population has diabetes and only 20% of obese are diabetic.

      So, in the grand scheme of things, while I am more likely to get diabetes than my thin counters parts, I’m still not very likely to get diabetes.

      As for your position on weight loss, I flat out think your wrong. I’m going with the scientific consensus that small amounts of weight loss are possible in the short term but sustainable weight loss is nearly impossible.

      And here are just a couple of the sources I’ve found to prove the overall fail-ability of weight loss:
      Wikipedia : Obesity Management
      Systematic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States
      Systematic review of long-term weight loss studies in obese adults: clinical significance and applicability to clinical practice

      What I’m actually trying to “promote” is the idea that how weight relates to health is nuanced. And I think all the focus on fat is a red herring, partly becasue the reduction of weight as a treatment is unsustainable and also becasue I think it’s a cog in a larger system, not the “independent” cause of most conditions associated with overweight/obesity.

    • August 27, 2010 5:42 am

      In the “Handbook of Obesity – Etiology and Pathophysiology 2nd ed” it says, “Obesity, at least when severe, is clearly associated with an increased mortality rate, and weight loss is associated strongly with reductions in many risk factors. Therefore, it seems reasonable to conjecture that weight loss among the obese will increase life span. Indeed, some studies suggest that intentional weight loss reduces mortality rate in persons with obesity-related comorbidities such as hypertension and diabetes. Among apparently healthy overweight and obese adults, however, the majority of studies suggest that intentional weight loss is associated with an increase in mortality rate.”

      One of my big arguments is that we should treat the patient, not the fat. I don’t have any problem with weight being one point in a risk profile…but I think there’s a problem with singling it out as the most important point.

      The route to weight loss can include various combination’s of exercise, nutritional changes, and calorie restriction. I would argue that different approaches in attempting to mediating the risk of have different results in relation to the different conditions you’ve mentioned.

      I’ll start with cardiovascular disease as an example. While the absolute risk of hypertension for obese is as high as 46% (based on a relatively recent gallup-poll) there is still a great deal of debate concerning the treatment of weight loss for hypertension.

      Another quote from the Handbook of Obesity, “However, one of the controversial aspects of these studies is whether the weight loss alone, independent of alterations in dietary sodium, was responsible for the observed reductions in blood pressure.”

      In a study of intentional weight loss on diabetes and hypertension, “a maintained weight reduction of 16% strongly counteracted the development of diabetes over 8 years but showed no long-term effect on the incidence of hypertension.”

      There is actually a stronger correlation of weight with diabetes and knee osteoarthritis. But, similar to diabetes, the absolute risk of knee osteoarthritis in the population is really low at 0.24%.

      And then they’re this tidbit, “Whereas once knee osteoarthritis was considered a ‘wear-and-tear’ condition, it is now recognized that knee osteoarthritis exists in the highly metabolic and inflammatory environments of adiposity…Further, pound-for-pound, not all obesity is equivalent for the development of knee osteoarthritis; development appears to be strongly related to the co-existence of disordered glucose and lipid metabolism.”

      But, the reasons WHY I disagree with the recommendation of weight loss for all overweight/obese to reduce risk is becasue of a lack of evidence that the benefit is equal for all or effective in the long term. The USPSTF admits that they, “did not find direct evidence that behavioral interventions lower mortality or morbidity from obesity.”

      As a critical thinker and attempting to be an informed consumer, I’ve been actively looking for the evidence that proves the long term benefit of weight loss for all overweight/obese. But, instead, what I’ve found is inductive logic.

      Epidemiological evidence shows a link between weight and certain conditions. In the short term weight loss improves metabolic indicators. So there’s this jump to a conclusion that all fat people should “aim for a healthy weight.”

      I do think there are perfectly health fat people who are not at risk. I also think there are fat people who are more at risk, based on their genetic predisposition and current metabolic profile.

      Like I said, I’m arguing for nuance.

  13. marchioness permalink
    August 25, 2010 10:09 am

    Shannon beat me to the punch! Here I go anyway.

    Chill folks, we’re on the same side!

    Before I get to the meat of my response, I’d like to address this. First, telling the people you’re debating with to “chill” is a derailing tactic, and doesn’t add to the conversation. Second, no – we’re not on the same side. We’re on quite different sides, mine (I won’t speak for everyone) being fat acceptance and health at every size, and yours being fat shaming couched in concern for the health of fat people.

    Shannon has addressed your examples so I’ll respond with this (PDF) study, which follows a group of fat, white, female chronic dieters, half of whom were placed in a diet group and half of whom were placed in a health at every size group. The diet group followed a regimen that sounds quite like what you term a “lifestyle change”: focusing on “eating behaviors and attitudes, nutrition, social support, and exercise. Participants were taught to moderately restrict their energy and fat intake, and to reinforce their diets by maintaining food diaries and monitoring their weight.” After 2 years, participants regained the weight and showed little improvement.

    The health at every size participants that focused on “disentangle[ing] feelings of self-worth from their weight”, and “letting go of restrictive eating behaviors and replacing them with internally regulated eating” were able “maintain long-term behavior change” and showed “heightened awareness and response to body signals result[ing] in improved health risk indicators for obese women.” Because when you listen to your body’s signals instead of ignoring them, you have a better sense if something is wrong.

    The problem with articles that say unequivocally “being fat contributes to [health issue]” or “being fat causes [health issue]” is that all other variables relating to fat are ignored because the relationship is presupposed and scientists are trying to support that supposition with evidence. Thus we go from “being fat is correlated with heart disease” to “being fat puts you at higher risk for heart disease so lose weight, fatties!” But perhaps that correlation has something to do with another factor – say, dieting. Fat people tend to diet more than thin folks because being fat in this society is a horrible experience and people do everything they can to avoid it. Chronic dieters tend to lose and gain weight in cycles (because diets don’t work [PDF]). This puts a lot of stress on your cardiovascular system, leading to increased rates of heart disease in fat people.*

    The idea that “fat is bad,” so firmly entrenched in all of our minds, leads to explanations like “The reason that the majority of fat people are still fat after dieting isn’t because dieting doesn’t work, but it’s the wrong diet/they’re doing it wrong/half the population of the U.S. has no willpower.” Fat people try many diets/”lifestyle changes.” Some fat people are even CEOs, or entrepreneurs, the people least likely to be accused of lacking willpower or mistaking fish and chips for steamed salmon.

    there’s a reason obesity is considered a public health crisis and 300,000 deaths are attributed to it each year in the US

    There are plenty of reasons why obesity is considered a public health crisis, and most of them have very little to do with actual public health. And that 300,000 number? IT’S NOT TRUE. The CDC screwed up their own data.

    Thank you, Shannon, for providing this forum!

    *Or Shannon’s example, which is made of actual facts.

    • August 25, 2010 12:50 pm

      Just to add to this awesome comment…

      Even if it WERE true that having the fat made one more susceptible to heart attacks, it is ALSO true that a Health at Every Size paradigm often leads to better health outcomes than a dieting paradigm.

      Whether fatties are intrinsically unhealthy is an interesting debate, but it’s actually not at all relevant to the question of whether fatties should diet to lose weight. To answer THAT question, we need to know which behaviors lead to better health outcomes for fatties, full stop. If HAES produces better results than dieting, than it’s a logical choice for fatties–even if those fatties would, in fact, be healthier in some parallel universe in which they were thin.

      • marchioness permalink
        August 25, 2010 2:11 pm

        To answer THAT question, we need to know which behaviors lead to better health outcomes for fatties, full stop.

        THIS.

    • Rich permalink
      August 25, 2010 5:24 pm

      Now a more general reply to everyone. I think we might be arguing about two different things. You seem to be arguing about what the best mindset is (the “dieting” mindset or the “acceptance” mindset). I’m arguing about what actually happens when you consume fewer calories than you expend. If “dieting,” as for the majority of people who do it, means eating less until you lose some weight, or until your body has adjusted to the reduced calorie load, then returning to old behaviors or not continuing to eat less than you expend, then of course it will fail. Studies don’t prove that dieting fails… they prove that people fail at dieting.

      • August 25, 2010 9:25 pm

        Well, yes and no.

        I’m not arguing that eating fewer calories that one consumes won’t eventually lead to weight loss. For most people, it probably will.

        Understanding the physiology of obesity is interesting scientifically and medically. However, this conversation is of limited immediate utility for obese individuals who are trying to plan their lives. For these folks, what’s important is to consider whether a particular behavioral strategy–dieting, long-term food restriction, or HAES–yields good results for people similar to them.

        We’ve all heard the mantra “eat less, exercise more.” However, it’s foolish to expect most fatties to be able to lose substantial amounts of weight, based on this maxim alone. It’s a bit like expecting poor people to get rich by “buying low” and “selling high.”

        There is real scientific evidence to prove that deliberate caloric restriction is not feasible for most people, that it will not necessarily produce thinness in everyone,
        and that it can have real and detrimental consequences for an individuals mind and body.

        This is not to say that no one can be successful with caloric restriction, or that no one can lose weight in a healthy manner. It does, however, mean that we should be very cautious about prescribing calorie deprivation as a “cure” for obesity.

    • Rich permalink
      August 26, 2010 2:39 am

      Also, saying “diets don’t work,” while true, is misleading and counterproductive. The link you provided only proves one thing: most people don’t succeed in permanently changing their diet. The most elucidating sentence in your article was “The more time that elapses between the end of a diet and the follow-up, the more weight is regained.” In other words, people are dieting and losing weight – then they stop dieting and regain it… the only thing this proves is that most people view “dieting” as a quick fix and a temporary state, and not as a permanent change of lifestyle. Saying that “dieting doesn’t work” is like claiming that smoking cessation doesn’t reduce your chance of getting lung cancer and using as your evidence all the people who smoked their whole lives but quit for a week somewhere along the way.

      • August 26, 2010 8:24 am

        Whether one chooses to blame the failure rate of diets on the diet or the dieters is a matter for legitimate debate.

        However, I have to ask: do you have evidence to suggest that long-term caloric restriction is a safe, effective method of weight loss for the majority of people?

        There is evidence to suggest that long-term dieting or “lifestyle” changes are, in fact, harmful or ineffective for many people.

        http://jn.nutrition.org/cgi/content/full/135/6/1347
        http://www.nytimes.com/2007/05/08/health/08fat.html

        That is, there is a real scientific rationale for blaming the diets, not the dieters.

        How you choose to interpret the data, and what conclusions you ultimately reach, are of course up to you.

      • HeatherJ permalink
        August 26, 2010 9:00 am

        Rich

        What you don’t seem to understand is that many people can’t stick to diets (or lifestyle changes, if you like) in the long-term because any calorie restriction or feeling of denial causes compulsive overeating and bingeing.

        I have personal experience of this – many years of eating disorders caused initially by dieting – which has now been cured by intuitive eating. My weight is now stable, but I know very well that if I tried dieting again, the urge to binge would rear its ugly head, and I would put on weight, not lose it.

        Dieting is counter-productive to many people, and those who don’t experience this reaction should count themselves very lucky instead of blaming fat people for their weight.

        Many fat people are fatter than they would have been naturally because of eating problems caused by dieting. Calorie-restriction is certainly not a cure-all.

      • August 26, 2010 12:54 pm

        Before you state again that dieting/lifestyle changes are some kind of solution, please provide evidence in the form of a study that demonstrates that long-term caloric restriction is an effective method for reducing adipose tissue. (And I include in “effective” any program that does not have an adverse psychological effect on participants – being thinner but constantly anxious/stressed is not a health improvement, because prolonged stress has a very real effect
        on physical well-being.)

        And I’ll address your “it’s the dieter’s problem!” argument to my assertion that “diets don’t work.” I’m going to assume, even though I think you’re flat out wrong, that diets (or “lifestyle changes”, they are the same thing – caloric restriction) actually work. Perhaps if I take my argument out of its current social trappings, it will be easier to understand. In this analogy, a diet is akin to a piece of computer software. The program looks great on paper (very simple algorithm: calories in, calories out!) so you release it to the public. The public gets their hands on it, and after a year or so you start getting e-mails and phone calls and letters saying that the software doesn’t work. Well, it works at first, but after long-term use the program starts to be less effective, and so stressful that people just eventually give up using it all together.

        So you, the developer, look at the software. You run it through every check you can think of, but the code is sound, the math makes sense (it’s not that complicated!), and it should be working. So you dig deeper.

        Eventually you find out the problem is user error; the way the software is designed results in end-users working the software incorrectly, and it happens almost the same way with every user regardless of computer proficiency.

        So, what makes sense: blaming the end-user for incompetence and asserting, over and over, that the software works fine, but none of you are capable of using it? OR, redesigning the software so it maximizes its benefits for the end-user?

        The latter choice – redesigning the software – is shifting from the diet mentality to the health at every size mentality. Like Simone said, the bottom line is to improve the health outcomes of fat people. HAES does that better, therefore, HAES is the better choice. End of story.

        • Rich permalink
          August 26, 2010 5:41 pm

          Marchioness, I think your analogy is brilliant, and I totally agree. I also agree that the goal should be improving the health outcomes of fat people. In the absence of weight loss, this would include maintaining cardiovascular fitness and healthy food quality (even if quantity remains high). As I’ve said before, however, losing weight drastically reduces your risk for multitudinous health problems (psychiatric illness/stress included, by the way – so perhaps the psychological stress of “dieting” is no more than the stress of being obese). This is why bariatric surgery is considered life-saving in many cases (though I certainly don’t support its currently rampant use among the mildly obese). And we’re still arguing about 2 different things… calorie restriction does work – that’s why people admitted in obesity clinics consistently loose large amounts of weight. “Deiting,” theoretically, (perfect use) will work just fine. Actual use, as you all rightly point out, is horrendous. So what needs to change is the way we approach the same goal (eating fewer calories). Whether it’s “dieting” or “intuitive eating,” the end goal should be to eat less… that’s what will reduce comorbidities.

          • August 26, 2010 5:48 pm

            That’s all very reasonable. The catch 22, however, is that having calorie restriction or weight loss as a goal is, in and of itself, harmful to some people.

            It’s also true that sometimes, eating fewer calories does not produce significant weight loss, because the body goes into starvation mode.

            And sometimes, weight loss can occur without a decrease in calories. Changing ones activity level, the types of activity one does, the composition of ones diet, the amount of sleep ones gets, or the medication one takes can all have an impact on body weight, in the absence of calorie restriction.

            So again, it is simplistic to say that reduced caloric intake per se is a useful or realistic goal for all fatties.

  14. Rich permalink
    August 26, 2010 7:24 pm

    Again, we have two different definitions of calorie restriction. I’m talking about burning (not just exercise, but every other physiologic process) more calories than you eat. This takes into account drugs, endocrine abnormalities (including cortisol changes due to pathological sleep patterns), muscle gain, or anything else that might change your basal metabolic rate. If you eat less than you burn (during activities and at rest), you will lose weight. While food composition may play a small part (cellulose, for example, has plenty of calories — none of which will be absorbed/used), the caloric value is generally a reliable way to think about the problem.

    • August 26, 2010 9:18 pm

      On some level, you are right: losing weight is a matter of metabolizing more calories than you consume. That’s basic thermodynamics. It’s very possible that a safe, effective, reasonably easy method for long-term weight loss does exist, and we just haven’t found it yet. It’s also possible that cultural change could create an environment in which most of us were a little thinner.

      If you agree with the following statements, then I really have no issue with what you are saying.

      (1) Deliberately reducing ones caloric intake can have legitimate physical or psychological repercussions.

      (2) Most people are unsuccessful with to conventional diet regimens in the long run–including many people who demonstrate tremendous willpower in other areas of their lives.

      (3) It is possible for a person to make a rational, informed decision not to pursue weight loss, even if one is overweight, and even if one might be healthier if one magically became thin.

      (4) Much is unknown about the biological and behavioral aspects of obesity, and contemporary dieting regimens may one day seem as outdated as bleeding, cupping and purging.

      I’ll be interested to see what other commenters thing.

      • Rich permalink
        August 26, 2010 9:36 pm

        1. Totally agree.
        2. Agree with this too, although the same could be said for alcoholism. Many successful people with self control in every other facet of their lives fall victim to alcoholism. It’s just a different kind of addiction.
        3. Of course. Everything is a cost-benefit analysis.
        4. Totally agree.

        • August 26, 2010 9:50 pm

          2. You make a fair point, in the sense that However, the alcoholism analogy is misleading.

          The major difference is that obesity itself is neither a behavior nor an addiction. Many obese people eat moderate diets, and engage in a reasonable amount of physical activity. Some of these people became fat through unhealthy choices; others became fat due to medical issues, or for some other unknown reasons.

          Many people become and remain fat, without engaging in behavior that is obviously destructive.

          Compulsive overeating, of course, is a legitimate disorder, that often requires medical treatment.

          That being said, the high failure rate of diets does not in and of itself prove that weight loss is a bad idea, or that no one should pursue weight loss dieting.

        • marchioness permalink
          August 27, 2010 7:34 am

          Rich, you have completely missed the point of my post. Also, you failed to provide evidence to back up your claim that losing weight in and of itself is beneficial, despite all of the negative side effects that come part and parcel with the attempt. (No matter how many times you say it shouldn’t be that way, it is – and we live in the actual world, not a hypothetical one where diets are effective.) I can’t engage with your argument if you don’t support it.

          As I’ve said before, however, losing weight drastically reduces your risk for multitudinous health problems (psychiatric illness/stress included, by the way – so perhaps the psychological stress of “dieting” is no more than the stress of being obese).

          You know what else would put an end to the “psychological stress” of being obese? Folks like yourself ceasing to tell fat people what is and isn’t good for them, as if you are some kind of objective observer and they are weak-willed children.

          Again, we have two different definitions of calorie restriction.

          No, we have the same definition. Eating fewer calories than your body needs to function, so it enters starvation mode and starts eating itself for fuel. And how you’re supposed to tell your body, “take the energy from the adipose tissue in my thighs rather than the energy I’d use to finish this project at work,” I have no idea.

          And the assumption that all fat people are addicted to food is just abhorrent. You’re addicted to food as well – if you didn’t eat it, you’d die. Not every fat person you meet eats two whole cakes for dinner every night.

          As a slight aside, check out Maslow’s hierarchy of needs. If you’re hungry, all of those higher needs go out the window. It doesn’t matter if you’re hungry because you can’t get enough food, or if you’re hungry because you’re voluntarily depriving yourself.

        • marchioness permalink
          August 27, 2010 7:54 am

          Oh, and since fillyjonk was awesome 2 years ago and I’m STILL sifting through it, here’s some great info on what happens when you alter your homeostatic body weight ~10% higher or ~10% lower. Basically – if you reduce your body weight by ~10%, it burns less energy. When you increase it by ~10%, it burns more energy.

          Could it be possible that when you eat enough food to be satiated, you’re giving your body exactly what it needs?

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