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Savage Intent —

March 7, 2011

Trigger warning: As you will soon see, this post contains a little bit of everything, but none of it is emotionally charged or personal in the least. I discuss anorexia mortality statistics, suicidal ideation among fat teens and teens with eating disorders, various elements of fat health and diet talk. But the greatest warning is that this is a long ‘un. I have no clue if Dan Savage will actually read it, but I wanted to provide him with a truly comprehensive post on what Fat Acceptance is all about, why it matters, and why he should stop treating fat people as though they are deserving of the scorn, disgust and derision that is regularly heaped upon them, including in his work.

The following is an open letter to Dan Savage.

Hi Dan,

I’m not a regular reader of your column (I’m really not a regular reader of anything), but I appreciate what you do in the form of activism, such as ushering in a more open and honest dialogue about our sexuality and the whole “It Gets Better” campaign. I appreciate your honesty and openness, but I think your attempt to confront obesity head-on is counterproductive on many different levels.

There seems to be a pissing match going on between Savage and the Fatties that is more about who can take the other down a notch than actually having the sort of dialogue that I would imagine you would typically encourage on such an important and controversial issue. So, here’s what I propose: a cease fire. An end to hostilities so we can actually talk about the important underlying issues, instead of resorting to homophobic and fatphobic slurs.

As much as I’m a fan of the well-executed, surgeon’s slice of sarcasm, I’m going to hold off on any negativity for now in order to lay out where I believe you may not be relying on the most accurate or reliable information, or your interpretation may be lacking a more comprehensive understanding of the issues.

A perfect example is when you say:

I will continue to post the links to stories about the obesity epidemic that catch my eye, stories like this that give the lie to the whole lack-of-exercise-has-nothing-to-do-with-it crap pushed by fat-acceptance crowd.

The story explains how Mississippi has the highest rates of obesity and sedentary behavior, while Colorado is the only state with an obesity rate less than 20% and is the third most active state. The author says that “it’s not likely a coincidence,” but it is a gross over-simplification to conclude that a lack of physical fitness is the only, or even the main, cause of obesity in Mississippi or leanness in Colorado.

For example, according to source for this article, the “F as in Fat” report (PDF), Mississippi has the highest rate of physical inactivity (32.2%) and obesity (33.8%) and Colorado has the lowest obesity rate (18.0%) and ranks 49th in physical inactivity (19.1%). They fits neatly into your theory. But then how do you explain Minnesota, which has the lowest rates of inactivity (16.9%), yet ranks 32nd in obesity (25.5%)?  Or New Jersey that ranks 42nd in obesity rates (23.9%), but is the 11th most inactive state (26.4%)? Or New York at 36th in obesity (25.1%) and 14th in inactivity (25.7%)?

In fact, the chart reveals that although there is some overlapping of the two categories, it is hardly what you would call a strong correlation (click the thumbnail below for the full chart):

But if you want to play the correlation game, I’ve got an even better one for you. Below is a map of states with the highest rates of people living below the poverty line from the US Census report titled “Poverty: 2008 and 2009” (PDF):

Among the 16 states with the highest percentages of people living below the poverty line are all 11 of the fattest states (Mississippi, Alabama, Tennessee, West Virginia, Louisiana, Oklahoma, Kentucky, Arkansas, South Carolina, North Carolina and Michigan). Coincidentally, Mississippi ranks the highest (21.9%), with the second closest being Arkansas (18.8%).

But more importantly, you and others frequently cite Colorado as a beacon of fitness and self-control, the last hope for our nation. You are among the multitudes crying, “What is Colorado doing right?“, “Why are Coloradans skinnier than everyone else?“, “Hey, let’s all be like Colorado!

Of course, what is left out of this discussion entirely is the fact that Colorado’s obesity rates rose faster than any other state, and another recent study says the same trend applies to childhood obesity in Colorado. So Colorado is the thinnest state, but they are getting fatter faster than any other state. Is that really proving your “exercise cures obesity” theory, Dan?

The problem is that America is having an entirely different conversation about obesity than the rest of the world. In the United States, we’re dead-set on the boot strap mentality for everything:

If you’re poor, pull yourself up by your bootstraps (nevermind the fact that intergenerational mobility in the United States is lower than in France, Germany, Sweden, Canada, Finland, Norway and Denmark).

And if you’re fat, just get your shit together and lose weight (despite widespread acceptance among medical professionals that the failure rate of significant weight loss (greater than 5-10% of original weight) at five years is 95%).

We like to place the blame directly on the shoulders of those we disdain and anyone who disagrees is obviously making excuses.

But while we’re busy ascribing blame to personal responsibility, the rest of the world is discussing the social determinants of health (SDH). In short, the SDH are all those factors that contribute to the many health issues that any society faces, including obesity and metabolic disorders.

For example, as previously mentioned, obesity and poverty are strongly correlated, but something we rarely talk about is how income affects health outcomes in obesity-related diseases.

Even in Canada with it’s single-payer health system, those with higher incomes fare better with diabetes:

The death rate from diabetes fell by one-third between 1994 and 2005, according to new research.

But the drop in mortality was dramatically greater in high-income groups than among low-income groups, underscoring that diabetes is increasingly a disease of poverty in Canada.

The same holds true for heart disease:

When socioeconomic factors were added into the FRS risk assessment, however, the proportion of low-income and low-education patients at risk for death or disease during the next 10 years was nearly double that of people with higher socioeconomic status.

“So what?” you say. “Just lose weight and you’ll reduce your risk factor for heart disease at every income level.”

Fair enough. But what if I were to ask you what the greatest risk factors for heart disease are. I’ve got to go with an assumption since we’re not discussing this in person, but I’d assume you’d suggest smoking and weight. I’ll even give you the benefit of the doubt and say that you’d throw in fitness levels and diet.

But check this out: smoking is the highest risk factor, but the second highest risk factor? Stupidity:

Data were collected for height, weight, blood pressure, smoking habits, physical activity, education and occupation; cognitive ability (IQ) was assessed using a standard test of general intelligence.

The relative strengths of the association were measured by an “index of inequality,” which summarised the relative risk of a health outcome (cardiovascular death) in the most disadvantaged (high risk) people relative to the most advantaged (low risk). This relative index of inequality for the top five risk factors was found to be 5.58 for cigarette smoking, 3.76 for IQ, 3.20 for low income, 2.61 for high systolic blood pressure, and 2.06 for low physical activity.

Emphasis mine.

Weight isn’t even in the top five. Of course, that doesn’t stop the authors from speculating that, secretly, weight really is in there:

The investigators note “a number of plausible mechanisms” whereby lower IQ scores could elevate cardiovascular disease risk, notably the application of intelligence to healthy behaviour (such as smoking or exercise) and its correlates (obesity, blood pressure).

And that’s fine, but let’s stop kidding ourselves that weight is the end all, be all of health, and that losing weight is the solution.

It isn’t.

If you’ll indulge me for a minute, I’d like to introduce you to the real experts on the subject of obesity and health. I’ve interviewed a few of them for my podcast, “On Hold with Atchka!“, which I began over a year ago because I was disappointed with the way the media has covered the obesity story. I had too many questions of my own, so I set out to interview the people who are at the center of the obesity and health debate.

The person I most wanted to interview was Dr. Arya Sharma, Professor of Medicine & Chair in Obesity Research and Management at the University of Alberta, Edmonton, Canada; Medical Director of Alberta Health Services Edmonton Region’s interdisciplinary Weight Wise Program; and Scientific Director of the Canadian Obesity Network.

In short, this guy knows his shit.

He also blogs about all the most recent obesity research developments and his site is a wealth of information about obesity and health.

I first learned of Dr. Sharma from this article, where he explains why recommending weight loss to obese patients is counterproductive:

“There is at least a proportion of obese individuals who at this point don’t seem to be at elevated cardiovascular risk.” Not only is their risk fairly minimal, “in some instances it’s better than individuals who are normal weight.”

“Treating obesity, like treating any other medical condition, takes resources, you never get it for free and if you’re asking people to do things where you know off the bat that most people are likely to fail then you’re really setting them up for disappointment,” Sharma said.

Dr. Sharma is encouraging physicians to stop recommending weight loss to patients because the dangers of weight cycling are far greater than keeping a person at a high, but stable, weight. So, with a bit of finessing, I got the interview and asked him why he was recommending against weight loss:

If you walk into my office today and you’re 300 pounds and you walk out of my office ten years from now and you’re still only 300 pounds, I’ve probably done a fantastic job. Let’s focus on preventing weight gain first.

He also strongly advises people not to base judgments of health or lifestyle choices on what a person looks like:

Don’t blame people for their weight because you can’t look at somebody and, based on their size, immediately jump to conclusions about their lifestyle. I’ve got a lot of patients in my clinic who are large, who are obese, who know more about nutrition, more about healthy living, and are actually practicing those principles than some of my thinner patients who come and have other problems.

It is true that for those patients who begin a permanent lifestyle change, there is a possibility of losing weight, but the average sustainable weight loss is 5-10% of your original body weight. Let’s say you see a morbidly obese person walking down the street: she’s 5’7″, 300 pounds.

You might look at her and think, “She should eat better, exercise, and not rely on fad diets, then she’d lose the weight.” This approach is best exemplified in the Learn Program for Weight Management by Dr. Kelly Brownell, Director of the Rudd Center for Food Policy and Obesity at Yale. Learn is the most commonly prescribed weight loss program and is also known as the slow and steady approach.

But Learn has its limits, according to this one-year randomized controlled trial of commercial internet weight loss programs. Participants either used eDiets or the Learn manual. Learn did better than eDiets, but only induced a 4% total body weight loss after a year and an average weight loss of 7.27 pounds (plus or minus 9 pounds). As you can tell by this table, the major weight loss was immediate, then tapers off. And I can’t find many long-term trials (which is pretty common among weight loss research).

So, that 300 pound woman could have already shed 10% of her original 333 pound body weight, but you wouldn’t know it. And according to Dr. Sharma:

The good news is for many obesity-related health conditions a 5% or 10% weight loss can have very remarkable effects.

Which brings me to my favorite interview of all time: Dr. Steven Blair, Professor at University of South Caroline Department of Exercise Science, specializing in the Division of Health Aspects of Physical Activity. He’s also one of the most widely cited fitness researchers in the field and is best known for his work ground-breaking at the Cooper Institute.

Dr. Blair concurs with Dr. Sharma’s comment that you can’t judge a fatty by his belly:

You can’t tell by looking if someone is fit or not. In fact, in our research if we look at adult men and women body mass index of 30 or greater, about half of them are fit by the cardiorespiratory fitness standards that we’ve used in our research and health outcomes.

A person in the Obese BMI category who engages in regular, physical activity (the minimum 150 minutes of moderate exercise or 75 minutes of intense exercise per week), are as healthy as physically active people  in the other BMI categories:

Our research has focused on what your fitness level actually is and we see the benefits of having at least moderate cardiorespiratory fitness being relatively comparable in people who are normal weight or overweight or obese.

Dr. Blair has also found that BMI or weight is not the strongest indicator of health by a long shot:

Bottom line, what we’ve found, is that low cardio-respiratory fitness, those who are unfit, is really one of the strongest predictors of morbidity and mortality of anything we’ve measured in this data set. For example, 16 to 17 percent of the deaths… over 50,000 men and women followed for on average more than 10 years and about 4,000 of them died. 16 to 17% of those deaths can be said to be caused by low fitness. 2 or 3% of the deaths were caused by obesity. I think that 4 or 5 or 6% to diabetes. The only thing that was even close to low fitness in terms of the number of deaths it caused in the population was hypertension in men.

So, while our society rails against people being fat, Dr. Blair’s work indicates that weight is not the most important factor in determining health.

In fact in our data, individuals who are normal weight but unfit on the laboratory treadmill test have a death rate in the next decade that is twice as high as the individuals who are obese, but moderately fit.

But you don’t get this message from the media because all of the research is skewed to reflect the correlation between obesity and health issues, and as you know, correlation does not equal causation. So, before you tout another Fat Acceptance myth-killer, keep Dr. Blair’s words in mind:

No journal should ever again publish a paper on obesity and any health outcome unless activity or fitness has been properly measured and taken into account.

Dr. Blair refers to studies that do not account for activity or fitness as “junk science.”

Hopefully, this information gives you a good foundation for understanding why health and obesity are not inextricably linked as the media leads us to believe. But you’re probably still concerned that obesity rates are rising and our nation will soon be awash in flabby rolls of excess flesh. Hell, just turn on the TV and you’ll hear all about how fat we’re getting every day.

Except, that’s not true either.

Obesity rates have leveled off:

The increases in the prevalence of obesity previously observed do not appear to be continuing at the same rate over the past 10 years, particularly for women and possibly for men.

In fact, the obesity rates for women and children have been stable since 1999 and for men since 2003. The author of that study is Dr. Katherine Flegal, Senior Research Scientist and Distinguished Consultant of the CDC’s National Center for Health Statistics.

She’s the one who completely debunked the CDC’s initial estimate of 400,000 annual deaths in the obese AND overweight ranges. Turns out, the obese AND overweight category are actually responsible for 26,000 annual deaths, but that’s due to the fact that the overweight category has a negative mortality (meaning they live longer than expected) of 86,000, while obesity is associated with 112,000 annual deaths. The CDC now accepts Flegal’s estimate as the most accurate.

When you compared the mortality of obesity to smoking, you are basing it on the old CDC estimate of 400,000, but even if you cite the 112,000 number for obesity alone, that still makes the mortality rate of obesity (4.6% of total deaths) much closer to the death rate of alcohol use (3.5%) than smoking (18.1%)

When I spoke to Dr. Flegal, she explained how the mortality rate for obesity has actually been dropping over time:

Our data suggested that in fact the association of weight with mortality might be diminishing over time. It was stronger in the earliest survey and weaker in the later survey.

Most of the excess mortality associated with obesity is due to cardiovascular disease and cardiovascular disease rates have been dropping tremendously. The drop is really very, very large of the last three or four decades. It’s probably less than half of what it used to be.

And if you break down the numbers, you’ll find that although 112,000 people die due to obesity each year, there are approximately 105 million obese Americans in all (34% of the population is obese). That means the annual risk of death due to obesity is one in 937 or 0.11%. That is not an astonishing risk.

But judging by your comments in this post, you would think fatties were dropping like flies:

It’s an article of faith that we can’t talk about how much crap we’re eating–or how awful we look in low-rise jeans–without inducing eating disorders in millions of silly and suggestible young women … Our obsession with anorexia, Critser goes on, not only covers up America’s true eating disorder (we eat too much and we’re too fat!), but it also hamstrings efforts to combat obesity, a condition that kills almost as many people every year as smoking does. Eating disorders, by way of comparison, lead to only a handful of deaths every year. If you’re truly concerned about the health and well-being of young women, THUD, worry more about the skyrocketing rates of obesity-related diseases in young people–like type 2 diabetes–and less about the imaginary link between anorexia and my low opinion of low-rise jeans.

Which brings me to my second grievance about your handling of the issue of eating disorders. You seem to be one of the people who says, “Hey, anorexia isn’t a big deal. It doesn’t kill that many people. Let’s focus on the fatties!”

Now, there are all kinds of estimates as to how much obesity affects your Years of Life Lost (YLL), but while doing some research on lap-bands in adolescents, the most commonly cited figure is 8 years. So, an obese teenager can have a life expectancy of 70 years versus the standard 78, which is tragic, but not exactly terrifying.

Compare that with adolescent alcohol consumption, which conservative estimates suggest shave 10-12 years off your life. But drinking in teens is to be expected, right? Besides, they’ll have plenty of time to turn themselves around and improve their health later on.

Yet you easily dismiss eating disorders because they lead to only “a handful of deaths” each year.

It disappoints me immensely, Dan, that you would be seen as dismissing eating disorders as a life-threatening problem among (especially) teenage girls. I’ve written about this subject at length, but I’m happy to provide you the salient data here because once again, your facts are skewed:

Females between the ages of 15 and 24 are 12 times more likely to die from anorexia than all other causes of death, according to the National Eating Disorders Association in America.

Anorexia is the deadliest mental illness among teenage girls, but it’s “just a handful,” right? So let’s take a look at the basic numbers: 0.6% have anorexia, which has a mortality rate of 0.56%.

That means that of the 1.8 million Americans have anorexia, 1,710,000 are between the ages of 12 and 25. Of them, 9,576 will die this year. The CDC states that “16,375 teenagers 12-19 years died in the United States every year from 1999 to 2006.”

Compare this to a recent study of nearly 46,000 Swedish men ages 16 to 20. Of the 367 obese participants, 49 died during the 38 years of follow-up. That shakes out to about 13.4% over 38 years. There are 21,469,780 teenager in the United States and 18% are obese, which equals 3,864,560. Of that group, 517,851 will die by the time they are 54 to 58. That’s 13,627 each year for 38 years. And I would venture to guess that it increases with age, but even so, the difference is startling:

Of 1,710,000 anorexic teens, 9,576 will die this year, or a mortality rate of 0.56%.

Of 3,864,560 obese teens, 13,627 will die this year, or a mortality rate of 0.35%.

The immediate risk of death is higher for anorexic teens than obese teens, yet we are fixated on that 8 years of YLL and you, and others, have decided that the immediate risk posed by anorexia is acceptable, since it pales in comparison to the long-term risks associated with obesity.

But Dan, do you know what the most common cause of death among anorexics is?

… the risk of death by suicide among by anorexic women to be as much as 57 times the expected rate of a healthy woman.

Likewise, obese and overweight teens have a higher rate of suicidal ideation than those in the normal BMI range.

Consider your message, Dan. What are you telling the many, many, many teenagers who read your column and look up to you? What do you say to the teenagers who are struggling with anorexia? What do you say to the teenagers who are struggling with being “too fat”?

You know what I hear? “It gets better… except for you fatty!”

I know this isn’t the message you want to send. But obesity and anorexia are undeniably linked. Both are powerfully affected by the all-pervasive message that thin is good and fat is bad. Anorexia, bulimia and binge-eating disorder are all influenced by multiple factors:

There is no single cause for eating disorders. Although concerns about weight and body shape play a role in all eating disorders, the actual cause of these disorders appear to result from many factors, including cultural and family pressures and emotional and personality disorders. Genetics and biologic factors may also play a role.

On the subject of weight and stigma, I interviewed Dr. Rebecca Puhl, Director of Research and Weight Stigma Initiatives at the Rudd Center for Food Policy and Obesity at Yale University where she is also a Research Scientist.

Dr. Puhl explained how weight stigma affects children both emotionally and physically:

For both children and adults who are teased about their weight or victimized about their weight, they are at much higher risk for depression, anxiety, low self-esteem, suicidal behaviors. But there are a number of physical health ramifications. When people are stigmatized because of their weight they are more likely to engage in unhealthy eating behaviors, things like binge eating behaviors, and avoidance of physical activity. Both of which may ultimately reinforce additional weight gain.

One of the unique aspects of weight stigma is that the victims will internalize the stigma and agree with people, like you, who place the blame squarely on their own lack of self-control. That combination of self and public stigmatization may be complicating our attempts to help people engage in healthy behaviors:

One of the things that we see even with things like weight loss treatment is that people are more likely to drop out, they are less to be successful if they are stigmatized. I think when people feel better about themselves, if they’re not being shamed because of their body size, that they’re more likely to want to engage in healthy lifestyle behaviors and to participate in those activities.

And this stigmatization has rapidly swept across our country:

In the research that we’ve done we’ve observed that it’s actually comparable to rates of racial discrimination in the United States and that it’s actually increased by 66% in the past decade.

The stigma is so pervasive that even young children have internalized it:

One of the most concerning things that we’ve observed in research is that these negative attitudes begin really early, as young as age three in preschools, where kids who are three indicate they would prefer to have playmates who are thin and they believe that obese peers are lazy or mean or undesirable playmates. These are messages that really become ingrained in our culture very, very early and just become worse over time.

So, when you say something like, “Most women don’t have the kind of bodies that look good in low-rise jeans, fat or not,” you are contributing to a culture that says that only one type of body is acceptable for public exhibition. You try to temper that comment by adding:

… pointing out that something isn’t flattering isn’t the same thing as saying that the person wearing the unflattering garment is unattractive

Fair enough. But when you begin to make such distinctions between what women should and should not wear, when you agree with the comment that nobody wants to see “fat rolls hanging over the tops of jeans or bulging out from under belly shirts,” you are sending a very clear message that society does not want to see the exposed flesh of fat women or women with fat rolls. You are sending a very clear message that, sure, you ultra-skinny babes can wear whatever the fuck you want, but fatties have to hide their bodies in “flattering” clothes.

To me, it sounds a whole fucking lot like people who say, “Hey hetero couples, we don’t mind if you make out in public, but you flaming homos can’t be all gayness and light in public.” Or, to bastardize your own words:

If North American homosexuals want to flounce around in leather chaps–and apparently we do–we should get the AIDS epidemic under control first.

It’s the same fucking ignorance, the same fucking hatred that you are fighting against on behalf of gay Americans. The only difference is that your aesthetic displeasure is on the other side of the fence now. Now you’re the one who feels disgusted and appalled by the public display of what you deem unattractive or unacceptable. And now you’re the one dispensing baseless conjecture, stereotypes and unfounded “science” to claim that your opinions, regardless of how hateful, are fully justified.

But despite all of this information, despite what I have shared, I do not think you are the enemy and I do not hate you or think you are a horrible person.

I think you’re an intentionally misinformed person, just like the rest of our society. You’ve been inundated with warnings and predictions of doom, and you are doing what you think is the responsible thing: encouraging people to lose weight and to not be so fucking fat.

But the people who know this issue best have a completely different understanding of why we are as fat as we are, and just what needs to be done about it.

Stigma and shame will not help. Pounding the “eat less, move more” drum will not help. Lecturing fatties on fashion faux pas will not help.

What will help is a more compassionate understanding of what health and obesity really means, and a less judgmental attitude toward those we deem “too fat.”

I’ve written this post to ask you — to beg you — to reconsider your current position on obesity and health because your current attitude is not helping, it is hurting many, many people. I believe that if anyone understands the terrible impact that ignorance (even well-intentioned ignorance) can have on others, it is you.

I am 100% open to a dialogue on this. By no means do I think I am the authority on all things obesity. I began my podcast to learn more about the subject because, like you, I’m fascinated by it. I am still learning about the subject, but in the past year I have come a long way.

I am willing to discuss this issue in greater detail with anyone who believes I’m distorting the facts or manipulating the data. In fact, I have debated two of the staunchest anti-obesity advocates I could find: MeMe Roth and Michael Karolchyk.

I look forward to hearing back from you and I hope that you have kept an open mind while reading this. I will be happy to answer any and all of your questions and challenges. This is a very important subject and I strongly believe that if we begin educating people on evidence-based treatment, rather than fear-based campaigns, we can improve the health of all people, not just the fatties.

Thank you for taking the time to read this long and rambling diatribe and I wish you the best.

Shannon Russell

42 Comments leave one →
  1. March 7, 2011 10:42 am

    Nice… Exceedingly thorough! I hope he reads this.

  2. CollieMom01 permalink
    March 7, 2011 10:45 am

    I just wanted to say Bravo!

    That is all. 😀

  3. vesta44 permalink
    March 7, 2011 11:19 am

    I’m going to bookmark this and point it out every time someone wants to argue with me about FA/SA and why I’m not dieting anymore. This is one of the most thorough posts I’ve read about FA and fatness.

  4. March 7, 2011 1:14 pm

    What Vesta said. Well researched and well said! *standing applause!*

  5. sweet Priscilla permalink
    March 7, 2011 1:37 pm

    I really hope he responds and engages you. I stopped reading his column years ago because of this.

  6. Selena permalink
    March 7, 2011 1:58 pm

    AMEN! Thank you for a well-written, thoughtful article. I’ve bookmarked this baby and will refer to it in the future when some idiot gets in my face about weight.

  7. March 7, 2011 3:51 pm

    Excellent research here. This may be one of the few level-headed, articulate responses to Dan Savage I’ve read. It’s very frustrating to me when people just lash out and say very extreme and negative things to people, however valid, because their tone and temperament discredit their argument. This is engaging and informative and I applaud all the work that you put in to this. The final product is incredibly thorough and a great resource for all.

  8. March 7, 2011 4:10 pm

    Thank you everyone for the kind responses. I’m working behind the scenes to raise the profile of this so we can get Dan’s attention with this one. Plus, I’m totally booked at work, so it’s an exciting, busy day, but I’m absolutely glowing with pride and appreciation right now. 🙂


  9. Holly permalink
    March 7, 2011 4:18 pm

    This may be the first time I have ever commented on FFF, but I had to chime in and say that this is really one of the best syntheses of obesity (or, “obesity”) research, and of FA talking-points in general, that I have seen in my vast trawlings of the Fat-O-Verse. I don’t have much more to say on that point, other than that it makes me really happy to see so much debunking organized into such a neat little package. I hope Savage takes the time to read and respond.

    On a slightly different note, my academic/professional focus is on science education, and I have to say that posts like this consistently fascinate and impress me from that perspective. Although the types of scientific reasoning and data evaluation I have seen on FA blogs over the years is not always 100% sound (and I don’t mean your post, but rather FA blogs in general), it is pretty awesome and – frankly – surprising to see so many non-scientists be so willing to essentially write up review articles and engage w/ complex data purely for the sake of their own curiosity and activism. Given the major problems that exist in trying to get kids interested science and to see its relevance to their own lives, I find myself thinking that educators could pull a few tricks from the FA playbook and use social issues like this as a catalyst for engaging their students. I’m a self-professed science nerd, and even I will admit to being way too lazy to attack a subject in such depth unless someone is a) paying me, or b) grading me. Citizen science and FA… there’s a great doctoral thesis topic for someone more motivated than me!

    • March 8, 2011 9:49 am

      Thanks Holly,
      The odd thing is, I’ve never really been a science-y person. But I think that when you care about an issue, you can overcome that science-phobia out of curiosity and determination to understand the issue thoroughly. At least that’s what happened to me. I think that could be the case with kids as well… find out what issues they care about, then have them find some research pertaining to it.

      One thing I wish I had was a proficiency in reading the statistical portion of research. I really want to get a book on data analysis so I can understand what confidence intervals are, or whatever those numbers in parentheses mean. 🙂 I think if we could give kids those basic tools it would go a long way to improving scientific proficiency, if only that they could read the raw research and know what it means or implies.

      Part of me is concerned that I’m misreading data and possibly promoting junk science, but I try to read both sides so I don’t get stuck in an echo chamber. I have yet to encounter anyone who can legitimately refute the fat and fit theory, and those that try rely on meta-analysis or some other easily-manipulated research. Compare any of that stuff to Dr. Blair’s work and it just collapses in on itself.

      Anyway, thanks for your comment. It really means a lot to hear science-people saying that we’re getting it right. 🙂


  10. Mulberry permalink
    March 7, 2011 5:52 pm

    Shannon, I greatly admire your patience and thoroughness.
    I would like to add that we can’t know the true deadliness of anorexic behavior, because it’s only considered anorexia when the sufferer’s weight is below a certain percentage of what their BMI “should” be. IOW, a fat person who succumbs to anorexia and dies from it may still be fat, but the cause of death will probably be counted as obesity.
    As far as Savage is concerned, allow me to point out that one’s natural weight is about as changeable as one’s natural sexual preference. It may not help matters much to say it, but I enjoy seeing fat haters spontaneously combust.
    What the Dan Savages of the world particularly hate is that there are some parallels between fat prejudice and homophobia. Apparently his calls for justice and equality are only meant for himself and his group. A rather sad, but nonetheless common example of human nature. One may note similarities in historic quests for religious freedom

    • sannanina permalink
      March 8, 2011 3:46 am

      I would like to add that we can’t know the true deadliness of anorexic behavior, because it’s only considered anorexia when the sufferer’s weight is below a certain percentage of what their BMI “should” be.

      This is an excellent point. And of course, there is also bulimia, which is also fostered by fears of being fat. Not to mention that an important aspect of binge-eating disorder is shame. It is a terrible misunderstanding that you can help a person with BED by telling them that they should lose weight (or even worse: that their body is diseased and disgusting). In fact, those things are far more likely to trigger further disordered behavior than to really help anyone.

      (Also, Shannon, this was great. Thank you for taking the time to write it.)

  11. Len permalink
    March 7, 2011 7:05 pm

    Beautifully written – I am another person who has bookmarked this for future reference in debating the value of FA. I hope Mr Savage is happy to respond – it would be a very interesting discussion.

  12. Quackfaster permalink
    March 7, 2011 7:29 pm

    I found this post through Jezebel and I just wanted to say that this is probably the best thing I’ve ever read anywhere. Just brilliant. Definitely bookmarking this and sharing on Facebook.

  13. March 7, 2011 8:08 pm

    FREAKING BRILLIANT! This is so very well done. Excellent points, relevant science, and nothing shrill or defensive. I really admire this piece and plan to keep it around.

  14. Jeannie_of_the_Papers permalink
    March 7, 2011 8:53 pm

    So. What then is the best route forward for someone who finds themselves in the 30+ BMI range? Is it really completely out of reach to hope to return to an average BMI with all of the advantages that do come with it? (I’m thinking super practical here: mobility, cheaper clothes, etc.) And, how can society in general best encourage people to start on the journey to a healthy lifestyle (regardless of skinny-fatness) while holding the two truths (1-stigma and yo-yo weight loss hurt and 2-un-managed obesity does have certain health risks attached) in mind?

    Obviously, encouraging people to be physically active and eat a more balanced and nutritious diet are useful. They both can lead to weight loss, but are more importantly in an of themselves going to improve general health if they become a part of a new lifestyle.

    Of the obesity initiatives out there that I’ve looked at (and I’ve looked at a surprising number of them) many of them do discourage stigmas, but most still say that being an average BMI puts you in a lower risk category, therefore people should be encouraged to lose weight if they are above 30 BMI. I think there is still some merit there, but only if it’s well-balanced guidance suggested in a purely positive manner. What of the new interventions that suggest people should aim for 5-10% sustained weight loss, with more physical activity and better nutrition?

    • vesta44 permalink
      March 7, 2011 9:43 pm

      Jeannie – The problem with those new interventions, for people like me (375 lbs), is that 5 – 10% weight loss still makes me DEATHFAT at 337 to 356 lbs and most doctors won’t stop at that 5% – 10% weight loss. Once I’ve lost that amount, they’re on my ass to lose another 5% or 10%, ad nauseum, until I’ve met whatever goal they’ve set (and they don’t care if I’m able to maintain it forever, as long as I lose it). How do I know this? I went from 396 to 375, a loss of 5%, and have maintained that loss for 3 years. Is my doctor happy with that? Hell no, she wants me to lose more, in spite of the fact that my blood sugar is normal, my blood pressure is normal (unless she’s pissed me off), and my cholesterol is normal. My heart and lungs function just fine, but she’s not happy with a 5% weight loss. She wants me to lose 50% of my weight, which isn’t going to happen, ever – not after having dieted off and on for years, having done fen-phen, and had a failed WLS. My metabolism is fucked 7 ways to Sunday, and I’m getting older, so it’s also slowing down, but according to her, it’s calories in/out and the Nightmare on ELMM Street (Eat Less Move More) will work to make me magically thinner in spite of all that. Yeah, right, not happening, no matter how nutritionally balanced my meals are and/or if I exercise the prescribed amount of time every week.
      When you want society in general to encourage people to do certain things for their “health”, you start down a very slippery slope. No one is obligated to be “healthy” for anyone but hirself, and only if that’s what zie wants to do. When society gets involved in encouraging people to do certain things, society tends to put a moral value on those things, whether there is any moral value actually attached (see the debate over “good” food vs “bad” food – food doesn’t have a moral value, it’s food, for crying out loud). And all those interventions are aimed at fat people, because only fat people are seen as sedentary gluttons who can’t possibly be healthy. There are quite a few sedentary thin/average-sized people out there whose nutrition sucks, but no one says anything to them about improving their nutrition or their exercise habits because they’re not fat, so obviously they’re “healthy”. Yeah, right, I don’t think so.
      Everyone, no matter what their size, can benefit from good nutrition and joyful movement – if they so desire. No one should be forced/shamed into doing anything that they don’t want to do, are uncomfortable doing, or can’t afford to do.

      • FabAt54 permalink
        March 8, 2011 6:44 am

        Vesta, your points about morality, food/fat and society are dead on! Thanks for articulating that so well!

      • Jeannie_of_the_Papers permalink
        March 8, 2011 9:42 am

        Well, I wanted to start and interesting and informative dialogue. Excellent!
        And: thank you.

        To explain my thoughts:
        For sure, no one can be forced into anything, nor should they. That freedom is a lovely given in this part of the world. The difficult thing about making generalizations about nutrition, exercise, obesity, thinness, etc. is that (as you brought up) everyone’s metabolism is a little bit different. Some people naturally carry more weight than others, some struggle to keep weight on and most are somewhere in the middle.

        A doctor’s job is to try to improve people’s health, or to put it another way to help them improve their own health. Since doctors look for symptoms, or indicators, that a patient’s health is failing for some reason, they are vulnerable to seeing the obvious ones first. So they check vital signs, run tests, etc. in the hope that they will effectively screen patients for dangerous indicators and catch them while there is still time to fix whatever the problem might be. So, yeah, the majority of the recent research says obesity is a contributing factor to some dangerous diseases, and doctors react accordingly. By the same token, if a thin person tests positive for high blood pressure, high blood sugar, or high cholesterol one hopes that any good doctor would address those in the same way they would address them with a fat person. One also hopes that they would use cheap, non-invasive preventative medicine (nutrition and exercise, etc.) before they used drugs. It’s really rather unfortunate that thin people are less likely to be screened for diabetes and high cholesterol than fat people, because that opens a crack for them to slip through. It’s also not at all good that fat people who are living healthfully are being badgered, stigmatized, belittled, shamed, what-have-you just because the weight their body settles to, under healthful conditions, is above the average range.

        I personally think that everyone has a responsibility to themselves to life in as healthy a way as possible. How one does that is, of course, one’s own prerogative.

        So, I have two requests.
        1-How could a doctor ideally deal with obese patients as a group, recognizing that they are not all the same? Or, how can they help their obese patients maintain or improve their heath, depending upon what their needs are? Some fat people may have recently been thin, or just slightly (insert adjective for mildly overweight here), want to return to their previous weight, and can.

        2-Would you please direct to me any scholarly papers that you know of (could be Dr. Flegal, or someone else) that counter the generally accepted view of obesity, weight loss, interventions, etc.?

        Again, thank you for your response and time. 🙂

        • Lisa permalink
          March 8, 2011 7:28 pm

          Hi – the best place to start would be Dr. Linda Bacon’s book “Health at Every Size”. It’s very well annotated, in regard to both the obesity “epidemic” and it’s causes as well as how to help fat people live healthier lives without asking them to diet.

    • Mulberry permalink
      March 7, 2011 11:34 pm

      I would LOVE to see unmanaged obesity. With the obesity bugaboo out of the way, we can concentrate on more important things like behaviors (for everybody) and actually learn how much of a threat obesity really is or isn’t. I submit that many health problems thought to be caused by obesity are caused by social stigma and its consequences such as second-rate medical care.
      If you aim for people to lose weight if they’re above BMI thirty, then you should also encourage them to gain weight if they’re below BMI 20. I would not suggest either, since BMI, if it’s at all useful, should be applied to populations, not individuals. But if you’re going to apply it to individuals anyway, you should be fair about it and use it on the thin side as well as the fat side.
      Being white rather than black, being young rather than old, being female rather than male, being rich rather than poor, all of these attributes put you in a lower risk category healthwise. Is it worth it to you to try to change what you can? Same deal for obesity, because obesity is an attribute and not a behavior.
      What should a person with a 30+ BMI do? Walk through life unashamed, yell like hell for fair treatment and opportunities, be good to fellow fat people.

      • Jeannie_of_the_Papers permalink
        March 8, 2011 9:49 am

        Point taken-BMI is tricky. What’s an equally simple-to-use method for judging how one’s amount of body fat, or mass, affects one’s health? And do you know of any scholarly papers on that method?

        About the unmanaged thing: I’m assuming that fat people are like most other people, in that some are actively trying to stay healthy, some don’t try as hard as they’d like to, and some have decided not to care.

    • March 8, 2011 10:08 am

      Four words: Health at Every Size.

      HAES (as outlined by Dr. Linda Bacon in the book I linked to above) promotes being physically active and intuitive eating, along with loving your body as it is. Weight loss may occur, but weight gain may occur, particularly if you are a restricted eater who has spent a lifetime pursuing weight loss in one form or another. The key is to allow your body to settle at the weight that is right for your body. That’s why self-love is the third leg of HAES, and probably the most important. It is difficult — if not nearly impossible — to successfully take control of your health and well-being through HAES if you aren’t able to learn to love the body that nature intended for you. If you cannot learn to love the little rolls on your hips or your double chin or your saddlebags (or whatever physical “scourge” has plagued your self-confidence your entire life), then you will never be able to settle for “simply” being healthy.

      Also, you mention the BMI of 30. As Mulberry explained, a BMI of 30 is not a death sentence or even an indicator of poor health. In fact, a BMI of 30 isn’t even all that fat. When you get some time, peruse Kate Harding’s BMI Illustrated Project, which has photos with BMIs to give you an idea of what we’re talking about.

      According to many of the experts I’ve spoken with and the research I’ve read, your weight only affects your health at the statistical extremes. HAES still works for them too, and it’s what Dr. Sharma promotes for his morbidly obese patients. He does still recommend WLS for those who feel their weight hinders their ability to pursue health due to mobility or comfort issues, but WLS is always a last resort.

      In my opinion, part of the problem that goes completely unmentioned in the mainstream health discussions is the role that promoting weight loss has had in creating the obesity “epidemic” we see today. Talk to any of those statistical outliers and odds are you will hear about the many, many, MANY desperate attempts they have made at weight loss. Psychologically, weight loss attempts really mess up your ability to maintain a stable, healthy relationship with nutrition and physical fitness. Taken alone, good nutrition and fitness will provide endless positive health benefits, but as part of a weight loss regimen, they become something perverted and grotesque. When your weight loss plateaus (and it will plateau), the dieter will begin to feel like the pursuit of good nutrition and fitness is utterly futile and will, eventually, breakdown and reject good nutrition and fitness in favor of what they were doing prior to the diet.

      It’s the restriction/disinhibition cycle that dooms essentially all diets, and when you tie nutrition and fitness to weight loss, you are basically encouraging the restriction/disinhibition cycle that makes weight cycling dangerous and unhealthy. Detach the two and promote good diet and nutrition for their own benefits, regardless of weight loss, and you will remove the negativity from those two concepts and allow a person to see them for what they are: tools of health, not weight loss.

      My goal is to utterly destroy BMI and weight as the primary metric of health. Can it be a tool in our understanding of health? Sure, but as I wrote above, it is not the least important tool, nor is it accurate. If a patient puts on a large amount of weight in a short amount of time, it may be in an indication of either a physical or mental health issue. But if a person has a high, but stable weight, then encourage them to pursue health, not weight loss.

      And, of course, as with anything, it’s about personal choice. You get to choose or not choose health every day. If a fat person doesn’t want to follow HAES, that is their right, which I fully support. I really just want to educate people on what health means and how it can be achieved.

      So, thanks for asking. I hope this helps.


      • Jeannie_of_the_Papers permalink
        March 8, 2011 10:42 am

        Thank you! I had heard of HAES before, and even got my hands on a few of the papers. I guess I’ll keep barking up that tree. I’ll add the Kate Harding project to my list as well.

        A thought: there are a lot of strong emotions about this, and understandably so. Regardless, when you’re a researcher like me, it’s hard to take people seriously if they sprinkle their (otherwise well formed) arguments with profanity. I’m perfectly willing to look past it and pay attention to the good stuff, but not everyone is.

        Secondly, I feel like doctors need to be informed, not villian-ized. Informed or mis-informed, most of them do have their patients’ best interests at heart. Exceptions unfortunately exist, but that doesn’t mean all doctors need to be tarred with that brush. If you have the facts, bring it up with them! Take the papers into the office and hand them over, and say you’ll discuss your weight again AFTER they’ve read it thoroughly. Better yet, use part of the appointment to talk over the papers themselves. That would be way more productive and go a long way towards combating the “fat, non-compliant patient” stereotype that’s out there.

        Peace always.

        • March 8, 2011 11:21 am

          I hope I haven’t villain-ized all (or any) doctors. My father-in-law is an OB, so I really respect the physicians perspective on these issues. I know they’re doing their best to stay atop the most recent and accurate information. The majority of doctors do have their patients’ best interests at heart, but there is so much influence by corporate interests on what is considered healthy or not, particularly when it comes to research funding. Corporate influence is a double-edged sword: it can help advance our scientific understanding tremendously, but it can also actively work to undermine credible science in order to promote their own interests above the public interest (which, IMO, is exactly what is happening with the lap-band issue).

          Dr. Bacon’s book includes an appendix with resources you can provide your doctor with. I wish I could find an online version, but I can’t. I absolutely agree that we should do our part to educate our physicians about HAES and this alternative approach to health at weight. The “fat, non-compliant” stereotype is a serious issue and is at the very heart of physician bias against fat patients. I think that providing physicians with a clear statement of what we will and will not accept will go a long way, but we also need to respect the physician’s training and background. I absolutely agree that there is too much skepticism about the intentions of physicians, but much of that skepticism has been hard-earned by some of the more, shall we say, stubborn practitioners.

          As far as the swearing goes… I know, I know, I hear it all the time. This particular post was aimed at Dan Savage, and not the scientific community per se. I think that of all our bloggers, I am probably the worst when it comes to language. But I write conversationally and sometimes nothing can substitute for a well-placed f-word. But when I write strictly science, I’m usually not responding to a specific person, so the conversational tone invites less profanity. I’ll try to work on it, but I can’t change my voice. 🙂

          I’m glad we have another researcher reading. I’m not a researcher in the least, but I am curious and voracious reader, so I hope that if you ever get the time, you will make sure that what I’m saying is based in fact, and not skewed by my opinion. I LOVE to hear from actual experts and I totally invite criticism and correction. That’s the only way we can get to truth. So, thanks again for reading.


          • Jeannie_of_the_Papers permalink
            March 11, 2011 3:51 pm

            I’ve been otherwise occupied for a few days, but yeah, these are all good points. I did get the book and I’m working through it. Certainly lots of papers there to dig through, not all of them directly pertaining to, but definitely interesting. Too bad I’m a student, too, and have to divide my time. I’ll gladly read through stuff and see if it matches up with what I know, but honestly I can only do that for the stuff that’s really pertinent to my research topic. I just don’t have time. That said, thus far, you seem to be doing well; avoiding some of the fallacies/mistakes/generalizations that some FA sites fall into. As in any emotional topic, it’s so easy for people to get carried away and start throwing blanket statements around!

            I’ll probably be back to bounce some ideas around once I get through some more stuff this weekend.

            Peace, take care.

  15. FabAt54 permalink
    March 8, 2011 6:42 am

    Shannon, what can I say; It’s PERFECT! Thank you for being who you are and telling it like it is (like it ACTUALLY is) from our perspective and from the rare, but available, unbiased world of SCIENCE and STUDIES. Thank you.

  16. March 8, 2011 9:22 am

    Standing ovation.

    I’ll definitely bookmark this page.

    Thank you!!

  17. March 8, 2011 10:04 am

    Thank you Shannon, this is excellent! As much as I appreciate Dan Savage’s efforts with the “It Gets Better” campaign, he’s a complete asshat when it comes to issues of fat people, women, bisexuals and transgendered people.

  18. March 8, 2011 3:25 pm

    Thank you, Shannon. All those statistics made my head explode, but hopefully they will indeed reach Dan Savage. I am saddened by his anti-fat tirades. I always thought he did a lot of good for the GLBT community, but he is alienating part of his audience–the heavy set. Fat does not mean lazy and in the long run who gives a rare rat’s ass about looking good or not in low rise jeans? I’m pretty sure those damn things fit comfortably on about 1% of the population anyway!
    As for the anorexia issue, I don’t know what he means about everyone “focusing” on anorexia. Hardly anyone focuses on anorexia–which is far more deadly than just simply being heavy. They’re too busy hating on big people. The “silly girls” worship the anorexic look because they’re terrified of becoming fat–after all, nothing’s worse than that, right?

  19. Christie permalink
    March 8, 2011 4:11 pm

    This. So very THIS!!! Standing and clapping with defiant tears in eyes:

    “It’s the same fucking ignorance, the same fucking hatred that you are fighting against on behalf of gay Americans. The only difference is that your aesthetic displeasure is on the other side of the fence now. Now you’re the one who feels disgusted and appalled by the public display of what you deem unattractive or unacceptable. And now you’re the one dispensing baseless conjecture, stereotypes and unfounded “science” to claim that your opinions, regardless of how hateful, are fully justified.”

  20. March 9, 2011 9:32 am

    Bookmarked, and passages marked for future reference. Wish I had this when I was dealing with the typical “blockhead-at-work” last week! I’m just going to hand it to him to read anyway. Maybe it’ll do him some good.

    Thank you Shannon.

  21. March 9, 2011 11:25 pm

    Incredible argument. I really hope he takes your offer to dialog and this opportunity to closely examine his own beliefs to heart.

  22. March 10, 2011 3:09 am

    Excellent work, Shannon. Even if he doesn’t read it, some of his fans might, and it might give them pause.

    So he thinks anorexia and bulimia nervosa aren’t statistically significant in people younger than 20, but type 2 diabetes is? I hate to break the news to him, but anorexia nervosa alone has a prevalence at least three times greater than the number of people under 20 diagnosed with t2d, and if you add bulimia in, make that TWELVE times greater. At least! Not to mention the overwhelming genetic link involved in diagnosing t2d that young (not that there isn’t one for EDs too, but t2d, outside of elderly populations, has possibly the strongest heritability of all illnesses).

  23. March 10, 2011 3:40 am

    Great post, Shannon. Thanks for all your work and activism.

    FYI, Linda Bacon (author of Health At Every Size: The Surprising Truth About Your Weight) recently co-authored an article in Nutrition Journal (“Weight Science: Evaluating the Evidence for a Paradigm Shift”) that has an extensive review of the science supporting a weight-neutral approach to health. The article is available on the web. She has links to it and other resources, including excerpts from her book and handouts for health professionals, at her website:

  24. Jeannie_of_the_Papers permalink
    March 11, 2011 3:51 pm

    Awesome… posting of more scholarly work… awesome…

  25. March 16, 2011 5:25 am

    As a heavy gay man, I have to say that I feel divided regarding Dan Savage. I have always loved his unapologetic, pro-gay stance and his willingness to stand up for the rights of his fellow homosexuals. But as a big guy, I can’t get down with his anti-fat attitudes. Knowing how it feels to be judged for who you are, how can he not see that this attitude is both hurtful and wrong? Just because he isn’t attracted to heavy people doesn’t mean that heavy people are unattractive, or even more so, that they are disgusting. His credibility is shaken with me because of this erroneous attitude of his.

  26. June 21, 2011 9:21 pm

    Surely imagine that that you stated. Your favorite reason appeared to be on the web the simplest thing to be aware of. I say to you, I certainly get irked although people consider concerns which they just do not perceive concerning. You monitored to hit the nail upon the top as well as outlined out the total matter with out getting side-effects , individuals may take a signal. Should most likely be again to get more.

  27. Hidi permalink
    January 7, 2012 3:28 pm

    I love your post! You rock! Now, I feel embarrassed about my research and analytical skills. *Walks to door, kicks trash can and leaves* LOL!


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