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Body Politic —

September 16, 2014

Note: I received a review copy of the book I’m discussing.

I’ve been asking questions about Health at Every Size® (HAES) since before I really understood what HAES was all about. Of course, Dr. Linda Bacon’s book, was out there as a resource, but I didn’t have access to a copy when I wrote an article for Skorch magazine about this new health and lifestyle philosophy. So if you listen to the interview I did with Dr. Bacon, you can hear the early skepticism I had regarding HAES.

Body Respect BookI did not arrive on the Body Acceptance scene knowing that there was a viable alternative to traditional health advice. Like most people, I believed that a healthy lifestyle led to weight loss which led to improved health. The idea that the middleman of weight loss was entirely unnecessary (or at the very least, overrated) seemed completely foreign to me. Our culture emphasizes that the weight loss middleman is essential for health and that if you’re missing that component, then you may as well not even be living a healthy lifestyle.

Before I talked to Dr. Bacon and read her book, that was my attitude as well. I was what you might call health agnostic. As a result of my family history of heart disease and the premature death of my ostensibly-healthy uncle, I felt as though the pursuit of health was Sisyphean at best and futile at worst. But HAES taught me that there were small, sustainable ways to improve my health without feeling like the cards were stacked against me.

As a result, I delved into HAES, both in my personal life and as a scholarly pursuit. Two posts from now, I will have written 500 blog entries for Fierce Fatties, the majority of which are deeper explorations of the peer-reviewed research that form the foundation of the HAES approach. I’ve grown quite comfortable discussing the subject of HAES and felt as though I knew everything there is to know about this new paradigm in healthcare.

And then, Body Respect came out, which you can purchase directly from the BenBella Books for about ten bucks.

Body Respect is Dr. Bacon’s followup with Dr. Lucy Aphramor, a dietitian with the National Health Services of the UK and founder of Well Founded, a HAES education company. This book expands upon her original HAES book and those original concepts of self-care.

The biggest difference between the original HAES book and Body Respect is its emphasis on the social determinants of health (which I seem to be the only person who abbreviates as SDH).

In a nutshell, the SDH are all of those socioeconomic influences on health that America by and large ignores in its discussion of healthcare. Of course, outside the US, the SDH is a widely-accepted concept that even the World Health Organization (WHO) has embraced:

The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.

Body Respect delves deep into the SDH, providing metrics to determine how your own health is affected by the SDH. For instance, there’s allostatic load, which is the “cumulative collective factors that influence an individual’s ability to cope with difficult circumstances,” which includes “genetics, personality, previous metabolic strain, and early developmental events.”

Understanding allostatic load can give us a powerful glimpse into the ways that power and privilege can impact our health independent of individual health choices.

I’ve been writing about the SDH for a while now, first mentioning it in my open letter to Dan Savage back in 2011 and later exploring it in greater depth during the Strong4Life campaign of 2012. I pointed out to Savage how our long-held beliefs on weight and metabolic health are challenged by socioeconomic confounders:

[O]besity 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 when I heard that HAES would be incorporating the SDH in its message, I was all on board. And Body Respect goes into the nitty gritty of how, explaining life-course, lifeworld, sense of coherence and sense of agency that can impact us even while we are objectively making healthy choices.

Jeff Winger

Winger learning that he’s a victim of the social determinants of health.

Interestingly, Veronica and I have been getting into the show “Community” and last night we watched the episode where Jeff Winger (Joel McHale), the narcissistic leader of a diverse group of ne’er-do-well community college students, learns that he needs to take cholesterol medicine. When Winger reacts indignantly, boasting about how he treats his body like a temple, Nurse Jackie (Patton Oswalt) sets him straight in typical geek fashion:

I can’t be the first person to tell you this, but the temple doesn’t last forever. This is a Temple of Doom, and you know what? Like the real Temple of Doom, it represents the fact that all good things — be it people or movie franchises — eventually collapse into sagging, sloppy, rotten piles of hard-to-follow nonsense.

Later, Winger confronts his friend Ian (John Oliver) over his utter disbelief that he spent his whole life abstaining from donuts and exercising religiously to no avail. In a snit, he tells Ian, “I could eat powdered bran every day while you suck down figgy pudding and I still might die first. It’s not fair. I want my donuts back!”

This is a sterling example of someone coming face-to-face with the reality of the SDH. We don’t know Winger’s full back story, but obviously there’s something besides the two main pillars of health (diet and exercise) that have led to his need for cholesterol medication. It could be family history, it could be the stress of his former job as a high-powered attorney, it could be the loss of coherence and agency that he feels at Greendale Community College. Whatever it is, Winger’s health is not solely the outcome of his fundamentalist fitness regime.

Central to HAES is this bigger picture that Winger must accept as his new health reality. And it’s something that we all need to accept: that our health is affected by things we don’t think about on a daily basis, let alone get lectured on by a health-obsessed culture.

Despite overwhelming evidence found in the groundbreaking Whitehall study, American culture virtually ignores the impact of class and status on our health. This is largely because, as a hardcore Capitalist economy, we like to ignore the impact that rigidly-enforced social structures have on our health, particularly on the job. We like our worker bees to be obedient, respectful and to know their place. God forbid we have an actual discussion on how treating people like cogs in a machine is doing as much, if not more, health damage than a highly-processed diet and a sedentary lifestyle. Because the medical community has answers for those last two problems: prioritize diet and exercise. But when it comes to the SDH, the medical community doesn’t have jack squat to say.

So I’m quite pleased with this new, updated, comprehensive version of HAES, which views health through both a macro and micro lens.

There’s just one part that bothered me as I read this book. Although all the evidence for the diet and exercise approach of HAES are included in this update, there seems to be an attempt to deemphasize the health effects of lifestyle choice:

[I]t is wrong to assume that diet, or even diet and exercise, are the main determinants of health. In fact, according to the U.S. Centers for Disease Control and Prevention and others, health behaviors account for less than a quarter of the differences in health outcomes between groups.

The net impression I got from Body Respect and from discussions with HAES advocates is that studies like Whitehall show that people with similar lifestyle choices, but different socioeconomic status have disparate long-term health outcomes. If you eat healthy, exercise and you’re in upper management, then your health outcomes will be good. But if you have a health lifestyle and are middle management, then your health will be dismal by comparison.

What seems to be missing from this framing, however, is what difference a healthy lifestyle has within socioeconomic status. If I’m a vegetarian Ironman middle manager, I might not have the same health outcomes as my boss who’s a vegetarian Ironman. But how does my health compare to another middle manager who is sedentary and eats mostly fast food? I have a hard time believing that, all things being equal, lifestyle choices won’t have a significant effect on our health, independent of status syndrome.

Over the years I have spent reading research, I have become thoroughly convinced of the protective effects of exercise in particular (although I recently shared some evidence supporting the health benefits of a Mediterranean-leaning diet). If we take a step back from the HAES ideal of moving your body in a way you enjoy and look strictly at the data, it seems that the American College of Sports Medicine recommendations for fitness yield the most potent health benefits.

Those recommendations include 150 minutes of moderate or 75 minutes of vigorous exercise per week, plus strength training. Strength training provides significant benefit for metabolic health because building muscle improves insulin sensitivity, which can have a dramatic effect on your metabolic health. Bacon and Aphramor touch on this effect briefly in their chapter on exercise:

Just a single short stint of activity … makes muscle cells more responsive to insulin, even when you’re not moving, which will help you manage your blood sugar, reducing your risk of diabetes and other conditions.

While this is true, it’s my understanding that while cardiovascular exercise certainly helps with insulin sensitivity, it’s the resistance training and muscle building that improves the efficiency of insulin production. So it’s not just activity that improves metabolic disorder, it’s a specific kind of activity. As I learned in my interview with Dr. Steven Blair, brief bursts of activity certainly do have a positive effect, but we can’t ignore the evidence that shows how specific kinds of activity are more effective than others.

This is not to say that only certain kinds of activity are acceptable or useful or appropriate. Any activity that you enjoy and can sustain is a net positive. I think the difference for me, personally, is that I did not come to HAES with a history of disordered eating or treating exercise as penance. So, when I decided to pursue HAES, I wanted specific metrics and goals to aim for, which I found in the ACSM recommendations. Knowing what the research says about fitness gave me a guidepost to aim for, though I don’t always hit that mark. But because of HAES, I don’t feel guilty about that either.

In the end, I’m left feeling that Body Respect wants us to tackle the macro health influence (the SDH), while being less concerned about the micro health influence (diet and exercise). But in my view, regardless of your socioeconomic status, there are micro health changes that can yield positive, long-term effects on our health. The trick is to strike that balance without triggering unhealthy behaviors or attitudes that ultimately undermine our pursuit of health. And to that end, Body Respect has a wealth of valuable information on how to navigate those treacherous waters.

9 Comments leave one →
  1. vesta44 permalink
    September 16, 2014 6:24 pm

    Great post, Shannon. I already have the HAES book, and I’ll be buying this one as well. It’s good to be informed of all the choices we have when it comes to maintaining our health, whatever that happens to be. But I think that knowing about the effects of the micro and macro health influences and taking that knowledge into account is more helpful than using either one alone.

    • September 17, 2014 9:39 pm

      Hi vesta,
      Definitely get it. It is a great view of health and adds a wonderful depth to HAES that I hadn’t even considered possible to connect. The SDH is a critical aspect of health that is largely ignored by health professionals, so I think it’s a great addition to the HAES model.


  2. September 17, 2014 2:03 pm

    “If I’m a vegetarian Ironman middle manager, I might not have the same health outcomes as my boss who’s a vegetarian Ironman. But how does my health compare to another middle manager who is sedentary and eats mostly fast food? I have a hard time believing that, all things being equal, lifestyle choices won’t have a significant effect on our health, independent of status syndrome.”

    Perhaps, but (having not read the book and going from your review alone) it seems that Aphramor and Bacon are (over)emphasizing the roles of SDH in this book because our society already overemphasizes ~~personal accountability~~. Like correcting the steering of an off-kilter car to get back on track, or so on.

    That said, I haven’t read either of Bacon’s books. I should get around to that….

    • September 17, 2014 9:43 pm

      I didn’t get the impression that this was about personal accountability, but more about systemic economic inequality that is a drag on the quality of life for most people, particularly in the United States. What seemed to be missing from the presentation of the SDH were suggestions of how to address that issue directly, let alone its consequences. The answer, of course, is that the deck is stacked against progress unless we had a Democratic Congress or, at the very least, a Republican Congress interested in something other than obstruction. Addressing the SDH is a long-term health solution, which is why we need to address both the macro and the micro. And definitely get both books. They are must reads.


  3. September 17, 2014 3:32 pm

    Great review. My first entry into HAES was much like yours, and about improving my personal health. As a stigma researcher I am learning much more about SDH and can’t wait to read this book. Being in the UK, mines on pre-order.

    • September 17, 2014 9:46 pm

      The SDH is sadly under-discussed in US medical communities. It’s all about preventative medicine. Addressing SDH is like preventative preventative medicine. You address the roots of chronic illness BEFORE you even get education patients on healthy lifestyle. With income equality comes access to better choices, which many people do want to make, but are struggling too much to afford or use. I think SDH is definitely another message that HAES should be promoting, but that solution is largely political and may require additional organizational resources to push for change. It’s very complicated, but I love a challenge. 🙂


  4. lucyaphramor permalink
    September 17, 2014 3:54 pm

    We appreciate that you enjoyed so much of the book, Shannon. We’re so glad you caught the emphasis on SDH and it’s interesting for us to see how this seems to have submerged the self-care topics on nutrition, activity, and emotional well-being for you, which are all in there too. You may remember the concluding chapter showing how a health care practitioner could integrate attention to both self care and social positioning/ life course clinically. It’s understandable why SDH and self care get so polarised from the cultural starting point we have in constructing health narratives. Lucy’s got an interview with you scheduled, perhaps this could be a fun topic to delve into.

    Lucy and Linda

    • September 17, 2014 9:53 pm

      Hi Lucy and Linda,
      I enjoyed the WHOLE book. The refresher on HAES principles surrounding nutrition, fitness and self-acceptance was like meeting up with an old friend, while the startling data on the SDH was a real eye opener to the challenge that we face in attempting to make health accessible for all people. I think my confusion comes from a few statements that suggested that the SDH reduces the efficacy of lifestyle change. Perhaps I misread the sections I got that impression from, but I took copious notes while reading and I’m very excited to discuss. I learned so much from our discussion in 2009 and I can’t wait to pick Lucy’s brain on HAES. Thanks for reading!


  5. Len permalink
    September 24, 2014 7:31 am

    Awesome article Shannon, I am currently going through a bit of a personal health review and I definitely intend to get this book and read it, also re-read Dr Bacon’s other HAES book.

    I go to a specialist counsellor to help me manage severe chronic pain. She has been talking for a while about the ‘SDH’ (I must pass on the acronym) as they impact on different people’s experiences of pain, and how treating pain is more effective when they are taken into account as an integral part of the management.

    Perhaps I’ll give her a copy as well 🙂

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