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Round and Round: Part 1 —

February 4, 2015

Weight LossFat PoliticsFat HealthFat ScienceExerciseEating DisordersWeight Loss SurgeryDiet Talk

Trigger warning: This post touches on issues of health and wellness, weight loss and eating disorders.

Perhaps you aren’t aware, but there’s a seismic shift happening within the Health at Every Size® (HAES) community. It all started with the book Body Respect by Lucy Aphramor and Linda Bacon.

As most of you know, Bacon wrote the groundbreaking book Health at Every Size, which tackled the way in which personal health behaviors can have a profoundly positive effect on metabolic health even if weight loss is not a  consequence of those behaviors.

Bacon’s book was a seismic shift in itself, directly challenging the orthodox view that weight loss is the end all, be all goal for overall health and well-being. When I began blogging back in 2009, my goal was to explore the science of HAES and to find out for myself whether weight loss was necessary for health. I’m pretty sure you all know where I stand now.

The seismic shift caused by Body Respect adds a depth of understanding to HAES that had previously been lacking. Namely, that the social determinants of health (SDH) have a broad-ranging effect on the health choices of both the privileged and unprivileged classes of every culture.

SDH Word Chart

If you’re White, middle class, cis, heterosexual, able-bodied and male, then odds are in your favor that you’ll have better access to healthcare, quality education, a variety of nutrition and exercise options, economic security and overall stability than someone who is a PoC, poor, transgender, homosexual, physically or mentally disabled, and/or female.

There is broad global agreement (starting with the World Health Organization) that the SDH affects health across the spectrum and has an enormous impact on the health and well-being of everyone, but a particularly nasty impact on marginalized communities. The stress of economic insecurity alone has been indicted as a primary driver of poor health.

In my review of Body Respect, I praised Aphramor and Bacon for incorporating the SDH into HAES as long overdue. I strongly believe that socioeconomic inequality is the biggest issue of our generation, and HAES can play a pivotal role in drawing attention to and addressing the SDH.

But in that review I raised some questions as to where this new focus on the SDH leaves the promotion of individual health behaviors. As the authors said in Body Respect, “Health behaviors account for less than a quarter of the differences in health outcomes between groups.” If that’s the case, then how should we frame personal behaviors within HAES? Does this signal a decreased emphasis on the health effects of diet and exercise? And if the SDH is the number one issue for HAES, then how can we, as HAES activists, fight against their toxic effects?

These are some of the questions I planned to ask Lucy Aphramor in my interview that she cancelled. So my first stop on my search for answers was the Association for Size Diversity and Health (ASDAH) blog, where Fall Ferguson wrote this post on health inequities. So I posted this comment and got no response.

After some consideration, I decided that maybe I could put together a panel of HAES experts to discuss the SDH. At first, I approached six HAES experts and arranged a sort of weekly email roundtable. But due to conflicting schedules and the impending holidays, it fell apart shortly after it began.

Still hungry for answers, I approached the Show Me the Data group, a private email list which includes most of the prominent HAES experts we know and love. I sent a message to everyone explaining the roundtable and how I would like to ask six questions and publish their answers here. Finally, I got a response and I was able to begin.

The First Three

The questions I chose were complicated, there’s no doubt. Asking “What do we do about the SDH?” is like asking “What do we do about that meteor heading for Earth?” We might have some suggestions, but the scope of the problem is so broad, so enormous, so all-encompassing that any answer will be, by definition, inadequate.

The SDH is woven into our systems, our culture, our heritage, where we equate success with hard work and poverty with laziness. And interweaving those economic issues are issues of racism, sexism, homophobia, transphobia, ableism and the inherent bias directed at marginalized groups. So, I came to the table knowing that we weren’t going to resolve the issue on a listserv.

However, I am optimistic that if we organize our thoughts, our knowledge, our understanding, perhaps we can construct a framework for advocacy so that we, as HAES advocates, can all push in the same direction. For example, a small, but (relatively) simple proposal that could have a net positive impact on millions of Americans is to raise the minimum wage. Hell, if I were King, I’d push for a living wage pegged to inflation. As they say, a rising tide lifts all boats.

If ASDAH and HAES advocates were to rally behind this economic issue, we could join the countless other social movements pushing for economic justice.

And so, it is with all of this context in mind that I asked my first three questions. I hope that this dialogue will provide insight into how HAES can play an effective role in addressing the SDH.

Question 1: If HAES is focusing more on the social determinants of health, what can individuals do to either reduce, mitigate or counteract the effects of the social determinants of health? What can/should we expect from the future of HAES advocacy in terms of addressing the root causes of the SDH (e.g., economic inequality, social injustice, institutionalized discrimination)?

David Spero, R.N.
A registered nurse with 35 years experience focusing on diabetes and the SDH

This is a very difficult question — what can individuals do about social causes of illness? It’s why my diabetes book was never popular with people with diabetes — learning about the social causes only made people feel more disempowered than they already felt. I usually suggest:

  1. Use knowledge of the pathways from economic and social inequalities to illness to stop blaming yourself.
  2. Be more open with others in your community about SDH to provide mutual support.
  3. Use knowledge of the health effects of oppression to make plans to reduce those effects in the limited, but still useful ways, that are available to you (e.g., relaxation, exercise, social support).
  4. If willing and able, get involved in trying to change some of the SDH that are affecting your community directly, which could be stigma, environmental pollution, poverty, lack of access to care or to food, etc. … there are a lot of them. The act of fighting back reduces the feeling of hopelessness, which is a major stressor, maybe the worst. Remember that stress is the number one way that oppression damages health in most cases.

Hope this helps. I am in no way saying that these are the only measures or the best measures. They are just the ones I know and use. People seem to like the sound of them, but I have no data on people putting them into practice.

Laurie Klipfel, MSN, RN, BC-ANP,WCC,CDE
Nurse Practitioner and Diabetes Educator

Well said David. I also am not sure we have the power to change socioeconomic status, but we can stop placing blame that only adds to the oppression and makes the effect much worse.

Lisa Du Breuil, LICSW
Clinical Social Worker who treats people dealing with addictions, eating disorders and problems post-weight-loss surgery at an outpatient psychiatry clinic in Boston

I really like David’s response to your question, Shannon.

In addition: Right now when I think of what HAES-oriented people can do to address root causes of the SDH, I think of working to get different voices heard by the people who currently have power in our health care system. I think about helping people actually see the systemic discrimination — what people used to call (still call?) “raising consciousness” — happening around these issues.

Question 2: How does one look at the effects of the social determinants of health, and the enormity of the institutions that ensure its ongoing existence, and not succumb to feelings of futility and immutable fate regarding one’s health and wellness?

David Spero

Shannon, you are asking the questions that politically-minded public health people have been wondering for years. A health approach to oppression, inequality, and environmental degradation gives the same picture that a social or political approach gives — the same problems and the same alignment of forces on different sides. If the 0.1% remain unwilling to share and willing to use all their power to maintain and exacerbate the status quo, it will be very hard to change conditions. Appealing to their sense of fairness or compassion sounds like a total waste of time to me. They don’t have such concepts about us.

So, to change SDH in a positive direction would require a very strong class-based movement, like in the US in the 30s or 60s, and in Europe until recently. On an individual, community, and family basis, we pull together to take the best care of ourselves and of each other that we can, we fight on issues where we have a chance, and we don’t give up. Beyond that, I don’t know.

Your questions aren’t new Shannon. Many activists have written books about how to keep strong in the face of the powers we are up against. Check out Joanna Macy for one, or Nelson Mandela.

Deb Burgard, PhD
Eating Disorder Psychologist and Past President of ASDAH

I guess I fall back on the skills that I use in the face of almost anything that seems overwhelming to me: I think, OK, this isn’t going to get fixed right away, but what can I do today to chip away at it? What can I do every day to chip away at it? How do I think about this so that I integrate it into my life as a part of my daily self-care? Care of the world = self care.

Practically speaking, I start with the low-hanging fruit and then build from there. What is right in front of me to do? Just start. And then just repeat. And then, just return (after I — inevitably — get interrupted).

Part of the problem is the dealing with the confusion about what is enough to do. It will never be enough, so how do we figure out whether doing anything is worth it? How do we figure out how much is worth doing?

I guess I am proposing Intuitive Activism — that there is something that is possible and worth it, and we need to free ourselves up to do it, and manage the sense of overwhelm/guilt/despair that lurks constantly over our efforts.

I think people underestimate the power of small, consistent, irritations on the status quo. I may not be able to change it all in my lifetime but that doesn’t mean I can’t use the opportunities that I have for being an obstacle to the Death Machine. If everyone did that there would probably be enough lack of cooperation that many of these big forces would lose at least some of their momentum. And because the big forces come down to money, if it becomes too expensive to fuel the big forces, then they stop getting fed.

The other thing that really helps me is to understand that the world I inherited was made better by those kinds of efforts that people before me made. I feel like I am part of a long chain, a long tradition that is the best human company there is. I want to be part of it. So I don’t want to do nothing, because I want those efforts that other people made to come to some fruition eventually. It is not just numbers of people who get momentum going, it is persistence over time and generations, and that is something that we do through institutions, traditions, oral history, activism. We are a team, it is my turn with the ball.

Jon Robison, PhD, MS
Researcher, assistant professor at Michigan State University and co-editor of the Health at Every Size journal

Love the sentiment — and for me it is always about the music — chippin’ away.


David Spero

Beautiful, Deb. It’s harder for me to maintain belief in the long-term when the long-term seems to be disappearing, but as long as we can hope for a future, I guess, we can keep trying to make it better.

Deb Burgard

Yes, David, many times before humans have had to face the worry that they will not be here much longer, even in my lifetime. I think our work is directly impacting the available energy for people to face those pressing and urgent problems and stop frittering away time and energy on fruitless weight loss projects.

I heard somewhere that pilots learn and practice to keep flying the plane no matter how close to crashing they are (I guess as long as they don’t have the option to parachute out!). I can see that being quite useful since you never know for sure.

Laurie Klipfel

Beautifully said Deb. Even after you are long dead, your chipping lives on. You really have no idea what your impact will be, or how big the small changes will grow. Watching It’s a Wonderful Life shows how little impacts can make a big difference.

Keep chipping!!

Carmen Cool
Psychotherapist with a focus on eating disorders

I am so grateful for this discussion — thank you everyone! I am totally in love with the idea of “intuitive activism”!

One of my favorite authors is Margaret (Meg) Wheatley. One of her most recent books, So Far From Home, was a tough but important read for me  because she takes on this issue of “feeling exhausted, overwhelmed, and sometimes despairing even as you paradoxically experience moments of joy, belonging, and greater resolve to do your work.”

This is the text of one of her posters, made from the book, and I was reminded of it while catching up on these wonderful emails!

A Path for Warriors

We are grateful to discover our right work and happy to be engaged in it.
We embody values and practices that offer us meaningful lives now.
We let go of needing to impact the future.
We refrain from adding to the aggression, fear and confusion of this time.
We welcome every opportunity to practice our skills of compassion and insight, even very challenging ones.
We resist seeking the illusory comfort of certainty and stability.
We delight when our work achieves good results yet let go of needing others to adopt our successes.
We know that all problems have complex causes.
We do not place blame on any one person or cause, including ourselves and colleagues.
We are vigilant with our relationships, mindful to counteract the polarizing dynamics of this time.
Our actions embody our confidence that humans can get through anything as long as we’re together.
We stay present to the world as it is with open minds and hearts, knowing this nourishes our gentleness, decency and bravery.
We care for ourselves as tenderly as we care for others, taking time for rest, reflection and renewal.
We are richly blessed with moments of delight, humor, grace and joy. We are grateful for these.

Question 3: How has HAES been supportive of and successful for marginalized communities? How has HAES fallen short? What are some specific ways in which we can support and reach out to those most affected by the social determinants of health?

I received no response to this question.

Tomorrow, I shall post the second part of this roundtable, which is a single question that got an overwhelming amount of response. Many thanks to all the HAES experts who participated.


3 Comments leave one →
  1. Dizzyd permalink
    February 4, 2015 1:41 pm

    I for one want to be a hammer “chipping away” at the wall of oppression!

  2. February 9, 2015 2:59 pm

    Hi all, thank you for the discussion AND I think we can do better. First, please let’s notice that this is a bunch of white people talking without any context given. White people commenting on the SDH once again re-enacts the centering of people with privilege. Maybe there is some interest in what we are saying or maybe not, but I think your readership deserves to know we represent a small corner of the universe of lived experiences on this very important topic. Next, Columbusing alert: The critique of HAES and FA to include a more prominent emphasis on the SDH was being discussed well before the fall 2014 publication of “Body Respect.” I have no doubt that going all the way back to the beginning, the response of people who are facing racism, a lack of access to financial resources or medical care, daily stigma or lack of access due to illness or impairment, etc., has been to respond to “eat intuitively” or “exercise for pleasure” or “find a doctor that is HAES-positive” or even “resist the pressure to lose weight” with, “that does not solve the problem.” In 2012 there was a critical discussion at the NOLOSE conference on the racism of the FA and HAES communities (see and the repeated failure to center the voices of people from marginalized communities. At the ASDAH conference in 2013, a project to re-visit the HAES principles was launched and Jessica Wilson co-authored the revisions which were published in 2013. I note this because we are still failing to give credit to the people of color who have no obligation to teach white people about these issues but are being overlooked when they do. This is also true of disabled people and people who are marginalized for all kinds of reasons.

    For people wishing to hear from some other voices, I suggest regularly reading Black Girl Dangerous, Leaving Evidence, The Body Is Not An Apology, It Gets Fatter, My Kitchen Dietitian, and invite others to leave helpful links here. There is an Anti-Racism Group for Size Activists on Facebook and ASDAH has begun a tumblr here:

    [PS For the record, I was never president of ASDAH – I think you are referring to Deb Lemire.]

    • February 9, 2015 4:51 pm

      You know that this is only part of the discussion I am planning to publish. You also know that the early version of the roundtables included POC HAES activists, but that this roundtable fell apart. I sent the questions to the Show Me the Data group and invited all to participate. Finally, you know that I’ve put together a diverse panel of people who have been negatively affected by the SDH which will be released in the coming weeks.

      I’m not attempting to “Columbus” anything. Body Respect was the first major discussion I saw of the SDH in the context of HAES. My lack of awareness of Jessica’s role in these discussions was not an intention to not give credit. It’s the fact that I reside outside of the academic sphere where these discussions were taking place. I’m not a part of ASDAH and I have never attended an ASDAH conference.

      Finally, I was part of that “wakeup call” from nolose, which I took very seriously. It’s the reason I hadn’t done any big projects for the past few years and it’s the reason why, when I started this project and Jessica suggested I put together a panel of people directly affected by the SDH, I spent months attempting to assemble a diverse panel to discuss their experiences. I am trying to center the voices of marginalized communities, but even in that attempt I am told I’m doing it wrong.

      I am simply trying to host a discussion of the subjects that were brought up in Body Respect, but my experience in doing so has been the living embodiment of “the perfect is the enemy of the good.” Quite frankly, I would never undertake a project like this again. Ever.


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