Tomāto v. Tomăto —
Trigger warning: Discussion of fat health and weight loss.
For nearly five months, I’ve tried to keep a relatively positive public stance on the discussions I’ve had behind the scenes about Health at Every Size® (HAES). My resolve hasn’t been perfect and I’ve lashed out at perceived hypocrisy, but I’ve tried to maintain a measured posture on what I have seen as a seismic shift in the HAES philosophy concerning the social determinants of health (SDH).
Today, I am ready to speak openly about my views, having finally published the HAES expert roundtable (Part 1 and Part 2), my interviews with SDH experts Dennis Raphael and Stephen Bezruchka, and the SDH impact roundtable (Part 1 and Part 2). What follows is what I consider to be my definitive treatise on HAES, the SDH, health and weight.
I first learned about HAES in 2009, when I began writing on my piddling Blogger site. Back then, the entire concept revolved around personal lifestyle choices and how a healthy behaviors can yield long-term, sustainable benefits regardless of whether it makes you thin or not.
That revolutionary concept — health regardless of weight — completely upended my belief system and sent me on a quest to find out whether the science supported this approach or if HAES was junk science. Along the way, I’ve read a shitload of research and talked to a number of non-HAES experts on health and fitness whose viewpoints may not have been identical to those of Linda Bacon et. al., but whose research reinforced the lifestyle components of HAES.
For example, from my interview with Dr. Steven Blair:
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 … 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, over 50,000 men and women followed for on average more than 10 years and about 4,000 of them died. Sixteen to seventeen percent of those deaths can be said to be caused by low fitness; two or three percent of the deaths were caused by obesity; I think four or five or six percent 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.
As my understanding of the evidence grew, my personal behaviors began to change and, consequently, my health markers began to improve. You know what didn’t change? My weight.
These concepts were already demonstrated in Bacon’s 2005 research paper which pitted a traditional weight-centric approach to HAES. After a two-year followup, the dieters had regained the weight and lost their metabolic improvements, while the HAES group remained weight stable and maintained their metabolic improvements.
For years, Bacon’s study was the cornerstone of HAES and the foundation of a lifestyle philosophy I felt compelled to research exhaustively and promote vigorously.
Then, back in September, things changed.
I read and reviewed Body Respect by Linda Bacon and Lucy Aphramor, which seemed to reinforce this earlier approach to HAES as lifestyle choice, but introduced a new emphasis on the social determinants of health.
From the beginning, I have been whole-heartedly supportive of promoting the SDH as a vital key to improving health on a population level. Address socioeconomic inequity and you put marginalized people on a level playing field in terms of chronic stress and baseline health needs.
My biggest question, though, was what affect does this new emphasis on the SDH have on HAES? Body Respect does promotes the idea of the importance of healthy behaviors, but there are caveats throughout the book like this one: “Blaming illness on behaviors stops us from addressing the policies and systems that shape our lives in unequal and unhealthy ways.”
And when I asked Linda Bacon these questions, she told me that the effects of personal health behaviors were “blown out of proportion in terms of how they affect health.” Elsewhere, I’ve seen Bacon emphasize the fact that stigma is the cause of so-called “weight-related illnesses.” For example, from her post on the American Medical Association’s decision to label obesity a disease:
The AMA decision also leads to more prejudice and discrimination, which unfortunately, also increases disease. Extensive evidence shows the chronic stress of stigma plays a role in almost every disease currently blamed on obesity.
While stigma certainly can contribute to disease (as I learned from my interview with Dr. Rebecca Puhl), I find this new framing problematic.
First, there’s the issue of how personal health behaviors fit into the context of the SDH. The implication is that the effects of the SDH are so overwhelming that you can’t blame behaviors for illness. For example, there’s this quote from Body Respect:
[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.
This is absolutely true. In the first HAES roundtable, I was stunned to find the following graphic on the CDC’s website regarding the SDH:
Likewise, Dennis Raphael said that two individuals on the same socioeconomic level who engaged in opposing ends of health behaviors would have about a 15% variance in health.
In my view, the question then becomes does that limited variance make a significant difference in the lives of those able to make those personal lifestyle choices?
Just four years ago, Bacon and Aphramor published a paper in the Nutrition Journal that made a compelling case that they do. So what has changed?
What I see changing is that we have left out of our discussions of HAES a significant segment of the population who begin life in poverty and oppression, which contributes to a lifetime of inequality, chronic stress and limited self-care options.
Focusing on marginalized communities is vital, and addressing the negative impact of the SDH will have a profoundly positive public health impact. But it feels as though the emphasis from HAES experts is swinging hard to the other side of the pendulum. We’ve gone from emphasizing personal health behaviors as the most important health factor to emphasizing poverty and inequality as the most important health factor.
And yet, both emphases are true and both are important.
The SDH is a diabolical factor destroying the health of far too many people across the globe. But not everybody is negatively affected by the SDH. In fact, HAES rose to popularity as a countercultural response to a weight-centric culture that drove privileged people to pursue diet and exercise as tools of health management. More likely than not, the people who adopted HAES were in a position where their biggest concerns were over lifestyle choices, not whether they could feed their family or who is going to care for their children or how they’re going to get to work.
As Dr. Raphael said, “Once you’re living in a poor neighborhood, it doesn’t matter what your weight or physical activity is in terms of your likelihood of getting cardiovascular disease.”
So the negative effects of the SDH, and therefore the public policy responses that HAES could support in response, rest on a gradient. The more wealth, power and privilege you have, the less the SDH will contribute to your negative health.
For those privileged HAES supporters who don’t have to worry about the SDH personally (myself included), they want to know what else they can do to improve and maintain good health for as much of their life as possible.
This was certainly my aim. I’ve written about my family history of cardiovascular disease, and how my interest in HAES is framed by the reality of that genetic inheritance. I want to know how to stave off a heart attack for as long as possible.
For me, the personal lifestyle emphasis of HAES led to behavioral changes that yielded demonstrable metabolic benefits in terms of my blood pressure, blood sugar and blood lipids. When I lapsed in those healthy behaviors, I watched those metabolic benefits erode and the indicators of metabolic disorder creep up.
The SDH has given me the privilege to focus solely on that 15-25% of my health that I can affect through my behavior. And given the evidence of Bacon and Blair’s work, I see that, all things being equal, exercise and fitness can help me reduce my risk of morbidity and mortality. To me, that’s enough to justify a continued emphasis on personal behaviors.
And yet, at the exact same time, I can look at the reality of the SDH and its impact on those with less privilege and feel equally compelled to fight for greater socioeconomic justice for all. The impact of personal behavior does not need to be diminished to make room for the impact of the SDH. What it needs is context.
Again, Dennis Raphael provided some great context to consider:
There’s this guy, David Seedhouse, who wrote a book called The Foundations of Health, and he made the argument, philosophically, that unless you provide people with the basics, you can’t go after them on these other issues. What I suggest to people is that all things considered, you want to do what you can. You do what you can no matter what level. If you’re an anti-smoking person, you do anti-smoking, but you don’t do it like “You guys are just stupid, stop smoking.” You do it in terms of empowering them.
Any time somebody comes along and says “We gotta stop Latinos from smoking,” although they don’t smoke that much, you come out and say, “Yes, of course we do, but don’t you think we should be spending some time on the kinds of employment opportunities and educational opportunities that kids have?” So you just try to shift that 99% of attention to 95% or 90%, or just work its way down.
To me, this is how HAES should balance the dual emphasis of personal lifestyle behaviors and the SDH:
If you look at your own life and your own situation in relation to Maslow’s hierarchy of needs, you can get a rough idea of which HAES emphasis will have a greater impact on you as an individual.
If you’re struggling with those basic needs at the bottom of the pyramid, personal behaviors are largely irrelevant. You have more pressing health concerns affecting your day-to-day health, so adding exercise or improving your diet are low priorities.
If you have aren’t struggling to satisfy your physiological needs, safety and security, and love and belonging, then, if you wish to improve your health, you are in a far better position to start working on self-acceptance, intuitive eating and joyful movement.
Then there’s an additional layer to this: if you’re at the top of Maslow’s hierarchy, if you have the kind of economic security that affords you the time and resources to engage in healthy lifestyle behaviors, then you can find additional eudaimonic (my new favorite word) well-being by fighting for equity in this incredibly unjust world.
And if you’re at the bottom of that hierarchy and want to reduce the health risks caused by the SDH, then Raphael and Bezruchka recommend civic engagement and community involvement. Bezruchka pointed out that although Latinos are frequently at the low end of the socioeconomic scale, they have some of the best health outcomes. He and other researchers believe the mitigating factor is the cultural emphasis on family and community and social support that is virtually absent in the more privileged, social media culture that many of us live in.
But what we should not do, as HAES activists, is treat the effects of the SDH as universally equal or the benefits of personal behavior universally futile. Likewise, this new attempt to paint metabolic disorders as largely caused by stigma is problematic.
Stigma certainly affects health, but if weight stigma is the driving factor of the metabolic disorders associated with obesity, then Steven Blair would not have found such radical differences in metabolic health between sedentary and active people. If stigma was the driving factor, then thin, sedentary people would have better health and fat, active people would have worse health because stigma would still be absent and present, respectively.
Likewise, Bacon’s 2005 study found metabolic benefits despite weight stability in the HAES group. Bacon’s current emphasis on stigma makes little sense if she was able to help subjects improve their metabolic indicators without affecting their stigmatization status.
What I have learned most over the past five years of studying HAES is that the relationship between weight and health is incredibly complicated and individualized. The worst thing we can do as HAES advocates is to issue blanket statements that oversimplify the issues. Not all fat is metabolically dangerous, but not all fat is completely benign; not all “healthy behaviors” lead to noticeable weight loss, but not all weight loss leads to improved health; not all fat people suffer the ill effects of weight stigma, but not all weight stigma is harmless.
HAES should educate people about EVERY aspect of weight and health, then allow individuals to process all that knowledge and all that truth through the lens of their individual life experiences. Only then will HAES be capable of improving lives across the broad spectrum of humanity.