(Dis)Ease: The American Medical Associations decision to reclassify obesity

A Month ago (June, 2013) the American Medical Association voted to reclassify obesity as a disease. This was met with some very good critique from Fat Activists (here, here, and here among others) and brief flurry of media attention - largely consisting of opinion waiving about obesity, fat people, and the future of health care in our nation-state.  The usual suspects were trotted out, interrogated, and in the end the matter was but back to bed with the usual sentiments regarding the need for more personal responsibility and education for those poor (or disgusting, depending upon the subtly of the audience) fat folks.  It was, it would seem, Much Ado About Nothing.  After all, as most news outlets informed us, the AMA has no legal standing and the move is a largely symbolic and/or semantic one. 

This is where a lot of news outlets - and scientists - got it wrong.  The AMA may not have legal power, but they certainly have epistemic authority.  This move might be semantic and symbolic, but that hardly means it is without consequence.  This move by the AMA has very real impacts upon fat individuals, upon the science investigating "obesity" and upon our ideas about disease. 

When starting this blog post I pulled up a bunch of dictionary definitions of "disease" I think I like this one the most:

1. A pathological condition of a part, organ, or system of an organism resulting from various causes, such as infection, genetic defect, or environmental stress, and characterized by an identifiable group of signs or symptoms.

2. A condition or tendency, as of society, regarded as abnormal and harmful.

3. Obsolete Lack of ease; trouble.

Though I will attend to the first two options throughout the Blog post, in the end I think we will find that #3, the archaic or Obsolete definition is perhaps the most salient one: Trouble. 

Defining Disease

With all the hullabaloo you might think that the AMA is the first professional association or medical authority to classify obesity as a disease.  You would be wrong.  Medicare classified obesity as a disease (and therefore eligible for benefits coverage) way back in 2004.  In a lot of ways the AMA is late to the game.  You might also be wondering, "what was obesity before June of 2013??"  After all, we have been fighting a war against an "obesity epidemic" - how do you have an epidemic without a disease?  And when you went to the doctor and they explained the BMI to you and informed you that you were obese, that seemed like a diagnosis, didn't it?  It even appears on the billing forms with an official number and everything.  It seems like we have been treating obesity like a disease for quite some time now, but prior to Tuesdays ruling the AMA considered obesity to be a "'complex disorder' (Policy 7 H-150.953), 'urgent chronic condition' (Policy D-440.971), 'epidemic' (Policy D-440.952), and 'major health concern' and 'major public health problem' (Policy H-440.902).[1]"  The council tasked with evaluating and making a recommendation about the classification of obesity as a disease (and incidentally recommended against the reclassification) noted that "disease" has no set definition.  They note that no definition of disease exists which if implemented would positively render all currently labeled diseases, as disease; "Indeed, the medical community’s definitions of disease have been heavily influenced by contexts of time, place, and culture as much as scientific understanding of disease processes.[2]" 

            Thus, part of the difficulty in deciding if obesity is a disease is that we don't really agree on what a disease is.  The Committee on Science And Public Health (CSAPH)  Rep 3-A-13 report cited an earlier report's table of definitions[3] - which amount to the conglomeration of several dictionary definitions of disease.  So the AMA did the same thing that I did for this post, or any college student writing a term paper might do.  They pulled open a bunch of dictionaries and tried to find some consensus. In the end what made obesity a disease wasn't whether it fit a definition of disease (though that in itself is an interesting query) or whether the subcommittee found evidence in the medical literature to support the classification of obesity as a disease -- No, rather like the stripping of Pluto's planetary status, Obesity became a disease by vote.

In fact a great deal of scientific knowledge becomes scientific fact through the democratic process of voting.  Voting is what made homosexuality a disease, and then a disease if it upset you to be homosexual (DSM IV), and then not a disease at all (DSM IV-TR) in the span of a few decades.  The world of classification is not the cut and dry pursuit of independent "fact" that we like to think of it being. Now, that doesn't mean that there isn't truth or fact to be accessed, it just means that the epistemological process isn't always linear and it is often influenced by time, place, and culture much more than layman discussions of science account for. In fact there is no reason to think that what we think of as a certain disease entity today, and what we label as being the same disease entity in the past - they may not be the same entity at all (For a far more eloquent discussion see Ludwick Fleck).  What is more important is that they certainly were not thought of, interacted with or treated in the same way in the past, and this changed how they were researched, conceived of and what explanations and treatments were accepted.

 So the designation of obesity as a disease, or condition, or lifestyle is a semantic move. BUT that semantic move has a lot of baggage and meaning attached to it.  It also has very real impact upon how that entity (obesity) is thought about.  We could take the AMA to task for the definition they used, or the applicability of that definition but I suspect this has been done elsewhere.  I know that other sources have discussed whether or not this decision will be good for fat patients (incidentally the AMA committee based their recommendation to not change the classification upon the assertion that such a change would NOT improve health outcomes), and whether or not the classification is valid - but I have not seen a source that gets to the epistemic impact of this move.  So it is far more interesting at this junction to attend to the fall-out of the AMA decision.

Fuzzy meets fuzzy - Defining obesity

One of the primary reasons the AMA's own council on Science and Public Health recommended against classifying obesity as a disease was a lack of satisfactory definition of obesity: "Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state. Similarly, a sensitive and clinically practical diagnostic indicator of obesity remains elusive."  We know that the use of BMI alone leads to erroneous classifications of obesity (Tom Cruise is obese using BMI).  However, it is not just a matter of weeding the fatties from the muscle bound - there is much more to an adequate definition of obesity.

What is obesity anyway?  If obesity is a disease, what is the disease agent?  Is it fat - does that mean we all have some of the disease in us?  Is it too much fat? How much fat is too much fat?  What do we use to determine what makes a certain amount of adipose tissue too much adipose tissue? Do we use population distribution? ... How many deviations from the mean are we allowed to go?  Does that mean that as the population gets fatter, the level of acceptable fat moves with the population?  Should we use Social standards?  Should it be based on the point when fat begins to affect your health?  But then we would need to know how it affects your health, what the mechanism is, when it affects your health - that sort of thing that we actually don't have a lot of information on.  We could base it on statistical evidence, so the point at which excess fat becomes correlated to negative health outcomes (though we would need to pick a threshold and have a way to measure fat that is accepted and standardized).

The difficulty, and what makes obesity research fruitful to investigate, is that defining obesity as a disease is where the fuzzy meets the fuzzy; the fuzzy ways we define disease and health, meets the fuzzy ways we define obesity.  In certain ways obesity as a disease reveals the circular logic that comes from substituting common sense for data.  

• According to the AMA obesity is a disease because it is associated with negative health outcomes. 

• BUT the category of obesity exists to designate levels of adipose tissue that are healthy from those that are unhealthy (by virtue of negative health outcomes).*

• The categories are arbitrarily chosen, and quite wide

• BUT the existence of increased mortality at the high end of the obese category supports the idea that obesity is associated with negative health outcomes.

• Therefore, obesity is a disease.

* Except, that the methods of categorizing obesity are actually pretty bad at distinguishing who has too much adipose tissue and who doesn't.  They are also bad at accounting for why some people who exist in the category of "obese" fail to have negative outcomes, while others who do not fall into the category of "obese" do have negative health outcomes (and the often the same negative health outcomes like Type II diabetes and metabolic difficulties). 

Hmm...that does seem problematic, doesn't it?

Impacts:

So, beyond the problems of validity this move poses, what does this rhetorical turn of events do?  Why should we care?

Well, first of all it makes it so that No fat body can be healthy.  This is a big deal.  When we thought about obesity as a condition or a risk factor there left some room to think about fat bodies as potentially healthy bodies.  If excess adipose tissue in and of itself constitutes disease then no fat body can ever be healthy.

Now the idea of the fat body as always becoming (and never stable) is an idea that is pushed around a lot in fat studies.  The fat body is always becoming something - and usually it is becoming one of two things:  1) thin or 2) dead.   There is a certain narrative to the way that we talk about fat bodies.  There is a constant state of potentiality - you as the fat body are always the "before" picture.  If you are a virtuous fat body you are pursuing the end goal of becoming thin. You are actively attempting weight loss (though scientifically speaking your likelihood of success is quite slim).  If you are not actively pursuing weight loss than you are left as a fat body that is rhetorically painted as diseased and doomed.  You are dying. This AMA decision extends this logic to the realm of scientific fact production.  By making obesity itself a disease, the health or ill-health of the fat body is taken off the table.  You are fat therefore you are sick, end of story.  So even if you are fat but otherwise in perfect health - good BP, good lipids, no joint complaints, good sugar, exercise regularly, eat your vegetables, don't smoke, don't drink - it doesn't matter because you still have a disease.  Now this is very reflective of the attitudes that many physicians (particularly Bariatric physicians have) about obesity.  The fat body even when not presenting symptoms is just in a state of pre-sickness.  When presented with the case of a fat person who is in good health the response is often that the person is "just not showing symptoms yet."  This vote reflects that attitude about fatness - without new data, without addressing the literature that indicates one can be fat and healthy.  The definition has become the justification for the disease.  This vote attempts to effectively end the HAES(r) discussion.

This is why we should care about this ruling.  This move by the AMA, in defiance of their own committee's recommendation, substitutes common sense for evidence.  That is something that no one should be comfortable with.  Whether you are a Fat Acceptance advocate or you identify with the idea that fat is patient's rights issue - even if you are a obesity researcher that believes to the tips of their boots that fat is unhealthy this still shouldn't sit right with you.  This is not evidence-based medicine and it shuts down productive avenues of investigation and inquiry.

The move to classify obesity as a disease comes to soon.  We don't understand enough about obesity to call it a disease.  We can't agree on what obesity is, better yet what causes it.  Is obesity a symptom, or disease entity on its own?   How does obesity cause all the myriad diseases it is supposed to influence?  How can obesity be a symptom for certain other diseases, an outcome of health choices and behaviors and a disease all by itself?  By classifying obesity as a disease before we answer these and other important questions related to fat that we have just finally started to ask the AMA has filled in the facts we don't have - and that is going to affect how obesity is studied and treated from here on out.

Just look at the effect that the 2004 Medicare decision had - it bolstered the obesity epidemic paradigm and set in a particular way of seeing fat and obesity.  Just as we start to unravel some of that set viewpoint this decision again forces a particular way of viewing fatness that will shape research and funding in the future.   Think about obesity research as a message that we only have some of the words from (a two word phrase from a game of hangman for instance).  This move fills in the first part of the sentence and assumes that it is correct (without knowing it is), and now researchers will investigate the rest of the sentence based on that assumption. 

This solidifies obesity as a disease entity in and of itself - that creates a bandwagon for researchers - just as the obesity epidemic did.  This is a way of thinking that is intelligible to scientists and can be accessed to access funding (or in this case insurance reimbursement) but that means that only those strategies which address this way of thinking will be considered and proliferated.  To make this move without foundation is very dangerous.  It will effect everything from funding, to policy to hypothesis formation for thousands of practitioners for years to come.

Lastly, this is move that is yet another transition from what we do to what we are.  Michel Foucault argued that there was a shift around sexuality, from what we do to who we are.  With this shift comes a great deal of baggage and problems.  This shift in the way we think about obesity medicalizes a bodily state.   Fat goes from something we have, to something we are, to a state of automatic ill health.  This is highly concerning and highly problematic.  The medicalization of the fat body is not new, it doesn't start with the AMA, but this move does compound that status. 

This AMA move was supposed to be about easing the burden for fat people.  As the NY Times notes, some at the AMA hoped this change would "reduce the stigma of obesity that stems from the widespread perception that it is simply the result of eating too much or exercising too little[4]."  However, historically classifying something as a disease or as biologically based doesn't absolve the individual of the burdens of stigma.  At best the question of culpability remains (as it has with addiction or LGBT status) and at worst the condition is compounded by the stigma of disease.  We already see strains of this in conversations about whether or not Fat can be "caught" from friends and neighbors.

In the end we are left with what we started with - Trouble.

---

[1] http://www.ama-assn.org/assets/meeting/2013a/a13-addendum-refcomm-d.pdf

[2] Ibid.

[3] See Appendix, http://www.ama-assn.org/resources/doc/csaph/a05csa4-fulltext.pdf

[4] http://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html?_r=0

Food banks, Food justice, and a living wage.

One of the things I love about teaching and presenting material is how much it pushes you as a scholar.  You present material and in the act of preparing and putting it all together you have to write a story about the subject you are trying to teach about. Story telling is a lot of what teaching is - you have to tell the story in the right way, with the right frame to get your point across.  You have to be careful of what narrative you use, and not to traffic in tropes and stereotypes.  However, whether you are teaching about society or mathematics there still needs to be a narrative arc.  This pushes you to figure out what the large themes are, what the take away is – where the plot twists and turns, who the actors are... 

Then once you have presented your story, you get questions and it just shatters the whole narrative.  To me, this is the best part. This is the moment you really figure out what you know about a subject, and this is the moment that “Ah-ha!” can happen.  I can’t tell you how often I present something and from the questions asked and the way I am forced to explain my thinking I get a whole new train of research.

Today, I presented on a subject both near and dear to me – and a bit of a hobby – Food Politics.  Most academics I know have two subjects they study.  One is dominant and the other is peripherally related to the dominant subject, but secondary.  You have to have something to turn to when you are overwhelmed with you current subject.  For me food and food policy, is my “mistress” research.  It is what I consume in dark corners, or on my days off, or when I cannot possibly face my primary research anymore.  I love reading about the ways people think about food, consume food, and try to make it better – then rail against the results.

Today I was asked why I study what I do, because it seemed interesting but not like something people would often get into.  I gave my stock “I am a science studies person and I think proof is interesting,” answer, and then anecdotal stuff about my struggle to eat food without soy…but the student asked what my undergraduate major was (Psychology) and it made me remember where my interest in food policy really began.

My first job out of college was as a social worker.  I was a Case Manager for adults with severe mental illnesses.  I was 23, newly married, and wholly ignorant of the world. I was an idealist; I had majored in psychology in part because I thought people were interesting but primarily because I wanted to help people.  I wanted to CHANGE THE WORLD – in that way that young people want to do.  Though my stint as a social worker was brief (I burnt out after three months) it was the most enlightening and depressing experience of my young life.  Having been raised in a progressive and liberal household I had sympathies for what I saw as the “struggle of the poor.”  I understood I had opportunities as a middle-class, white, American that were in no way universal.  Until I took that job I had no idea how extensive that privilege was, or how hard it is for people to overcome with hard work alone. I had no idea what being poor or poverty looked like.  I thought I did, I thought I had seen it represented on television.  What I found out was that what most Americans think of as “poor” is really just lower-middle class. I had no idea that some people live in what for lack of a better term are called motels – week by week rentals with rooms not much larger than a single bed and rents that are quite frankly outrageous – because they can never manage to save enough to pay a month of rent up front.  Of course the cost of the weekly rental helps ensure that they never will.  I had never seen someone living out of their car while maintaining a job, or what a homeless shelter looked like.  I had never seen poverty, hunger, desperation… I do not care to list all the things I witnessed in those months, the result was that I realized how very privileged and sheltered my life had been. It was incredibly humbling, and overwhelming.  Particularly as I realized that my job as a social worker was primarily triage – stop the bleeding – I didn’t really have a chance to heal the problem.

I remember the first day it was my turn to be on food box duty.  Many of our clients (that is what they preferred to be called) made use of food pantries in addition to food stamps to meet the needs of their household.  They often could not get to the food bank themselves. We as case managers would take turns going out to the food bank with the paperwork for all the clients from out team that needed food boxes, collecting the food boxes and then distributing them.  I went and picked up eight food boxes that first day – which turned out to be eight grocery bags of food.  These were mostly shelf stable items, cans of vegetables, Spaghetti-O’s, beans, cereal, and pasta.  But that week they included a rare commodity – some fresh grapes.  The woman at the food bank was kind and matter-of-fact as she processed the paper work and helped me haul the bags to the car.  She told me how lucky this group was to get fresh fruit, they rarely had it to distribute. She then reminded me of policy that each family could only get one box each month and to talk to the clients about how to avoid needing to use the pantry in the future. 

I set off to drive those eight boxes to eight families in need.  I don’t know exactly what I expected of those homes, I only remember that what I found was not what I thought would be there.  Each home was different.  Some were in small motel rooms like the one I mentioned, some lived in apartments, some people owned their homes but just couldn’t afford food that month.  They lived all over the city.  Each place, each person, each story was different.  What was constant was that each person was happy to see me – not a common occurrence in case management. They were happy to see the food - even when some of them lamented about the type of food available to them (“I hate green beans”, “ugh, wonder bread” “oh this pasta is expired”– it ranged the gamut of tastes and concerns).  Being a young and new social worker I dutifully discussed food budgets with each person I delivered a box too.  I was shocked at what I found.  Contrary to what my younger self had thought these individuals were doing all they could to make their budgets stretch.  No, many did not cook from scratch as I had been taught to advise, but they had very good reasons not too.

Some just didn’t have the time.  One woman who cared for her sister worked two full-time jobs and cleaned houses in her “down time.”  When was she going to find the hour plus a day to prepare a meal from scratch?  Her sister was not able to prepare food unsupervised so the family relied on quick and easy to prepare meals and often fast food.  There was an elderly woman who lived on Social Security who had the time and know-how to prepare meals from scratch, but her home only had a microwave.  She didn’t even have a burner – just a hot plate that if the landlord found out about she could be evicted for.  Another woman (and overwhelmingly that day I spoke to women) did prepare meals from scratch for herself and her children, but had trouble accessing ingredients.  She did not have a car and the Phoenix bus system was woefully inadequate.  Hauling home a gallon of milk the half mile from the bus stop in 110-degree weather? – forget about it! Would it even be edible by the time she made the hour-long trip home from the grocery store? She relied on powdered milk, but the children hated it.  Again and again I found that though each person listened, either with interest or an air of knowing this was the price of the food box, they made it clear they had reasons for needing the food.  Yes, some of the clients I encountered had lost their food money through illegitimate means – they spent it on drugs or alcohol – but this was the minority of those that I saw.   Seeing the conditions they lived in and knowing the mental health challenges they faced I began to see even this as not so much a personal failing, but a symptom stemming from the system.

Ultimately the experience changed my life.  It made me realize how much of the problems we face as a society can be traced back to systemic issues.  It got me to think about food and all the moral issues that come with it.  The way we often deny the needy the right to have tastes and preferences (if you are hungry enough you will eat it).  The way we deny them the right to desires and pleasure through food.  The paternalistic notion that people are poor or hungry or lacking in means because "they don’t know any better."   It also made me an advocate of food pantries – Please people donate to your local food bank!  You cannot imagine the good they do.

The concept of a food desert has caught on lately, and certainly they are challenges to health and food security, but the problem goes deeper than putting in a grocery store.  We need to be certain the people in a community can afford to shop there – and have the time and resources needed to prepare the food found there. 

Today I was asked, essentially, if taxing soda wouldn’t work, what will?  I answered that if we want to address health we can’t just address weight – it is a poor indicator and a lazy stand in for good public health practices.  If we want to increase the health of the social body, we need to increase access to fresh food AND the ability to prepare it. It is about equalizing choice (no not that elegantly). 

 Having thought about it I would now add the following.  If you want to combat the illnesses associated with poverty, raise the minimum wage, increase public transit, and expand the safety net –including some form of universal access to health care.  We might also try subsidizing the kind of food we want the public to eat, rather than subsidizing dairy, meat and corn syrup and then calling the fall out from it a personal failing. 

A living wage will allow people to work fewer hours to meet their basic needs – which gives them time to prepare food for their families.  A living wage means being able to access transport to the store to buy food.  It means no more working poor – people who cannot access services but cannot meet their own needs even though they work full time.

Public transit means getting to a store with produce or a farmer’s market and getting it home without a car, and without it going bad.  It also means more people walking and less fumes in the air (environmental justice being a whole other important topic).

In the short term, donate to your local food bank. 

The problem with talking about your fat as pathology

    Recently, Jezebel, published this article Titled "I Ate So Men Wouldn’t Pay Attention To Me" which garnered the typical mish-mash of "Fat is so unhealthy, glad you are getting thin!” "Don't fat shame", and "jeez, it is so easy to lose weight people just eat less, duh!" commentary. Perhaps most striking is how little discussion there was about street harassment in an article that at its core was about street harassment.  The discussion, such that is was (and general fat-is-so-bad-eat-some-celery nonsense aside), split along two camps:  Individuals concerned about the way that this woman's story enforced certain stereotypes about fat ladies and contributed to fat-shaming, and camps who wanted to honor the person's individual experience and a general right to her own narrative.  The thing is, both camps are right, and also a little bit wrong.  Most importantly this article illustrated how hard it is to talk about disordered eating and personal trauma in a fat positive framework.

            I have seen this sort of conflict come up before within fat acceptance circles.  On one message board I frequent a new member posted the question “Why are you fat?” along with an in depth evaluation of her perception of the psychological torments that she believed had driven her to eat.  What followed were a series of comments ranging from other tales of pain, to flippant comments about bacon consumption, to angry retorts about genetic predisposition and general uncertainty about why anyone is the size and shape they are.  It was a hornet’s nest, and the girl who had started it all had no idea why there was so much emotion floating around – and I can hardly blame her.  The notion that fat is a sign of emotional distress is a pretty common perception.

           

            I once took a graduate level Cultural Psychology class with a very passionate, well-intentioned, progressive teacher.  She spent the semester trying to convey to her students the reality of racism and sexism and how important policies that mitigated institutional racism were.  She wanted us all to be aware of bias and prejudice, to work against it.  And then one day she told us all – in a very matter of fact way – that no fat person can ever be happy in the United States. Ever. Fat people are just sad, depressed, damaged people.  And she didn’t just mean that institutionally we won’t allow for the concept of happy fat people, she meant that ALL FAT PEOPLE ARE DEPRESSED.  She was utterly baffled when I tried to explain how biased and hurtful this statement was.  I learned so much from that instructor and I am forever in her debt for the ways she was able to influence my ideas and approaches, but part of my still feels the sting when I remember her comment, and all those eyes swiveling toward myself and the other noticeably fat girl in the room.

            This is a refrain many fat people are familiar with; our fat represents pain.  Overwhelmingly, there is a perception that fat people cannot possibly be happy. We can’t be happy with our bodies, and we can’t be happy with our lives.  This is an idea that floats around, both in general society and in psychological communities.   Watch some TV talk shows or pick up a women’s magazine talking about fat, in particular women’s fat, and you will likely see a lot of talk about emotional eating, stuffing our feelings, and how releasing of emotional baggage is necessary (and leads to) the release of our physical “baggage” as well.  I have read articles claiming that fatness is related to hoarding, that my cluttered house is making me fat, that sexualized youth leads to fatness, that all over-eating is emotional eating.  Fat is a sign of depression, or anxiety.  Flip on Dr. Phil and hear all about how each pound of fat is a physical representation of the overwhelming sadness of the fat person.  The lesson seems to be, “Don’t scorn fat people, pity them instead”  -- of course this sort of attempt to humanize fat through pathology just results in what Eve Sedgwick would call an “Open Secret” about our fat.  Which is that even if people buy into the idea of fat being the result of pathology, it will always come back to a matter of willpower in their minds.  We all know that even when we talk about addiction or emotional pathology, in the last instance it is a matter of choice – to smoke the cigarette, eat the donut or suck the dick.  We open our mouths and commit the act. (which of course presumes a direct link between how one looks and what one consumes or other behaviors, but that has to be a subject for another day) So not only have we taken on the mantle of pathology, we are still stuck with the label of weak willed.  We end up both pathologized (a problem in and of itself) but scorned too.  Sick and weak willed.

            You can easily see this trend in the comments of the Jezebel article.  Respondents who see the author’s position as merely justifying her actions, who still impeach the author’s credibility by seeing this retrospective explanation as unlikely or suspicious.  Even those who embrace the idea that fat can come from fear and pain still admonish the author to lose the weight and get healthy – in this instance not only is physical health conflated with body size, but mental health as well.

            Now, you might be thinking, “That is all well and good Julia, but some people do have disordered eating and pain.”  And to that I would say, “You, betcha! And that is the catch, that is the double bind in the way we have to construct ourselves as fat activists in order to gain power, gain favor and gain rights.”  We have to fight against stereotypes, we want the world to know that fat bodies aren't necessarily sick bodies, and fat people can be happy, healthy people. But that makes it hard to find a place in our community – better yet outside of it – to talk about disordered eating, or painful experiences that might be linked to our bodies.  And we need to talk about it, because identities and bodies are complicated, and our experiences of our bodies are complicated too.  But, in order to access rights, we have to counter the open secret, and so we end up committing rhetorical gymnastics.  Because there is a WHOLE LOT WRONG with the way this article in Jezebel was constructed and presented, but there is also a whole lot wrong with not having a place for voices that want to talk about what this article was about.

       Part of what this Jezebel article fails to address is that the ability to talk about your personal relationship with food, or your personal food and body related pathology, without the expectation that this anecdotal evidence reflects upon everyone in your size category, is a privilege.

            When someone who is of a normal, or "socially acceptable" body size talks about their personal struggles with food, body image and pathology, they are just talking about their own experience. There isn't an existing paradigm that says all "normal size" ladies (and gents) are screwed up about food, or psychologically damaged. However, there is an existing perception of fat bodies as already always representing pathology.  Big bodies represent out of control appetites, damaged psyches, and undesirable bodies.  Thus when a fat person talks about their disordered eating, it is often taken as a reinforcement of existing stereotypes - it is seen as representing all fat bodies. Skinny women have a similar stereotype floating over them - thin women often deal with accusations of eating disorders whether they have them or not.  When your body sits at either end of the poles and you talk about your body, you are also unfortunately representing all bodies at your end of the pole.  It isn't fair, but it is the truth.  And this renders public self exploration of psychological pain or disordered eating habits as personal expression a thin privilege.

            The Jezebel article also presumes a level of agency over body size and shape that is problematic for many within the Fat Acceptance community.  To compare weight to a “baggy shirt” implicitly incorporates the idea that weight can be put on and taken off at will – like an article of clothing.   This is a very common notion about weight and it is often represented in how we speak about the experience of fat, when we speak pejoratively.  Evoking the notion of a “fat suit with the zipper stuck” or a baggy shirt implies that the body is malleable, and will bow to our will if only our will is strong enough.  It also supports the notion that inside all fat people there is a thin body just trying to climb out.   For fat people who have struggled with the reality that bodies have agency, and we cannot always get them to do what we want them to, this is a particularly offensive and troublesome idea.

            Last, this article engages with the important topics of street harassment, sexuality, and by extension sexual assault and their relationship to weight in a non-reflexive fashion.   The author speaks of her perception that fat women were not sexualized (and by extension not sexual) beings without examining to what extent this perception is real.  Nor does the author consider the flip side of the bind that she finds herself in.  She wants to be free of harassment and thinks that adjusting her body to be “unattractive” will prevent this harassment.  However, the fat body is not necessarily unattractive – there are many men and women who find voluptuous fat bodies attractive, drop dead sexy even.  Indeed, fat women in particular face a strange set of perceptions when it comes to our sexuality.  We are branded as unattractive and thus ascribed a certain asexuality – we are at least expected to be celibate even if it is against our will – and often we are supposed to be all right with that asexuality if we want to be socially acceptable.  The jolly fat lady who has put her days of sexuality behind her, but has lots of hard candy to pass out so it’s alright love.  *Wink*    The flip of this is the hypersexual fat woman.  She refuses to take on the mantle of asexuality and so her desires are constructed as monstrous, excessive and even dangerous.  This is the large woman we see in situation comedies who seems to think she is sexy, even though we all know she isn’t! As a community we laugh at her desperate attempts to mimic sexuality.  In either case the fat woman’s sexuality is always impotent, and unreciprocated.  

            Thus, the author’s failure to acknowledge that her perceptions were just that, perceptions and internalized stereotypes, ends up committing a kind of violence against fat women and their sexuality.  It is an unintentional and unreflexive violence, but violence none-the-less.  And it is a damn shame, because delving into this topic could have been both productive for the community and potentially healing for the author.   

The perception that fat women are asexual, (and therefore subject to potential violence for violating the implicit contract with make hetero-normativity to be available for consumption) and conventionally attractive women are sexual, and always available for consumption are two sides of the same problem.  Wouldn’t it have been amazing if we could have gotten to that conversation instead of being stuck on the open secret of will power, fatness, and pathological bodies?
We need to have these conversations people.  We as the Fat Acceptance Community need to be able to talk frankly about the threat of pathology and how it keeps some silent about the violence and pain associated with their bodies.  And we as a feminist community need to have a frank conversation about bodies, fatness, and sexuality – because it is important to combating street harassment and rape.  This was the perfect storm, we each community, derailed the other.  It is the perfect example of why feminism needs fat acceptance and why fat acceptance needs feminism – so we can talk about these things without reciting some thin-privileged, patriarchy affirming script. 

This article is influenced by Eve Sokofski Sedgwick's Chapter on "Epidemics of the Will" from her book Tendencies

Health Justice and Obesity Epidemic Language: The Temptation and Constraint of Available Rhetoric

This last week, Michelle Obama appeared on The Daily Show  (The interview begins around 11:36), to promote her new book on gardening and ended up discussing her quest to "End Childhood Obesity."

Though the interview is supposed to promote her book,  John Stewart begins the interview by talking about Michelle Obama's project as first lady, which he describes as a quest to "get children to eat well."  Almost immediately upon responding, The First Lady redirects the description of her program by first stating "It was really my experiences as a mother trying to get my kids to eat well." She then continues, "What most people don't know - we're seeing an epidemic of childhood obesity.  One in three of our kids will be overweight or obese, and we are spending Millions of dollars in health care costs for preventable illnesses."

              Now this statement is all kinds of problematic.  It projects that children that are now obese will become obese adults - which isn't actually supported by what we know about patterns of body weight (there isn't a one to one relationship between childhood obesity and adult obesity).  Although there is increased risk of becoming an obese adult if you were a "fat" baby - that relationship is only an increase in risk and not an imperative.  Further, the relationship between fat babies and fat adulthood is mostly confined to those at the extreme upper end of the bell curve.  This is just one of the problems with these sorts of projective statistics.

 The statement also conflates a message about health with a message about body size.  The unintended consequences of Michelle Obama's conflation of obesity and health has been discussed elsewhere.   Of further concern is the implication that obesity leads (as a cause) to particular health problems, which in turn cost an ambiguous "us" Millions of dollars.  This one is a whopper - and I think I will have to come back to it later.

Though the above statement  is ripe for a variety of analysis focused upon the dangers and difficulties of the "obesity epidemic" language - that is not what I want to talk about today.  Today I would like to do something different.  I want to think about why The First Lady may be using the rhetorical strategy she is using - because her intentions and the message are not always syncing up.

*********

I want to start off by saying I really rather like Michelle Obama - I always want to root for her when I see her in appearances.  This is why the above statement struck me right in the heart when she said it.  I want to be able to back The First Lady's plan - in part because it gets so many things right.   I mean, getting kids to eat better and exercise, pushing equity of access to activities to lead to health... These are things I can really support.

So why, WHY, the use of obesity epidemic rhetoric?  Why focus on the chubby tummies (appearance) if what you want is to effect the cute little feet(actions)? 

Well first lets review all the other things about health Michelle Obama said in her interview...


After her statement about the statistics of childhood obesity she then goes on to talk about her own observations about the causes of poor health for America's Children:

• Two busy parents who don't have time to cook leading to eating out too much
• Excessive television watching (or overall screen time)
• Activity being eliminated from schools

Those all sound like behavior and action based observations - and ones that would fit into HAES (health at every size) approach to nutrition.

Further investigation at the "Let's Move" website indicates a similar preoccupation with trends that reduce the activity of children while increasing their caloric consumption.   So it has shades of calories in/calories out, and it insists on an idea that what one eats and activity are directly (And without mitigation) causal for obesity.  It is hardly fat positive - but if you look past the parts about obesity epidemic the focus upon eating in moderation and with variety and moving more to gain good health isn't such a bad one.  Also, the focus upon schools as a sight for activity is encouraging to me.

Mrs. Obama goes on to say, "It is a different world...with modern life things are changing.  Many kids are living in communities where their parents don't feel safe having 'em run outside.  You know fast food is the ... rule rather than the exception."

Her recommendations to solve childhood obesity

• The garden as a way to start the conversation
• Kids being involved in where their food comes from
• (implied in conversation is getting children to move more)

And from the "Let's Move" website...

• Move Every Day!
• Try New Fruits and Vegetables
• Drink Lots of Water
• Do jumping jacks to break up TV time
• Help make dinner

If you read through the Let's Move! website it becomes increasingly clear that the program is: 1) surprisingly HAES friendly and 2) contains a very strong social model of health. 

Now I am not saying that the methods presented in Let's Move! forgives the anti-fat rhetoric, nor do they compensate for the disservice that conflating size and health does. What I am saying is that the message about childhood obesity and the message given by the method presented are contradictory - and it made me wonder why?

And then I thought about the interview she did with John Stewart.  The way he introduced her was to say that she was on a campaign to make kids eat their vegetables.  So what does she do?  She jumps in with a rhetorical position that puts weight (no pun intended) behind her position.  She isn't "Momming" the world, she is tackling a serious problem that requires serious resources.

This is the double edged sword of the obesity epidemic language - this is the power it bestows!  When you evoke obesity as an epidemic you tap into a sense of urgency, professional medical authority, and moral righteousness that gives your claim power.  When you then link that rhetoric to concerns over finances (an increasingly popular tactic), particularly skyrocketing health care costs, your quest to get kids to eat their vegetables suddenly seems a whole lot more legitimate.  It becomes a crusade to save the Future of America - not a quintessentially feminine endeavor focused on the generalized welfare of children.

Thus, I think the simple answer to the question "Why is a project focused upon health behaviors, like Let's Move!, invoking childhood obesity as the problem it is solving?" is that linking Let's Move! to the existing hullabaloo about obesity gives it instant authority and urgency.  It is the most effective rhetorical trope available to make the public and press care - and to access funding.

Michelle Obama could have declared her project childhood health, or more pointedly Health Justice for Children.  The project that she could put into place for those goals probably wouldn't have looked that much different from what she has proposed now - when you really get into the vision of the Let's Move! campaign, it is focused upon societal level actions for societal level problems: reinstating physical education in schools, making neighborhoods safe for the engagement in physical activity, making certain all neighborhoods have access to affordable, fresh vegetables...these are health and food justice issues!

But what would have happened if Michelle Obama had unveiled a plan that stated her goal was to guarantee equal access to the predictors of health?  Particularly in the climate of the 2008 election?  I imagine that if the initiatives listed on that website were framed as issues of equality or social justice they would very quickly have been labelled as "socialism" - after all, there wasn't much in that time period that wasn't being labeled socialism.

Is that what the people who marketed Let's Move! were thinking? I have no idea - in many ways this is nothing more than a thought exercise.  But that doesn't make the result of the scenario any less important.  Because, truth to tell, programs that tend to social welfare and social justice in this day and age are woefully under-funded.  They are increasingly unpopular.

This is the temptation and the danger of obesity epidemic rhetoric - and this is what we must learn to wrangle with if we want to change the discourse; If you can build into your social justice program - any social justice program - an element that will combat the obesity epidemic you have access to funds.  Desperately needed funds.

But here is the rub.  In accessing and using those funds, you are buying into the discourse. And that means all these great health and social justice ideas are wrapped up in ideas about personal responsibility and the pathology of the fat body.  That is why you can't have a discussion about obesity epidemic, or fat without also having a discussion about gendered, raced, and classed bodies.  All of our discussions about obesity epidemic are inherently political, and inherently about which bodies are fit and which ones not -and how we tell.

Why do your arms look like that?

As women in this country we are subjected to the reality that our bodies are (presumed to be) public property.  They are gazed at, commented upon, judged, policed - touched without permission. Ask any pregnant woman and she will relate to you the experience of strangers stroking her belly without even asking.  Who among us has not been subject to disapproving and judgmental stares?  To comments upon out clothing being too tight, too short, too loud -- too much or too little?  Female bodies are seen as decorative bodies, there for the viewing and pleasure of others.  Whether it is the subtle perusal of an unknown man, the disapproving gaze of other women - or the blatant cat calls of street harassment, the experience is objectifying and largely unpleasant.

"And sin, young man, is when you treat people as things"

This is the objection of Granny Weatherwax from Terry Pratchet's Disc World Novels (Carpe Jugulum),  followed by her ubiquitous attitude of "I can't be having with that sort of thing"

I am inclined to concur.  The trouble with the male gaze or the ostensible public property of female bodies is that they make people into things. Which leads me to the subjects of street harassment and fat shaming.  Street harassment is something most women have experienced from time to time - the experience of being yelled at, usually in a sexual or lewd way.  It is one of the many ways that we are reminded of how our bodies are public spectacle.  If you are a fat woman, street harassment may often come with comments about your weight.  It may also come from other women - in the form of dieting advice.  I have heard stories from fat women about being cornered in restaurant bathrooms and being given advice on how to slim down.  Or having other shoppers at grocery stores glare and comment upon your food selections (or in one particularly strange story start removing "fattening" foods from your cart).  The experience of being treated this way is complicated and upsetting - but I think what all experiences of street harassment and fat shaming have in common is that they treat people like things.

I have had mercifully few experiences with street harassment - either directed at my weight or my general appearance. I've been yelled at by boys from a moving car ("fat slut!"), and once in Cork a man came up and barked at myself and three other girls, and of course I have had the near ubiquitous experience of fat-shame in the doctors office (a subject for a different post).  However, the worst experience I ever had with fat shaming came from a surprising source - the Open House at a Women's Studies Graduate Program.

I know there are a lot  of well meaning people in the world who want to teach their children or themselves to not judge others based on size or skin color or impairment.  I met one such well-meaning individual when I was deciding which graduate program to attend. She was, admittedly, a bit strange from the get go.  She asked me a lot of impertinent questions about which schools I had applied to; where I had been accepted, where else I had gone to open houses - how much funding I was being offered.  This continued to be pressed until I finally told her I was considering one other school at that point, a UC - and no I would not tell her my funding package.  When she heard the name of the school she became strangely agitated that I had been accepted there "They took you? They didn't take me!" - it was a bit shrill and a bit condescending as we stood in the restroom after having lunch with faculty.  I really didn't know what to say.

This woman confused me, she presented herself as very friendly, open and progressive but also seemed strangely obsessed with me and my body.  She asked me about my experiences as a fat lady - did I get harassed? No, I said - I rarely had anyone comment on my body.  She nodded and seemed a bit confused.  It was hard she said, being a woman - so many pressures to be thin.  This woman had a daughter, and she confided that the state they came from (Bay Area, CA) was very appearance obsessed.  That she was concerned that her daughter would grow up to hate her own body - and that she (the mother) wanted her daughter to be accepting of everyone. She related that her daughter had started noticing differences in people.  She told me how she wanted to be sure that her daughter knew that everyone came in different sizes.  What did I do - she asked - if children commented on my weight?

            I was a little uncomfortable at this point.  This was before I had found Fat Acceptance as a group and the useful language that comes with it.  I had been fat for years and I was comfortable with who I was.  I had read Marilynn Wann's "Fat!so?" and even before that had come to the moment with family and friends where I requested that they stop insisting I wasn't fat. I as fat, I knew it - it was OK.  Fat was only a problem if you said it as an insult.  So I was torn, on the one hand I found this woman's insistence on talking about my body rude and a little bit insulting.  On the other hand I wished more people would be aware of the messages they were telling kids about bodies.  So I grinned, gritted my teeth and tried to hand out a few enlightening tid-bits about the idea that people come in all shapes and sizes and that she ought to treat questions about fat the same way she would inquiries about hair color.  I walked away and hoped it was the end of it.

It wasn't.

I must interject at this point that I had been nursing a migraine all day during this experience.  By early afternoon I couldn't take it anymore and I went home to take medicine and sleep for a few hours in the hopes of feeling better in time for the evening's mixer where I could meet faculty and staff.   By the time night fell my headache was manageable, though not gone.  I got dressed, went to the party and tried to have a nice time. And for the most part  I succeeded, until this same woman cornered me in a room with just her and her daughter.  The kid was cute - what 3-year-old isn't? We had a somewhat pleasant conversation where I told her about life in Tucson, AZ - until part way through the child tugged at her mom's skirt and a whispered conversation occurred.

I was informed that the little girl was fascinated by my upper arms.  The fat on my arms hung over my elbow - her mother informed me and reached over to pinch the fat.  The little girl nodded furiously.  I was shocked - not that the little girl noticed, kids do that.  They get to an age where they are figuring out how people are similar or different - they comment on people's skin color, their weight, their hair color, their able or disabled bodies.  The child in this was innocent.  However, her mother was not - and I could not believe they way she was handling this situation. 

 

The Mom proceeded to whisper to her daughter, they both whispered back and forth behind their hands (no really, actually behind hands).  She looked at me and said "I told her that it is because you are fat."  She looked at me and then in a very pointed way said "Remember how we talked about how people are different and that's OK?" More whispers.  "Some people just eat more than others, and they get big arms" There was then something about eating well and dancing a lot if she didn't want arms like mine ... I just stood there, flabbergasted.

This woman thought she was doing the right thing, she thought she was teaching her daughter acceptance and diversity -- and I had never been treated with such bigotry in my life.  I wanted to yell at her - I wanted to tell her that you don't pinch other people's fat.  That you don't use the word fat with a child and follow it up with a discussion about the presumed poor eating habits of the fat person.  That if you want to teach your child to be open to diversity and the broad spectrum of people in the world you should probably also teach them that it is rude to whisper and point!  That the act of whispering and pointing makes that person into a fetish - an object to be observed and commented upon but not interacted with.  I wanted to tell her how rude and intolerant she was being and how awful she had made me feel.  But I didn't.  I didn't because blowing up at another prospective student at an open house is unlikely to reflect well upon you no matter how justified the reaction, particularly when there were no witnesses.  I also didn't because my migraine had come back and I simply didn't have the reserves to deal with this crap.  So instead I just walked away.

When I went home that night I cried to my husband about how I had felt bullied by a three year old and her awful mother. The hardest part was that I felt like somehow this was my fault - that I had permitted this to happen by saying that pointing  out diversity was OK.  That somehow the fault was mine, that it was my issue with my fat since the pointing out of that fat made me feel hurt.

It took me a while, but eventually I realized that was crap.  The problem wasn't that the child had noticed I was fat - or even that Mom had said that I was.  The problem was that this woman had treated me all day as if I was nothing but my fat.  She treated me like an object - not a person.  All day she had been trying to be the progressive, accepting, hip graduate student who understood my "challenges" -- but what she was really being was judgmental. She only saw my fat.  She only interacted with me as fat.  She asked about being fat - what is it OK to call fat people? How do you deal with people seeing your fat? She never bothered to notice that I was a person.  When she sat there whispering, staring and pointing - she treated me as an object. And she taught her daughter to do the same. I was upset because that night I was treated as fat personified, a walking cautionary tale/diversity visual aid. I was changed from a person into an object.

I wish I could have that moment back, that I could tell her how this moment where she thought she was being progressive and open was the most humiliating fat experience of my adult life.  I wish I could tell her that if she wanted her child to learn to be open to all people, to not judge that she should first teach her daughter to treat all people as PEOPLE not parts - not skin colors, or fat arms, or old wrinkles. PEOPLE. And that part of that was treating all people with courtesy and respect - and not pointing and whispering.

The Moment I knew I had to Stop Dieting

If you haven't seen it, the Huffington Post has a series of "The Moment I Knew" which they describe as "user-submitted video series where readers tell the stories of life-changing moments they have experienced. Each section of HuffPost has chosen a different theme -- whether it was the moment you knew you wanted to marry your spouse, the moment you knew your marriage was over, the moment you knew you loved college, or the moment you knew you were broke. You can also tell us about any other life-defining moment you'd like to share. The possibilities are endless!"   Of the endless possibilities out there HuffPo decided to kick off its Healthy Living Section's Moment I knew with ""The Moment I Knew I Had To Lose Weight."  Dr. Deah Schwartz wrote into HuffPo and asked them why they chose this topic, why not The Moment I knew I had to Stop Dieting  They responded by stating that if such sentiments existed and readers sent those videos in, then HuffPo would be glad to post them.  I have seen several of the videos and find them poignant, inspiring and at times quite sad.  I lack a web-camera, but I found this topic inspiring.

I have had this blog space sitting empty for quite some times.  I knew I wanted to use it to take a Feminist and Fat Acceptance look at standards of beauty and health, but the blog never quite gelled.  However this "The moment I knew" seems the perfect place to start.

The moment I knew I had to stop dieting I was in the car with my Mother.  I honestly cannot say what age I was, I just recall it being High School.  It was a beautiful sunny day. I remember that, though how many days aren't sunny in Phoenix, Arizona?  My mother was driving our old, grey van. We were heading out of Ahwatukee - I can recall the exact part of the strip of Chandler Blvd. we were on the moment is that salient in my mind.  I do not recall the exact conversation that lead up my Mother's statement, but I imagine it was some conversation about my discomfort with my body, my weight, my size - my hips, my breasts.

Since blooming into womanhood smack dab in the midst of middle school I'd had an increasingly ambivalent relationship with my own body.   I was uncomfortable with my widening hips, my developing breasts, with having a body that looked like a woman's when I still felt like a child.  I disliked the way these changes to my physical form effected the way my body moved, the way I ran, the way I swung a bat.  The day I had to buy a C-cup bra I sat in the dressing room and quietly cried.

At the same time, I loved my body.  I felt powerful.  I could stand and feel deeply connected to the earth. I could move and enjoy the experience.  I was getting taller and stronger.  And perhaps most frighteningly, I also had a growing suspicion that maybe, just maybe I wasn't precisely ugly. 

My developing body had been the source of conflict within my household as well.  My parents worried about my weight.  Endemic to their own relationship was contention about size and fat - and some of that anxiety spilled over onto me.  My mother and I fought - often productively about my size and about how I wanted it to be addressed.

In part from the pressures of my parents and in part from my own ambivalence I had dabbled in the world of dieting.  I had tried the "First! Two Week Diet" that was supposed to drop you two dress sizes in two weeks.  We had engaged, as a family, in the Carbohydrate Addicts diet (though I generally refused to participate).   My mother had quietly, and as kindly as possible, tried to teach me about portion sizes, counting calories.  I don't even think that she really thought of me as all that fat. I think she saw it as part of what it is to be a woman.  Women had to think about these things.  On one of our notable confrontations on the matter she told me that she only wanted to protect me. That she didn't see anything wrong with how I looked and she knew I was healthy, but she knew how cruel the world could be and she wanted to spare me that.  I remember standing in that parking lot (what is it with teenage confrontations and cars?), crying and declaring that I did not care what the world thought, I only wanted to know that my mother thought I was beautiful!

It would be unfair to typify my mother's reaction to my size as not supportive.  Prior to this moment in the van, when I had complained about my looks she had always responded by "working the problem."  If I felt I was fat we could do something about that.  I could diet. I could take control of my body.  What I always wanted to hear from her was that I was fine just as I was.  I think deep down she always thought that, but she thought it was somehow her duty as a mother to steer me toward weight loss instead.

Back to that moment in the van.  I had made some comment about my body and I had expected to hear the same offer of modifications to the family diet from my mother. Instead she was very quiet for a moment.  She spoke to me, quietly, about how she had been thin.  That she had lost weight, that she had dieted herself down to the size that an unnamed party found acceptable.  Then she said that the way she was now, though it was fatter than others might like was the best she had felt.  I remembered looking down at my mothers thigh and thinking how slim it was, how beautiful I thought she was and I could not fathom why she would think she was not perfect at that moment and that size.

She went on...What she said next I think I will always remember.  She told me that If I wanted to lose weight for myself that was fine, that was my right. It was my body.  But, she told me "I have been fat and I have been thin and the only thing that changed was my body.  All that other stuff that I thought would change when I lost weight, it was exactly the same.  So just know that.  If you want to lose weight, you can do that, but the only thing that will change is your size."

This was a revolutionary moment for me.  Like so many young women I had spent my life inside my head, making lists of the things I could do if only I were thin.  "When I am thin" I would think "I will do amazing things"... I would have a boyfriend, and travel, and cure cancer.  It was amazing how every hope and dream I placed before myself I prefaced with the idea "When I am thin..."

That moment, in that car, my mother gave me a great gift. I stopped prefacing my world on the idea of waiting until I lost weight. I stopped prefacing my world at all.  With that one conversation my mother freed me.  She broke the chains that society places upon us.  Did I suddenly have a perfect relationship with my body? No. But I stopped feeling like I had to put my life and my worth on hold until I made my body into what the world wanted it to be.  It put things back into their appropriate boxes - body size is about the size of my body.  Everything else is about everything else.   I knew I was trying to diet not to be thinner, not to be beautiful, but to give myself permission to be all the things I wanted to be.  I had been putting everything on hold until I was a size 8 - and that seemed stupid.

To at that moment I knew, I had to stop dieting and start living. Start being brave. I had to leap and hope there would be something there to catch me - even if it was just my own fat ass.