Category Archives: Obesity

General, Obesity, Running, Uncategorized

On Running, Anti-Fatness, Diet Culture, and Body Liberation

A few things off the top:

  • This post discusses bodies and weight stigma. Please proceed carefully if these topics are triggering.
  • I write this as a straight-sized, cis-gender, white women who holds tremendous privilege in the context of this particular conversation.
  • This post is meant as a conversation starter, a toe-in to a conversation I don’t see in the running community, but a conversation I think we need to have. I am by no stretch an expert on diet culture, anti-fatness, fat phobia, or fat liberation. I am learning and this post is a dialogue on some of what concerns me. I am guilty of much of the behavior I discuss here.
  • At its root, anti-fatness and fat phobia are white supremacist beliefs and behaviors. I do not get into that aspect here, simply for the sake of brevity (this post is already too long), but want to be clear that the these behaviors are white supremacy in action.

Over the last few years, the running community has started a reckoning with our deep history with eating disorder culture. We’ve acknowledged how women in particular have been harmed by sometimes (but not always) well-meaning coaches who place an outsized focus on body weight in competition. We’ve learned how girls as young as junior high and all of the way into the professional ranks have been scolded for the number on the scale. Runners who’ve been told they’re too fat to be fast, even while they compete at the upper echelons of the sport in very thin bodies.

But what I haven’t seen much of is a dialogue about how anti-fatness and diet culture have weaved their tentacles into running culture, particularly among the non-elite. Runners such as Mirna Valerio, Latoya Shauntay Snell, and Kelly Roberts have been vocal advocates for more inclusivity for fat bodies in the running community. As women in curvy bodies, and for Valerio and Snell black, curvy bodies, they’ve shouldered much of the burden of holding a mirror up to the running community. And while we work to make space for runners of all shapes and sizes, I don’t hear us talking about anti-fatness or fat phobia, or the ways in which it influences the behavior of straight-sized, mid-pack runners, never mind the ways in which it excludes people from the sport. I also don’t hear us discussing how diet culture repackages itself as a desire to be fit particularly among women athletes.

Anti-fatness: opposed to obese people

Fat phobia: irrational fear of, aversion to, or discrimination against obesity or people with obesity

Diet culture: a system of belief that worships thinness and equates it to health and moral virtue

Anti-fatness among the running community looks like clothing companies with limited sizing and with apparel that doesn’t take the needs of fat bodies into account. Shorts that are too short (longer shorts reduce chafing and increase comfort), sports bras that don’t account for an ample bust and in the rare instance they do, are ugly and utilitarian. It’s tops that aren’t long enough. Compression gear only in straight sizes. Sportswear catalogs and advertising that feature only straight-sized athletes and models. Running stores that carry clothing only for straight-sized athletes, or that carry a small offering of “extended sizes” on a small rack in the back corner. Running stores that don’t have any fat runners on staff. It is publications that feature exclusively straight-sized runners, except for the occasional feature about fat runners, which is the only time runners of size are seen.

Diet culture with a side of fat phobia is straight-sized, mid-pack runners monitoring their calories in the off season so as to not gain weight. It’s women wearing shirts when they run in the summer, until they are “thin enough” to run without it. It’s straight-sized runners saying they are fat – even as a joke – when they pick up a few pounds in between training cycles. It’s women wearing tights when the weather is hot (this can also relate to shorts not being long enough). It’s anytime someone covers their body for reasons that don’t include the temperature. It is going out for a long run to “earn” the cheeseburger, the pizza, the ice cream. It is the way we hide behind training, hide behind “wanting to be fast”, as an excuse for our calorie restriction. It is the folks who comment on Snell’s Instagram videos of her workouts, saying how they are smaller than her and couldn’t do what she does. It’s the people who see those videos and think that same thought. It’s complimenting each other on weight loss. It’s “transformation Tuesday” posts where the transformation is almost always a smaller body.

American culture is deeply fat phobic. Fat people are less likely to be hired for a job, less likely to have their complaints taken seriously at the doctor’s office – the solution to a sore throat is to lose weight, and more likely to be shamed for taking up space in public than straight-sized people. They are never the romantic lead in a movie. They are not the CEO of a company. Their size is always something to overcome, to succeed in spite of. Fat women of color are particularly invisible or when they are visible, it is never in positive ways. There isn’t a comparable state of the body that people are so thoroughly blamed for, even though body size is due to a very complicated set of circumstances, personal choices being but one incredibly small component. People are very comfortable making value judgements based on someone’s size. We are comfortable assuming how they (don’t) care for their body, and what must be their (ill) state of health.

Fat activist Caleb Luna states that fat phobia and anti-fatness pressures thin people into monitoring their bodies. I believe that many runners, particularly women runners, use running as one way of monitoring their body. A socially acceptable way. We can hide our internalized fat phobia and participation in diet culture behind our desire to be “fit” to be “fast”. I don’t doubt that we also want those things, but I don’t see how the pervasive anti-fatness of our culture isn’t also a factor in how we monitor our bodies in sport, especially when we belong to running groups that do not include any fat people, buy from companies that don’t make products for fat people, consume media that doesn’t include fat people or consider their needs.

Diet culture is an avenue for monitoring our bodies. Factor in a genuine desire to be a better athlete and it can be a perfect storm. Diet culture leaves us hungry and obsessed with food. It tells us to track our calories, to never be full. It tells us that low-carb/high fat will solve all of our problems, even if there is no medical reason to eat that way. It instructs us to skip the snack and to not eat after 7p. It is the belief that we need to earn our food.

Rejecting diet culture is understanding that we can eat whatever the fuck we want, whenever we want. It is the realization that we can be fit, we can be fast, without the obsession about our diet. It is acknowledging that we are humans who get hungry. Virgie Tovar says that “extinguishing our hunger is extinguishing our desire”. And that at it’s root, “desire is about power”. A patriarchal society thrives when women are kept small and distracted. Sociologist Sandra Gillman states that “dieting is a way that women express to their culture that they understand their role and are willing to accept it”. Gillman is a man, but his observation is accurate. Our hunger and our distraction keep us small. It keeps us focused on what we’re going to have for lunch instead of the art we want to make, the problem we’re trying to solve at work. It prevents us from being fully present with those we love.

Within the last year or so, Oiselle expanded their size offerings and now include runners of a variety of sizes in their advertising. They are one company, and a smaller company at that, but it feels like an important step forward. Oiselle has been called out over the years for not featuring diverse runners in their advertising and for not offering apparel for all sizes, and to their credit, they stepped up to the plate in both instances. Unfortunately in both cases, it was runners of color and runners of size who were the most vocal about the omissions.

When running creates space for fat liberation, it will be straight-sized runners pointing out these absences just as vocally. It will be straight-sized runners who notice the community isn’t fully represented, not just those who’ve been left out. Just as we’ve come to expect to see black and brown runners included in advertising and feature stories, we’ll expect to see fat runners included as well. We’ll expect to see fat runners in our local running groups, at the local run store. We’ll expect to see clothing for fat runners displayed right along clothing for straight sized runners. We’ll see companies developing cute, functional bras for fat women runners, just like they do for straight-sized women runners. We’ll realize the fat phobia inherent in our comments about our own bodies, and the damage those comments inflict on not just the fat people in our communities, but on straight-sized folks too.

Want to give white supremacy and the patriarchy a big middle finger? Embrace your hunger, love your body, run hard because it fills you with joy. Understand that bodies aren’t a problem to be solved, our own or other people’s. Consider not commenting on other people’s bodies at all. Stop viewing weight loss as progress, your own or other people’s. Take a deep dive into your own beliefs about fat people, regardless of your size. Read the work of authors who talk about fat liberation, authors such as Virgie Tovar. Eat the cheeseburger. Most of all, savor your food. What a tremendous privilege it is to have delicious, ample food.

ACA, Obesity, Uncategorized

Obesity and the ACA

Early in my career, I had the privilege of working in cardiac rehabilitation. I was an exercise physiologist, so much of my job included writing exercise prescriptions, teaching education classes (mostly on modifying lifestyle behaviors such as diet, stress and smoking) and individually counseling patients living with heart disease. In all of those years, what I didn’t do was ask any of my patients, not one of them, about the environment in which they lived. I didn’t ask about how often they shopped for groceries, or whether or not their neighborhood was safe. I didn’t ask if their local grocery had fresh fruits and vegetables, and whether or not they could afford them. I didn’t ask if they could afford all of the medications prescribed to them by their physician. The care I provided followed the guidelines of what I was taught, what we all were taught: exercise at least 30 minutes most days of the week, eat at least five servings of fruits and vegetables per day, reduce stress, quit smoking, take meds. Period.

Throughout my undergraduate and graduate education, not once did we discuss the influence of the environments in which we live on health. Nor did we discuss how to counsel and advise patients in the context of their home environment. Telling someone to go for a walk everyday when they live in a neighborhood with poorly maintained sidewalks, or in one that is plagued by crime, is absurd. I can only wonder about how many of my patients went home feeling despair or defeat because they did not know how to follow our recommendations due to their circumstances.

Over the past 15-20 years, research has taught us a lot about what causes obesity. At a societal level (so not in the context of your neighbor who enjoys too many cheeseburgers), our personal choices have very little to do with what is making us, the collective us, fat and sick. But first, a few facts (all stats from CDC):

  • 36.5% of Americans are obese
  • Non-hispanic blacks have the highest age-adjusted rates of obesity at 48.1%, followed by Hispanics at 42.5% and non-Hispanic Asians at 11.7%
  • Obesity rates are higher among middle age adults age 40-59 years (40.2%) and older adults age 60 and over (37.0%) than among younger adults age 20–39 (32.3%)
  • Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.
  • The percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2012. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period.
  • In 2012, more than one third of children and adolescents were overweight or obese.

Americans are fat. And getting fatter. But why? The social determinants of health (SDOH) tell us much about the insidious forces contributing to this epidemic. Social determinants of health are conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.

In looking at the pyramid above, the education I provided my patients was at the tippy-top. My advice, no matter how good it was, was not going to have much impact on the factors that contributed to their illness. Similarly, a physician telling their patient to lose 30 lbs is not likely to have much of an impact, if any, on that patient’s health status. That’s not to say that those conversations shouldn’t happen, because they should, but that can’t be our only approach.

The obesity epidemic in the United States will continue unchecked as long as our solutions continue focusing at the top of the pyramid. So, what do policy, systems and environmental approaches to reduce obesity look like? If educating people isn’t the solution, what is? This list is by no means exhaustive, but provides some context:

  • Interventions that address poverty – poor communities bear the enormous costs of disease (including obesity) at disproportional rates. Programs that stabilize those living in poverty and that support people as they transition to a more stable financial environment can have significant impacts on health.
  • Interventions that address housing – many people living in poverty reside in structures that are unsafe and unhealthy, riddled with mold and poor air quality. Working with city governments to improve codes and code enforcement, and working with landlords to improve living conditions can go a long way to improve conditions such as asthma. But wait a minute, I thought we were talking about obesity? We are…would you spend your free time being physically active if you had uncontrolled asthma due to your mold-ridden home?
  • Interventions that address inequities – despite what you might hear on certain news stations, all Americans aren’t equal. Great health disparities exist, and often they fall along racial and gender lines, and around how much money you make, where you live. Did you know there are communities in this country where living 10 miles at opposite ends of the same road means a ten-year difference in life expectancy? In some communities, the disparities between neighborhoods can be as great as 25 years. In many places, your zip code has more of an influence on your health status than any other variable.
  • Interventions that address community environments: Improving the built environment to encourage walking/running and biking. This can include building/improving sidewalks, adding bike lanes, improving safety and addressing play deserts. Increasing access to healthy, affordable foods by expanding farmers market initiatives, corner store initiatives, addressing food deserts, improving the nutritional value of food in schools, and examining/changing national food policies to incentivize healthy, whole foods.

So what does the Affordable Care Act (ACA) have to do with all of this? While many people are familiar with some of the hallmarks of the ACA such as free preventive care, the ability to keep children on a parent’s policy until age 26, and prohibiting discrimination due to gender or pre-existing conditions, what you might not know is that it also requires not-for-profit hospitals to conduct a community health needs assessment every three years. In addition to the needs assessments, hospitals must also develop a community health improvement plan and report progress annually. All of this is required for a hospital to maintain its non-profit status.

To develop the needs assessment, most hospitals utilize both an extensive review of primary and secondary data (this can include community surveys, hospital statistics such as emergency department utilization rates, heat maps by diagnosis, etc), in addition to more qualitative approaches such as focus groups and stakeholder meetings. In my community, the two non-profit hospitals have gone one step further, in that they’ve partnered with each other, the local health department and a community service organization to develop one needs assessment and implementation plan for the entire community. Nearly 50 organizations participated in the development of our community’s assessment and implementation plan.

In addition to the assessment and implementation plan, non-profit hospitals must divert a percentage of their funds for “community benefit”. In the past, much of these community benefit funds went to uncompensated care, meaning the funds the hospital spent to care for patients who were uninsured. As uncompensated care went down with more people being covered by insurance, the expectation is that these dollars would begin to flow out into the community to address needs identified in the assessment and to fund portions of the implementation plan.

Back to obesity…not surprisingly, many communities are identifying obesity as one of their top health concerns. Not only is it a prevalent, stubborn issue, but it is a co-factor in so many other conditions such as heart disease, diabetes, certain types of cancer, depression, etc. Many people believe that if we can crack the obesity nut, we will go a long way to solving some of the other persistent (and expensive) health issues plaguing Americans. The ACA created a framework for community partnership beyond anything that existed previously. Many hospitals are taking their assessments/plans seriously, dedicating significant staff time and funds to the efforts.

When these teams go looking for best practices to address the obesity epidemic, they immediately bump into the social determinants of health. Within the context of the social determinants, when they go back through their own primary data – heat maps of particular diagnoses such as asthma for example – they can begin to see very real patterns emerging in the community. As hospitals work to improve patient outcomes and reduce re-admissions (also an expectation of the ACA), these new approaches to care are vital, and great for the patient. The ACA was the foundation for all of this progress. No longer are hospitals only responsible for the patients that walk through their doors, they are responsible for the health of the community, just as health departments have been for decades. Only by looking for solutions outside hospital walls will they move the needle on such complex problems. In this situation, there are no losers.

In the doomsday scenario discussed by some Republicans, meaning a complete repeal without a replacement of the ACA, not only will many Americans have a reduction in coverage or lose their insurance altogether, communities will lose a transformative platform for change in how we approach community health. These new collaborations are in their very early stages and we’re several years away from knowing how powerful they might be. One thing is for certain though, communities will not solve complex health problems such as obesity by working in isolation, and unfortunately organizations often need a nudge to do the right thing. The ACA provided a powerful platform for improving community health and addressing obesity. On the hierarchy of bad things that would happen with a repeal, this might not feel as urgent, but for our vulnerable communities this is one of the better opportunities we have at making a real dent in the disparities that affect their health every single day.

People can’t make healthy choices when they live in communities that aren’t safe, that lack access to fresh, healthy, affordable foods, that lack safe places for walking, biking and other types of physical activity, when they reside in homes that are contaminated and when they face the multitude of challenges that accompany being poor in this country. Offering “personal responsibility” as a solution is irresponsible. The price we pay for poor health is obscene. Not only is it the  direct cost in medical bills, it is sick time at work, lost productivity, missed days at school. Until we recognize that solving these issues is going to take more than finger pointing, obesity rates and related health problems, will only increase. Gutting the ACA will add fuel to the fire.

Photo credit: Marty Barman