How to promote health without being healthist

Have you ever felt suffocated by the pressure to be healthy? To eat “clean food,” run 5ks, go vegan, lose weight, tone up, eat paleo, buy agave nectar, do Crossfit, meditate, track your steps, count calories, eat organic, go paraben-free, switch to coconut oil, try acupuncture, use a Himalayan Salt Lamp, or quit sugar?

Do you ever feel like a bad person for failing to meet this standard of health so clearly articulated on sites like Pinterest?

health on pinterestWhen it’s your job to promote health, it’s also your responsibility to be aware of the barrage of health messaging out there and of the way it can make people feel: confused, overwhelmed, frustrated, insufficient, lazy, incapable, flawed, ugly, less-than, defeated, worthless, or even hopeless.

I’m going to throw out a radical thought experiment. What if I chose to be unhealthy? What if I simply opted out our contemporary culture of wellness? What if I decided that I didn’t care about longevity or preventing disease? What if I wasn’t interested in athletic pursuits? What if I was happy with my life without any of that stuff?

Would that make me a “bad” person? Would that make me less deserving of civil rights and legal protections? Healthcare? Federal or state assistance? Education? Would it make me less deserving of respect? Kindness? Compassion?

What if rejecting the active pursuit of health and wellness was a valid choice? 

Believe it or not, I do think it’s a valid choice. This may be surprising coming from a public health professional. But I think it is especially an important perspective for health professionals to have. My job is to promote health and wellness as well as to prevent and alleviate illness, violence, and suffering in the community I serve. Convincing people to care about their health and wellness is part of my job, but it’s something that has to be done carefully and thoughtfully so that I do not fall into the trap of perpetuating an oppressive culture of “healthism.”

What is Healthism?

The term “healthism” can be traced back to a 1980 article by political economist Robert Crawford, “Healthism and the medicalization of everyday life”:

Healthism represents a particular way of viewing the health problem, and is characteristic of the new health consciousness and movements. It can best be understood as a form of medicalization, meaning that it still retains key medical notions. Like medicine, healthism situates the problem of health and disease at the level of the individual. Solutions are formulated at that level as well. To the extent that healthism shapes popular beliefs, we will continue to have a non-political, and therefore, ultimately ineffective conception and strategy of health promotion. Further, by elevating health to a super value, a metaphor for all that is good in life, healthism reinforces the privatization of the struggle for generalized well-being. –  Inlt J Health Serv

Implicit in healthism is morality, a driving force behind public health since the Civil War. The sanitation movement of the 1860s and 70s was largely led by the social (and moral) reformers of the Women’s Christian Temperance Union, who fought unsanitary living conditions and prostitution in the same breath.

Sylvester Graham (of Graham Crackers) and later Dr. John Harvey Kellogg (of Kellogg’s Cornflakes) were practicing healthists in the 1880s. They believed in a connection between immorality and disease, and prescribed bland foods and abstinence (from masturbation especially) as part of a healthy lifestyle that would produce a “higher. purer, and nobler type.”

Petr Skrabanek, whose 1994 book The Death of Humane Medicine and the Rise of Coercive Healthism explored this issue, wrote that healthism begins when all human activities are judged according to their health impact, and deemed either “healthy” or “unhealthy”, “responsible” or “irresponsible”, “acceptable” and “not acceptable” based on this measure. Skrabanek goes further to claim that “healthism either leads to, or is a symptom of, incipient totalitarianism … Healthism justifies racism, segregation, and eugenic control; for the healthist, what is ‘healthy’ is moral, patriotic, and pure; while what is ‘unhealthy’ is foreign, polluted, and impure.”

In his review of Skrabanek’s book, Bryan Appleyard wrote:

Skrabanek has two arguments against healthism. First he insists that this kind of pressure and coercion amounts to a fascistic imposition on the lives and freedom of individuals.

And, secondly, he points out that most of the healthist assumptions are either not proven, wrong or highly biased. For example, he says that screening – a central doctrine of healthism – has been found to have no health benefits, but that this finding has been suppressed. And he regards the caring of the healthists as a hypocritical cover for crude authoritarianism.

‘As healthism is driven by power,’ he writes, ‘rather than by concern for the welfare of fellow men, it is devoid of any moral principles.’

, calls healthism “the new Puritanism“:

Healthism is an avenue for subliminal narcissism. There is something seductively deterministic and morally appealing about eating like a cheese-fearing vegan rabbit and looking better, living longer and getting 50 % of the insurance premium back thanks to Affordable Care Act’s Zen-sounding Wellness provisions.

In short, healthism is the new puritanism. The old puritans worked for God’s glory with a famed work ethic which, according to Max Weber, might have been the chiefly responsible for the success of capitalism.

The righteous, mirthless, po-faced, lycra-clad new puritans are forever punching numbers in to risk calculators and obsessing over arbitrary thresholds of LDL-cholesterol whilst watching the Dr. Oz show with the fastidiousness with which the old puritans internalized Leviticus, lest they miss another opportunity for a miniscule relative risk reduction.

Fall Ferguson, Assistant Professor of Health Education at John F. Kennedy University and current President of the Association for Size Diversity in Health says:

Healthism includes the idea that anyone who isn’t healthy just isn’t trying hard enough or has some moral failing or sin to account for … More subtly, healthism represents the widespread ethic of individual responsibility for health in our culture. In the debate over U.S. health care reform, we obsess over the health of individuals, whether it’s reshaping individual behavior to our liking or finding ways to pay for the expensive treatment protocols that we see as being needed because of people’s personal “failure” to care for their own health.

At best, “healthism” refers to a cultural preoccupation with health. At worst, it describes an ethical paradigm in which certain health behaviors are considered moral imperatives and a person’s value and character is judged based on their adherence to those behaviors. A person might also be denied services, benefits, and rights based on their adherence to those behaviors. This is highly problematic.

People engaged in the work of health education/promotion, public health, medicine, nutrition and fitness, etc., must be aware of the pitfalls of healthism, and try to avoid them whenever possible.

Why is healthism bad for INDIVIDUAL HEALTH?

Obsession is not healthy, even if it’s an obsession with health. Encouraging or condoning this kind of preoccupation or obsession in others can be seriously detrimental to their mental, emotional, and physical health. It’s what leads to disordered eating and exercise behaviors, as well as what some are calling “orthorexia nervosa” – a rigid fixation on food quality and purity. It teaches people to ignore their body’s signals – to “push through the pain” – resulting in injury. It robs people of time and resources that they otherwise could put towards fostering social connections, creative hobbies, community service, and other worthwhile pursuits that foster well-being and happiness.

Healthism also creates and encourages stigma, particularly fat stigma. By promoting this idea that “fat = always unhealthy” (which is just not true), fat people are singled out as failing to uphold their “personal responsibility” to maintain their health. As a result, they are labeled as “lazy,” “ignorant,” “lacking willpower,” “gluttonous,” “greedy,” etc.

Whoever came up with the idea of making dieting about health is simply brilliant. Now, society can be prejudiced, but it is ok because it’s about health. Now, you are not shallow if you focus all your attention on dieting, you are righteous. And, whoa be to you who do not diet – for thou art sinning! – Lonie McMichael in Talking Fat

If fat people are automatically “sinners” by virtue of being fat, then it becomes socially acceptable to insult them or shame them. In some cases it can even be seen as a moral imperative to insult and shame them, especially if one believes that will cause them to lose weight. But being fat does not necessarily mean someone is unhealthy. And not only is insulting and shaming people a generally shitty thing to do, it DOES. NOT. HELP. PROMOTE. WEIGHT. LOSS. In fact, it can result in weight gain. So, not only is it cruel, it’s detrimental.

laci green quoteWhy is healthism bad for PUBLIC HEALTH?

Another major problem with healthism is that it tends to focus the attention and resources of public health work on fostering individual behavior change, when we know that social determinants of health influence our health more than individual behaviors do. Public health professionals and health educators pay a lot of lip service to the socio-ecological model intended to address these social determinants.

S-E-ModelYet, due to the influence of healthism, health professionals tend to concentrate most of their efforts at the individual level. Fall Ferguson writes:

In my own field of health education/health promotion, there is a disturbing disconnect between the evidence about the social determinants of health and the profession’s focus on changing individual health behaviors. Even “ecological” approaches to health education, which are inspired by systems perspectives that highlight the interconnected web of health causes, tend to focus on the end result of changing individual behavior rather than collective solutions to health issues. A 2012 article in Health Education and Behavior reviewed 20 years of reported ecological health education interventions; the article acknowledged the field’s shortcomings in this arena, and noted that in addition to certain structural barriers, we may need to move past our own training: “health educators may not have the training or resources to successfully plan and implement institutional-, community-, or policy-level programs.”

Maybe it’s more than just our training that holds us back. Maybe we need to acknowledge our basic healthism instilled by our cultural milieu as well as our professional training. And maybe we need to unpack the privilege that has allowed us to focus so much attention on the role of individual behavior in health.

Why is healthism bad for SOCIETY?

Today we often speak about eating and exercise in terms of morality, often to the point of absurdity. Amy Schumer did a great job of calling out the way we self-flagellate for eating dessert in her sketch, “I’m so bad!”

But this is one symptom of a much bigger problem. Healthism is a social justice issue. To focus on wellness requires resources, namely money, access, and time. This is a matter of privilege. Who has access to organic foods in their neighborhood and who does not? Who can afford childcare in order to exercise and who cannot? Who has healthcare benefits and who does not? Who can devote time to their meditation practice and who cannot? Fall Ferguson writes:

It seems to me that healthism is reflective of deep privilege; it is (in my opinion) a classic “first-world” problem. Healthism can only thrive in a culture where the dominant groups do not have to worry about such things as famine, infectious disease, war, poverty, and hatred as factors that affect their health. It’s privilege that allows us to make health a “project” that we can judge others for not taking up.

Those with lower socioeconomic status do not always have the luxury to focus on their wellness, especially if they are struggling with the basics of Maslow’s Hierarchy of Needs, like safety, housing, and hunger. We cannot talk health behaviors as “necessary” or “essential” or “mandatory,” (as in, “eating GMO-free is basically mandatory”) when they are often beyond the reach of lots of people. We must not judge people for failing to prioritize wellness based on our assumptions about their lives and our paternalistic ideas about what is best for them.

We also must remain vigilant and push back against legislation and policies that discriminate against people based on their health. As Ragen Chastain, educator, activist, and fitness enthusiast, frequently reminds us: “the rights to life, liberty and the pursuit of happiness are inalienable and not size, health, or healthy habit dependent.

The good news? There are things we can do to help avoid the pitfalls of healthism.

Here are some tips for health professionals:

  • Do not focus your work solely on individual behavior change. Make sure that you’re spending equal, if not more, time and resources on addressing social determinants through policy and environmental approaches. If your wellness program is focused solely on individual behavior change and there is no additional support for addressing social determinants in place, you need to rethink your program.
  • When sharing health promotion knowledge/tips/techniques/advice, always start with a disclaimer. For example, “Nobody has any obligation to participate in exercise, however for those who would like to participate – or just learn about the benefits of physical activity- I’m going to share the following info and tips.” Remind people that their heath habits have no bearing on their worth, their moral “goodness,” or their human and civil rights.
  • Be reasonable with your goals and expectations. Not everyone has to have the body of an athlete. Not everyone has to eat like a “health nut.” When you share guidelines, make them reasonable for the average person. Remember that for some people, the absence of illness and suffering is healthy enough, and that’s their choice and it’s valid.
  • Do not impose your beliefs about health and morality on your patient/client/student by automatically assuming they want to lose weight or devote time and other resources to fitness, nutrition, wellness, or weight loss. Use motivational interviewing techniques to find out what their motivations are for seeking help and work from there. Find out what they believe and respect their goals and value system.
  • Understand that shame and guilt are NEVER good motivators. Under any circumstance. Not only do they NOT WORK, they have a negative impact on a person’s mental and emotional well-being and can actually discourage them from participating in healthy behaviors.
  • Help every person cultivate a positive body image. It will not “promote obesity,” I promise.

Have you encountered healthism in your life or work? Have any other tips for how to avoid these pitfalls? Please share your thought and experiences in the comments!

14 thoughts on “How to promote health without being healthist

  1. Apologies in advance for what may be a very long response ….

    Awesome article – and the Lonie McMichael quote could have, were it not for the lack of more colorful metaphors, come from George Carlin (a high compliment, I assure you!)! Where I live, there is definitely an atmosphere of health / fitness and class. If you are overweight, it’s unlikely that you will be taken seriously about anything other than how the Currywurst tastes. Healthcare professionals here are sometimes all-too-eager to use a patient’s being overweight as a way of getting out of having to spend any of their allotted money (doctors in this country typically are allowed to spend only so much on their patients, per quarter) on fixing the actual problems. An example: my knees are an absolute wreck. I can’t jog with them, I can’t even swim or ride bicycle without the blasted things trying to come loose. My first orthopaedic doctor, and the one I went to for a second opinion, told me, point blank: “You are carrying too much weight, and this is the reason why your knees are in such bad shape … lose weight, and we will see what we can do to make them better.” If they would have bothered to look at me as a patient, rather than a set of numbers and statistics, they would have perhaps taken the time to listen to my complete history; which includes having injured my knees repeatedly in my younger years while playing American football (because everyone told me it was ‘healthy’ to do so, and I was dumb enough to believe them). I was, in fact, highly athletic and had been in tremendous physical condition for years when I had my second knee surgery at the age of 22. But having a too-high BMI was my ‘real’ problem with my knees, according to these doctors. Well, I can still walk; and I do so rather extensively (a 5 km walk before breakfast is not uncommon for me – and throughout the rest of the day, I walk when I have time and opportunity; but because I enjoy moving, and not because I want to be skinny). While I have lost some weight over the years, my BMI is still high – I’m simply built the way I am. And, as far as I’m concerned, ‘BMI’ is no more than a Civil War relic that has been taken way out of its original context – it and ‘healthism’ are in serious need of being addressed at any and all levels of society and culture; which is why I am SO thankful you posted this article. I know heavier weight is harder for the joints and various organs to work with – that’s a simple enough logic that I’m capable of grasping – but it’s wrong to pin problems in their entirety on weight as a knee-jerk reaction.

    How to avoid situations like this? Where I live, avoidance isn’t really practical. I get out, I have fun, and I live my life the way I see fit … if others have problems with me, the problems are their own, and they (except for the occasional doctor) seem to only have these problems behind my back. So, at the risk of sounding a little unsocial, I could care less what such people think about me. Regarding health care professionals who won’t bother to see me as an actual patient, I have no problem seeking a third opinion and lodging a formal complaint against such doctors with my health insurance company – as was the case with the two I referred to in the above paragraph. We still have rights: not pursuing all of our options is the first, worst mistake.

    What happens when all of a society is fit? The people live longer lives, are able to work much longer into their older years, put more money into the tax system, and (theoretically) take less money out of the health system. What happens when a cult of healthiness is built to encourage this, and it works so well that overweight people (who, as you point out, are more often than not genetically predisposed to be overweight, to some extent) are persecuted and shamed relentlessly? Well, these people will find themselves depressed and overall uncomfortable in society. They will withdraw. Through this, they will be prone to illness at a greater degree than they would otherwise be. They will require more money from the health system to treat. They will die sooner, and not contribute to society for as long as they could have if they’d been allowed to lead happier lives. This, of course, will only serve to build the statistics that the health cultists need to justify their own perspectives – even if they have no one to blame for this rising statistic than their own selves.

  2. The other issue I have with the cult of healthism is that we live in an age where someone dealing drugs to children goes away to prison for a very long time – and rightfully so; but the purveyors of the most unhealthy fast / junk foods, which are also understood to be addictive, who pander this stuff to children from the earliest age, make untold sums of money while sitting in their offices, unafraid of the police hauling them off to prison. When parents try to keep their children safe from such foods, they are often accused of heartlessness by more than just their children. That this is allowed to continue in a society governed by the same body that promotes ‘healthism’ is, in my opinion, an injustice; and it suggests very strongly to me that the primary motivation behind the healthism movement has less to do with health, and more to do with money.

  3. Hoo boy, this has been an issue of mine for a long time. IOW, I could go on, and on, and on . . .

    You wrote: “I’m going to throw out a radical thought experiment. What if I chose to be unhealthy? What if I simply opted out our contemporary culture of wellness? What if I decided that I didn’t care about longevity or preventing disease? What if I wasn’t interested in athletic pursuits? What if I was happy with my life without any of that stuff?”

    I think you know this already, but “opting out of the contemporary culture of wellness” is not (not, not, not, not!) the same as choosing to be unhealthy. You can opt out and still enjoy athletic pursuits and want to do what you can to reduce your chances of getting sick or hurt.

    “Healthism” does indeed have deep roots in U.S. culture, as does its first cousin, health faddery. But one of its parents or godparents has to be weight-loss dieting, which is rooted (I do believe from long observation) in the fear that our bodies are just itching to run amok and kill us. So our duty is to beat them into submission with diets and exercise regimens. It’s a joyless way to live, which is to say it fits right in with the Protestant ethic of guilt, guilt-tripping, and compulsive abstinence.

    It also emphasizes individual solutions and acts as if social, economic, and environmental conditions don’t affect our health and our options for dealing with it. Which makes it classist, racist, and sexist in effect if not in intent.

    Your tips for health professionals are great. They’re also great for non-professionals, who in my experience are some of the worst about spreading healthist misinformation. Carry on!

  4. OMG I love this. I recently watched a media piece on ‘orthorexia nervosa’ and immediately recognised this as being what I had as a teenager. My obsession with ‘health’ stayed with me long enough to complete my studies to become an accredited practising dietitian (bachelor of science and master nutrition and dietetics). However, my attitude to food changed and I became very cynical about “diets” and the obsession with losing weight predominant in our culture, which was also reflected in the clients that I saw. I wanted people to enjoy a variety of food and be happy with their bodies. I couldn’t subscribe to the healthism kind of thought anymore but that is what the clients specifically wanted so I left the profession. I am big on social justice so I’m a little chuffed that my natural radar picked up on healthism and rejected it (even though you opened up my eyes a little wider with the social justice angle). I have been sharing articles like this one ever since I joined social media a couple of years ago. Thanks for adding this excellent one to the mix.

  5. I really admire and appreciate you taking on this topic.
    I often feel judged even though I probably spend more time thinking about my health than most. I eat and prepare good food and am as active as possible. My body does not reflect this. I have a chronic and crazy painful disease that I will live with until it kills me. I don’t have this disease because I am unhealthy, I am unhealthy because I have this disease. It’s ruining my body and I do everything I can to squeeze any sense of goodness left in my life. So when I hear people harping on about “beach bodies” and the like, I fume inside, and I know I’m not alone.

  6. Pingback: READ THIS BLOG | The Finely-Tuned Machine

  7. Reblogged this on The Finely-Tuned Machine and commented:
    I could rant and rave for post after post but this entry from Talkin’ Reckless basically sums up everything I am feeling at the moment but wasn’t composed enough to put into words.

    Do yourself, and all the people you may meet today, a favor and read this. Take it to heart. Promote the well being of yourself and your community by uncoupling the morality issue from the health issue.

  8. This blog addresses my feelings. When I’m dieting my healthy friends love me and praise me but my heavy friends roll their eyes, when I don’t care and eat the dessert by heavy friends join me and my healthy friends roll their eyes and shake their tiny heads. Btw that Amy schumer video was life!!!

  9. Pingback: Body Image: A Lite* Rant | Life Loofah

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