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!

The Thing About Being a Fat Health Educator

I am a college health educator and I am fat. I suspect that people do a mental double-take when I introduce myself as a health educator. My educated guess is based on the fact that fat stigma exists. In 2009, Salon published an article asking if Dr. Regina Benjamin, a renowned MD and recipient of the MacArthur genius award, was “too fat” to be Surgeon General. If folks are asking that about her, it’s not much of a stretch to imagine they’re wondering about me too. But here’s the thing. I don’t think my weight has any bearing on my qualifications as a health educator, and here’s a whole list of reasons why.

  1. Nutrition, fitness, and weight management are only one small part of a college health educator’s job. Depending on a college’s size and organization, they may not be in the job description at all. For example, my job description instructs me to spend at least 60% of my time on alcohol and drug abuse prevention, with a secondary focus on running our peer health education program. My next prescribed priorities are stress management, sexual health education, tobacco cessation, and sexual assault prevention. In my copious spare time (sarcasm alert) I attempt to cover the rest, including cold and flu prevention, cancer prevention, eating disorder prevention, and education around sleep, nutrition, and fitness.
  2. Not every health educator became a health educator because they’re a nutrition and fitness enthusiast. In fact, a lot of college health educators get into this field because of the badass health topics we get to cover: sex, drugs, and rock n’ roll. My academic interest in sexual health politics (the HIV epidemic, Roe v. Wade, etc.) are what led me to this field; learning more about other wellness topics in the process has been a bonus.
  3. You can’t accurately judge my health status based on my weight. Health does not equal thin. Plenty of thin people engage in unhealthy behaviors, and plenty of fat people engage in healthy behaviors. It is folly to assume that you know anything about a person’s health based on their appearance.
  4. Sometimes being a fat health educator can actually come in handy. Students struggling with weight, body image, or eating disorders sometimes feel more comfortable speaking with someone who they believe can relate to their experiences. Just as they might judge fat health educators as being able to relate to those experiences, they may judge thin health educators as being unable to understand their struggles. Clearly, you cannot tell by looking at a person whether or not they have struggled with weight, body image, or eating disorders, but it’s not far from the mark to assume that a visibly fat person has probably experienced fat stigma and can relate to what that feels like. The desire to receive help and support from someone who shares your experience or perspective is not unique to this issue. For example, many people struggling with substance addiction seek help from other recovering addicts. We see this in the sponsorship model in Alcoholics Anonymous and Narcotics Anonymous. It’s also not surprising that at any given time, 37%-57% of addiction counselors are in recovery themselves. I do not intend to equate the experiences of being fat and addiction because they are two completely different things. But sometimes it really helps to talk to someone who’s been there, you know what I mean?
  5. As a fat health educator, I know first-hand that nutrition, fitness, and weight management are not easy or simple – despite what some people would have you believe. I also know first-hand the unintended consequences of talking about weight management as if it were easy, simple, or even attainable for the majority of people. Those unintended consequences can range from frustration to self-hatred, from “fat talk” to dangerous disordered eating and exercise behaviors. As a result of this knowledge and experience, I am incredibly careful in my messaging around nutrition, fitness, and weight management. I avoid using calorie counts because those numbers can be triggering for people struggling with eating disorders. I stress Health at Every Size – a philosophy that promotes healthy eating and exercise behaviors for their own sake, regardless of whether or not they result in weight loss. I do not promote dieting, but I do promote making healthy dietary choices. I teach nutrition, fitness, and positive body image within a framework that supports an understanding of wellness as multi-dimensional – and I trust students to decide for themselves which dimensions they will prioritize.

It has been suggested to me that I should lose weight in order to be “taken seriously” as a health educator. This is so, so, so problematic on so many levels.

First of all, this is essentially saying that in order to escape the consequences of fat stigma, I should stop being fat. That’s a bit like suggesting a black person change their race in order to avoid the consequences of racism in the workplace, or that gay people stop being gay in order to avoid the effects of homophobia. With social stigma, the morally correct response is to fight to end the stigma, not eliminate the group of people who are stigmatized.

To be sure, being fat is different from being black or gay. I do not mean to equate these different experiences of oppression. Instead, I am suggesting that it’s not really helpful to think of being fat as something a person can necessarily change.

People do not always have control over the circumstances of their lives, especially in regards to health and disability, access to medical care, and financial security. Sometimes people may have medical reasons why they cannot lose weight. For others, the time, money, and energy it would require to lose weight may be more than they have to give. To assume that every fat person could lose weight if they chose to is a hugely reductive perspective, based in stigma, that denies fat people the right to their own individual stories, situations, and experiences.

To get more personal, I guess I could be classified as a person who “could” lose weight if I chose to. The thing is, I have made that choice in the past and it didn’t go so well for me. You can read all about in “My Breakup with Exercise.”

From my past experience, I know that In order to be a thin health educator, I would have to sacrifice to a degree that would have an overall negative impact on my life and personal wellness, as well as my job performance. For me, maintaining a low body weight is a mentally exhausting and extremely time intensive endeavor. It requires devoting nearly all of my free time to exercise and meal planning, to the extent that I do not have enough time or brainpower leftover to hang with friends, see shows, or work on creative projects like quilt-making, comedy writing and improv, and this blog.

The “decision fatigue” from focusing so much attention on food choices would also take its toll at work, leaving little decision-making power for my actual work. Plus, have you ever tried to go a whole work day on yogurt and salad? It’s not easy to keep that upbeat smile going when you’re hungry and irritable, and it’s definitely inconvenient when a serious one-on-one with an at-risk student is continually interrupted by your stomach growling.

However, with moderation, I can maintain a decent level of health without making those kinds of sacrifices. I may not be thin, but I can live a full life and perform my best at work.

For me, wellness continues to be a journey.

A Softer World

Each year I adopt new behaviors to improve different dimensions of my health and wellness. My priorities may change, but I will be continuing this journey for the rest of my life. My weight may or may not fluctuate as a result of my choices, but I refuse to think any less of myself for doing health education – or any work, for that matter – in a fat body.

So the next time you judge a health professional for being fat, take a step back and check your prejudice. It is up to all of us to create a future where professionals are judged not by their appearance, weight, race, ethnicity, religion, gender, sexuality, or gender expression, but by the quality of their work.

Bystander Education is Not a Silver Bullet

Bystander intervention education is great. I really believe in its power to make the world a better place, and to make college campuses safer and more welcoming for all. But I also believe that bystander education won’t do much to prevent sexual assault until we agree that sexual assault is a gendered issue, and that sexism is still a big, fat, effing problem.

Let me explain.

Bystander education teaches students how to step in and intervene when they see or hear something that’s not okay. When they witness someone in trouble. But it will never be effective at combating sexual violence or harassment if we can’t even agree on the basic premise that yelling at women on the street is not okay. Or that having sex with a really, really, blacked-out, drunk person is not okay. If that’s where students are stuck, then bystander education is a waste of everyone’s time. Those students don’t need bystander education. They need Sexism 101.

But do students get taught Sexism 101? Ever in their 12 years of grade school? Nope. Not one bit. Why not? Because we – the adults – can’t even agree that sexism still exists.

DESPITE THE FACT that most women experience street harassment on a daily basis. DESPITE THE FACT that most women would love to “Lean In,” except for that whole bit about how it so often backfires because nobody likes an assertive woman in the workplace. DESPITE THE FACT that most women have experienced being groped by a stranger at a dance club. DESPITE THE FACT that even the supposedly-feminist “girl’s” toys are pastel pink. DESPITE THE FACT that news about women is a separate category on news sites as if women were a special interest group instead of half the population. DESPITE THE FACT that intimate partner violence is a leading cause of death for pregnant women. DESPITE THE FACT that Game of Thrones Director Alex Graves thinks a textbook rape scene isn’t rape. DESPITE THE FACT that rape-threats and death-threats are “just another day at the office” for female bloggers. DESPITE the wage gap, slut shaming, “BLURRED LINES,” and multiple pro-rape Fraternities, we still can’t reach consensus that women are marginalized in America.

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Despite all evidence to the contrary, respectable, educated people still argue that sexism isn’t a thing anymore. That we are living in a “post-sexist” America. (Just like we are living in a “post-racial” America, amirite?) But not only are they arguing that feminism succeeded and we’re fine now, they’re giving space in publications like the New Republic to voice the concerns of MRA’s who think that men are now the primary targets of gender discrimination, and who have been known to harass, stalk, and bully feminist writers and activists to further their cause.

really

Some college students respond really well to bystander intervention education. They recognize the problem and want to help. Other college students think that bystander education is unfair and “biased” because sometimes men are the aggressors or perpetrators in various scenarios.* Try telling them the truth – that even though most men do not rape, 99% of rapes are committed by men – and they argue back that that’s one-sided. Biased. Unfair. Demonizing. The only sexual assault prevention education they’re interested in is one in which men and women are “equal,” regardless of the reality.

Equal?

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*The scenarios I use feature men, women, and the gender-neutral “Jamie” as aggressors, yet that special minority of students will still accuse me of bias against men.

As an educator, you have two choices. You can pretend that men and women are “equal” when it comes to sexual assault, thereby validating this inverted thinking and perpetuating the fallacy that women are just as likely to rape men as men are to rape women. And you can rationalize it by telling yourself “Well, if that’s what I have to do to get them to come to the table and talk about this stuff then it’s worth it.” You could do that. But you’d be wrong.

Sexual harassment and sexual assault are not equal. They are not even. They are not fair. They are gendered issues. Who are most likely to be victims? Trans people and women. Who are most likely to be perpetrators? Men. Sorry. That’s the reality.

Am I suggesting that men are evil? That men are hardwired to be horrible, violent, abusers? No. Not even close. Men and women are shaped by the society they live in, and our society is one that tells young men that women are asking for it, that drunk women are “DTF,” that women lie about being raped because they regret having sex, and that real men want sex all the time no matter what. That a boy being raped by a woman at age 8 will help him grow up to be a “beast” at sex. That being offended by homophobic slurs makes you a “pussy.” That the worst thing you can ever be accused of is being feminine – or gay, because it’s basically the same thing.

And even so, men who grow up in that society, espousing those hideous, sexist beliefs, usually don’t rape people. Except for a small few. But those hideous, sexist beliefs of the majority allow the violent few to rape with impunity. Because who would ever believe that drunk slut anyway, right? 

All the bystander intervention skills and techniques in the world won’t make a damned bit of difference to a student who won’t accept the simple premise that rape is real, and it is gendered. That “false rape accusations” are not happening as frequently as actual rape. That sexual harassment is actually harassment, and not a compliment.

The White House recently created a Sexual Assault Task Force and handed down a bunch of new mandates for colleges under VAWA and the Campus SaVE Act and Title IX. One of those mandates is bystander education. And I think that’s good and right and important. But nowhere in that recent White House report did it say anything about addressing sexism. Nowhere is anti-sexism education mandated. Some colleges have Women’s Studies programs and Women’s Centers and those are amazing. But plenty of schools don’t. And at those schools, no one is standing up and acknowledging that sexism plays a major role in campus sexual assault. No one is mandating that first year students take an anti-sexism seminar.

What about primary and secondary education? Grade schools have taken up the anti-bullying flag, but still, no anti-sexism flag. It’s okay to talk about being an active bystander and standing up to bullies, but it’s not okay to talk about sexism because the grown-ups still can’t agree that it exists.

Until we start teaching anti-sexism, bystander education can only do so much. When it comes to primary prevention – actually preventing sexual assault from happening – bystander education is not our silver bullet.

Until our students understand what sexism is, what it looks like, and the role it plays in perpetuating sexual violence against women and other marginalized groups in our global community, bystander education will not be effective as a primary prevention strategy to combat rape. Unless our students can understand and identify situations of sexual harassment and assault, bystander education will remain a solution to a problem-they-don’t-believe-is-actually-a-problem.

As an educator charged with the task of bystander education, I am frustrated. I love doing bystander education because when students are ready for it, it is the most fulfilling and inspiring and uplifting part of my job. But lots of students aren’t ready for it because they have no understanding of sexism or gender discrimination or gender violence. And who takes responsibility for that? Where is the accountability for that?

Your fat is not your fault

Your fat is not your fault.

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You are not lacking willpower.

You are not lacking willpower because you can’t stick to your diet. You are fine; it’s dieting that doesn’t work. No really. Diet and exercise DO NOT CURE BEING FAT. They may help you lose weight for a few months to a year to six years… but, according to a massive analysis of every long-term weight loss study, no one — statistically speaking NOT A ONE PERSON — has kept off a significant amount of weight (i.e. more than 15-20 lbs) permanently. There is a lot of emerging evidence that when a person goes on a diet, their chemistry changes so that they’re bodies will continue to fight against weight loss long after the dieting has stopped. As David Wong from Cracked put it, “It’s like being an addict where the withdrawal symptoms last for decades.”

You are not lazy.

You are not lazy because you choose to focus your time and energy on things other than losing weight. To quote David Wong again, “The people who successfully [lose weight and keep it off] are the ones who become psychologically obsessive about it, like that weird guy who built an Eiffel Tower out of toothpicks.” So congratulations, you aren’t spending every waking moment of your life focusing on your waistline. You are doing amazing things, whatever they are. Seriously! Whatever you are doing with your precious time and brainspace (reading, writing, working, creating, studying, caretaking, being nice–contributing to society in any small way) is worthwhile and meaningful and more important than spending it obsessing about your weight.

If you want to be more active, then cool. Go for it. Hopefully you’ll find some activities that will bring you pleasure and joy. But don’t think that being more active is going to make you lose weight. It’s not. (See above). So don’t force yourself into a lifestyle that doesn’t work for you–you’ll only end up making you feel worse.

tumblr_mab2gzHeHb1qm339ko1_500You are not unhealthy.

You are not unhealthy just because you happen to be fat, I mean. Isn’t that great? Your weight and your health are two different things. You can be healthy at any size.  Health is determined by your behaviors, luck, and genetics (more luck). Your behaviors are up to you. And they are NO ONE’S BUSINESS but yours. For whatever reason, being “healthy” has been equated to being moral or being “good” in our society. Let me blow your mind for just a second by throwing this nugget out there: You have a right to be unhealthy. For any reason. It’s YOUR body and you can treat it however you wish. But if you choose to be healthy, eat nutritious food and try to sleep for 8-10 hours a night. Find some active things to do that you enjoy and quit smoking. But don’t conflate your health with your weight. Losing weight probably wont improve your health, and improving your health often times doesn’t result in weight loss. This is okay.

You are not stupid.

You are not stupid for trying that juice cleanse or hoping that trying Weight Watchers or eating paleo or forcing yourself to go to the gym every day would “fix” your fat. Our society believes that diet and exercise cures fat. This is what our doctors tell us. This is what the medical and public health arms of our government advise. They are wrong. They have failed us.

Instead of focusing on fixing the real, structural, environmental problems that cause people to become overweight, like poverty or food deserts or lack of sleep or being overworked/overstressed, food advertising, agricultural subsidies, high fructose corn syrup and processed flour…. public health officials have spent millions of dollars and time and energy telling you to diet and exercise. Why? Because it’s easier. It’s much, much easier (politically) to tell individuals to diet and exercise than it would be to fight the lobbyists or make any real headway in regulating the food industry or addressing poverty or our tradition of overwork in America. As Gary Taubes wrote in The Daily Beast, “…the reason the anti-obesity efforts championed by the IOM, the CDC, and the NIH haven’t worked and won’t work is not because we’re not listening, and not because we just can’t say no, but because these efforts are not addressing the fundamental cause of the problem. Like trying to prevent lung cancer by getting smokers to eat less and run more, it won’t work because the intervention is wrong.”

You are not weak.

You are not weak. In fact, your strength is incredible. You are living in a world that does not make it easy for you. You are living in a world that tells you you have to look a certain way in order to be loved, and at the same tells us food is love. You are told to resist eating foods that are scientifically engineered to be literally irresistible — as in, they trick our senses in order to make us physically unable to resist eating them. You have struggled with stigma and shame and guilt and survived. You are alive and you are living.

So let me say this one more time: Your fat is not your fault.

it-s-not-your-fault-o

Give yourself permission to forgive yourself.

Go out and live your amazing life.

Addressing the sleep deficit, NOT one person at a time

The more I learn about health and wellness, the more convinced I am that sleep is magic.

Not only does getting the recommended 7-9 hours help you feel awake and refreshed in the morning, it also helps regulate your metabolism and improves your memory, focus, judgment, problem solving, and athletic performance.

New and terrifying research links not-enough-sleep (the 5-6 hours most Americans currently get) with weight gain, increased risk of cold/flu, diabetes, cancer, and ADHD-like symptoms. Additionally, not getting enough sleep results in poorer cognitive abilities (lack of focus, concentration, ability to remember what you’ve learned), poor judgment, and impaired driving on par with drunk driving. It’s also correlated with depression, anxiety, and other mental illness.

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When I saw this New York Times post basically summing it all up (and providing links if you want to check out the research) I was ecstatic and all “That’s what I’ve been saying!” Then I read the comments.

“You assume it’s a choice, that people actively choose to get less sleep and, if they want to, can choose to get more. That may well be true of upper class people who can hire others to do their work for them – housework, tutoring, etc. As for me, a middle class shlub, well, I would LOVE to get more sleep. But I am a single mom. I have to get up at 5:30 am for my job. And I have to work or I will land in the street with my kids. ANd I have to stay up at least until 10:30 pm most nights to get this or that child hither and thither, help with homework, and son on. I cannot hire anyone to do any chore– lawnmowing, housecare, homework, driving, shopping, bill paying, college planning for kids, etc etc etc etc. Basically, I work from the moment I get up until the moment I sleep. I have no time to exercise either.”

And it hit me. The sleep deficit is a lot like the obesity epidemic; it is a systemic problem that cannot be solved by encouraging individuals to make healthier choices.

I work with college students who probably could get more sleep if they spent a couple fewer hours playing videogames.

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Shit college students say.

Of course, some of my students work more than the recommended 10 hours per week and can’t choose to sleep more. But in general, I feel okay about trying to encourage them to prioritize sleep over partying or more time on Reddit because they can usually make changes without too much trouble. For the general adult population, however, this really isn’t the case.

The comments on the New York Times post read like a laundry list of reasons why Americans are not sleeping. Parents are kept up by new babies. Physicians-in-training are working 28-hour shifts. People who travel constantly for work (flight crews, journalists, musicians, etc.) are forced to keep irregular schedules in different time zones. Single parents are working full time jobs in addition to the “second shift” just to make ends meet.

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But it isn’t just our jobs, families, and full schedules that are keeping us up. The world has changed. Energy drinks and caffeinated latte drinks are sold on every corner and and marketed either as health supplements or entertainment. We are constantly connected, if not tethered to, our phones, tablets, and the internet — whether it’s for work, entertainment, or connection. A recent study found that the light from backlit screens can disrupt sleep by suppressing melatonin, a hormone that helps regulate our circadian systems. But this is even bigger than a gadget issue.

Our circadian rhythm, which is how our body knows when to sleep and when to wake, is informed by both light and temperature. Darkness and cooler temperatures let our bodies know it’s nighttime, and therefore bedtime. So what happens to our circadian rhythm when we live in consistently temperature-controlled environments? And about that darkness thing? Yeah. We don’t really have that anymore. Just check out these NASA images of the world at night.

Captured in 1994

Captured in 1994

Light pollution projected growth

Light pollution projected growth in 2025

So basically our artificial environment is  really screwing with our circadian systems, and we wonder why no one can sleep? Some scientists are even concerned that light pollution is killing off wildlife.

Animals need sleep too.

Animals need sleep too.

It’s no wonder that the New York Times post, which encouraged readers to get more sleep and discuss the issue with their doctors, made some people angry. For so many of us, sleep is simply outside our realm of control. Before I’ve made the argument that our obesity problem should not be addressed through individual behavior change because it is a systemic problem that can really only be solved through systemic changes to our environments and our policies. When we try to treat obesity as if it were simply an individual problem, it manifests as shaming people for things beyond their control. When we consider that sleep and weight are inextricably linked, it’s not surprising that the same thing happens when we tell people they need more sleep.

And, just like weight shaming can cause people to develop eating disorders or depression/self-esteem issues that lead to further weight gain, warning people about the health risks of sleep deficit can actually make the problem worse:

“As a law school graduate studying for the New York Bar and planning an impending move to NYC–without yet a job, praying to find one in public interest law–I lie awake every night, worrying.  But at least now I know all of the harmful things that are happening to me.”

“Constantly counting the number of hours of sleep I got each night hasn’t been good for my mental health either. It’s like counting calories. It made me obsessed. So I stopped.”

“One thing that would help me sleep is not being constantly told how awful it is not to get it.”

The Health Belief Model of behavior change tells us that if you scare people about a health issue without providing a clear solution for how they can prevent or treat it, they are not going to respond well. Telling folks the dangers of not getting enough sleep without providing realistic solutions will cause them to feel like it’s hopeless and shut down. This issue cannot be solved by telling people to try to get more sleep.

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So how can we address the sleep deficit at the systematic level? In college health we have an advantage because we have a fair amount of control over the environment our students inhabit. We have the ability to provide a campus that encourages and supports healthy behavior. We can close down our libraries, gyms, labs, and campus centers at 10 pm. We can ban 8 am classes to let our students sleep in later. We can mandate quiet hours in our residence halls. We can ban Red Bull and 5 Hour Energy from promoting their goods on campus. It’s a little more complicated in the real world.

tumblr_inline_mmq91iJGyJ1qz4rgpWhat could some of those systemic changes look like? Is it even possible to regulate light pollution in urban areas? How would we accomplish that? We could tax the crap out of energy drinks like we tax cigarettes. We could create similar disincentives for 24-hour service availability. For example, in Spain, most businesses are closed during siesta in the afternoon. People simply have to run errands another time, and they make it work. We could also place stricter regulations around the “full time” (read: eligible for benefits) work week, reducing it from the standard 4o-45 hours to something closer to 35. (Again, a lot of Europeans do it this way.)

But beyond regulation, true systemic change requires a culture shift. We need to foster a culture that doesn’t reward employees for putting in extra hours, or make anyone feel like they need to put in extra hours to keep their job. In industries where it’s possible, like in most office jobs, we need to institutionalize flex time and let workers telecommute in order to snooze that extra hour it would take to commute. We need to change the norm from one where we lie in bed with our phones checking email to one where that kind of behavior is uncommon. We could stop creating reasons for people to stay up late, like scheduling evening events earlier and no longer airing popular TV shows after 10 pm.

But this kind of societal change takes decades and requires tireless efforts from public health folks and other advocates. Perhaps the first step of that work is recognizing that the sleep deficit is bigger than you and your insomnia, her and her new baby, or him and his ridiculous work schedule. For those who can make the choice to sleep more, doing so will definitely improve their health. But the focus of public health messaging and health journalism should not be to scare or shame people who, for whatever reason, can’t get enough sleep.

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TL;DR sleep zombie friends?

What I’m really trying to say is that the only way to really address the issue is to treat society’s sleep deficit as the gigantic, systemic, clusterfuck of a problem that it truly is.

Goodnight.

Goodnight.

My new identity as a college health educator

I returned from South America in late August, unemployed and not at all sure where I’d end up or how long it would take. I could not have imagined that in only three weeks, I’d have landed my dream job. I finally get to combine my personal interest in health with my training in health communication and my love of education as a bonafide health and wellness educator at a college in Boston, MA.

In my new role, I teach classes and workshops, coach students in individual sessions, design and run education campaigns and behavior change interventions, plan events and programming, collect and analyze student data, and advise a student group of peer health educators. My new world revolves around alcohol and drugs, sexual health, stress management, sleep, nutrition, fitness, eating disorders, mental health, and wellness.

I absolutely love, love, love my new job. And what’s more, it’s prompting me to think about a lot of new things and considerations. For example.

My role as role model

  • So, like, can I never mention drinking in a tweet ever again?
  • Must I now avoid bars where there might be undergrads?
  • If I choose to get drunk, does that make me a hypocrite?
  • Will people be watching my personal health/eating habits more closely?
  • Does it reflect poorly on my authority/credibility as a health educator/expert if I am overweight?

Serving a population that is 85% male and 15% female

  • How do I make sure to dedicate enough resources to women’s health topics when women are such a minority?
  • Opportunities for sexual assault prevention aimed at a male audience (bystander education)
  • Making sure that sex ed/sexual assault/body image/eating disorder programming reflects feminist perspective
  • What men’s health issues do I need to learn more about?

Education vs. social marketing

  • Social marketing has traditionally not been used at this college; in what cases is it worth pushing for change?
  • How much time/effort/money do I dedicate to educational initiatives when I believe behavior change interventions would be more effective?
  • How much time/effort/money do I dedicate to the complicated process of designing behavior change interventions?
  • When is it worth designing original materials vs. using materials already available?

Health vs. Wellness

  • What’s the difference?

Pretty great stuff, right?

I look forward to exploring the intricate details and delicate dilemmas involved in college health education with you at Talkin’ Reckless. In addition to my usual gender- and health-related ranting.

“All Adventurous Women Do”

HBO's GirlsOn the third episode of HBO’s new series, Girls, the protagonist Hannah (played by creator Lena Dunham) is diagnosed with human papilloma virus (HPV). Distraught, she tells her best friend, who replies with the most revolutionary phrase ever uttered on television regarding STI stigma: “All adventurous women do.”

STI stigma is not difficult to understand. Since STIs are sexually transmitted, they’re easy to interpret as punishment for promiscuity. People with STIs are often characterized as slutty, dirty, trashy, or stupid and reckless. And when someone is diagnosed with HPV–no matter how confident she is in her choices, no matter how careful she is–she’s faced with the crushing weight of this stigma. She must try her darndest not to internalize it–not to believe that she is being punished for her sexuality, not to believe that she brought this upon herself, or that this viral infection is indicative of poor moral character. This is extremely difficult because no one has prepared her for this, and she will almost certainly go through it alone.

Since HPV and STIs are treated as a shameful secret, we don’t ever talk about what the process of diagnosis and its aftermath is like, and as a result, we never hear what it was like for someone else. We each have to figure out how to cope on our own, in silence, without the comfort or guidance of those who have been there and can understand. There are no celebrity spokespeople for HPV. No star athlete role models. And so very few narratives in television, film, or literature.

It’s rare to see STIs on television. Rather, it’s rare to see STIs on television outside of medical and crime dramas where STIs are used as a “who done it” plot device to reveal some unexpected twist regarding infidelity or some otherwise inappropriate sexual behavior. It’s rare to see a character simply living with an STI–getting diagnosed, experiencing treatment, navigating relationships, and dealing with shame and stigma in every day life. It’s rare, but it shouldn’t be.

HPV is the most common STI in the United States. The CDC approximates that 20 million Americans currently have HPV, with six million new infections occurring each year. (For reference, 20 million people is roughly the population of Beijing, New York state, and the entire country of Australia.) The CDC estimates that 50% of sexually active Americans (men and women) will contract HPV at some point in their lives, although the American Social Health Association thinks it’s closer to 75-80%. For women, the rates are even higher: the CDC estimates that, by the age of 50, at least 80% of women will have acquired sexually transmitted HPV.

So, if at least 50% of Americans will one day have the experience of being diagnosed with HPV, shouldn’t we be doing something to prepare them for that moment so that the bottom doesn’t drop out from under them? Shouldn’t we let them know that this is a shared experience and that they don’t have to feel so alone? Shouldn’t we be working to combat stigma at the social level so that we can reduce the emotional damage it inflicts?

Writing HPV and other STIs into television narratives is a great way to challenge and combat stigma. Especially when the character is able to make peace with the diagnosis, providing a model for the rest of us.

“All adventurous women do.”

In that one glorious sentence, Girls let us know that HPV is common and that instead of a being a sign of poor character, it’s a mark of an adventurous spirit. This one line erases the stigma and reframes HPV as something normal, even positive. “All adventurous women do” allows Lena Dunham’s character Hannah to own the diagnosis, to embrace it, to wear it as a badge of honor. And it teaches the rest of us–all of us girls who have felt the waves of shame and guilt crashing on top of us, suffocating us–that we are okay. That HPV, much like traveler’s diarrhea, is just another part of the experience of being an adventurous woman in the 21st Century.

Positive body image won’t make you fat: The case for body positive health promotion

I’m currently designing a social marketing campaign to improve body image among undergraduate women at a major university. On three different occasions, my classmates—a cohort of public health, nutrition, and health communication students in leading graduate programs—expressed concerns about my project, asking “Aren’t you worried that you’re promoting obesity?”

There seems to be a dangerous misconception in the public health community that the goals of positive body image promotion and obesity prevention are at odds. That somehow, by helping people feel better about their bodies, we will inadvertently “encourage” obesity.

But body image promotion isn’t about glorifying fatness, just like obesity prevention isn’t (or shouldn’t be) about the glorification of thinness. More accurately, body image and weight management are interconnected elements of holistic mind-body approach to health and ultimately, the public health community has more to gain by thinking of them as complementary rather than competing interests.

Obesity prevention efforts may appear to benefit from a status quo that stigmatizes fatness and worships thinness, but the evidence just doesn’t support it. We live in a culture that idolizes underweight supermodels and relegates fat actors to fart and food jokes, and yet none of it has done anything to make people healthier.

A lot of people worry—myself included—that without body dissatisfaction, we would lose our motivation to slim down. It’s an easy trap to fall into because, for many of us, negative thoughts are the only motivation to lose weight we’ve ever known. It’s scary to imagine life without our internal “fat talk”; it takes work to imagine using positive feelings as a source of motivation.

But contrary to popular belief, shame is not a good motivator. In addition to reinforcing an impossible, demoralizing standard of beauty, using fat shame as motivation will always backfire. Fear, shame, and self-disgust may prompt people to change their habits temporarily, but once they start to feel better and the bad feelings dissipate, they are bound return to old habits. Motivation-by-fat-shame doesn’t create a culture of health; it creates a culture of yo-yo dieting and January gym memberships abandoned by March.

Not only does fat shaming fail to help people get healthy, it actively hurts people, leaving maelstrom of negative body image, low self-esteem, depression, eating disorders, and other pathological eating and exercise behaviors in its wake. This is no small matter, as these conditions cause pain and suffering for millions of men and women, of all ages, all over the country and the world.

Obesity prevention efforts that reinforce the thin-ideal status quo are doomed to perpetuate a broken system where body image dissatisfaction is normative, obesity rates keep rising, and the multi-billion dollar weight loss industry capitalizes on both. But obesity prevention efforts that embrace positive body image promotion, on the other hand, have a chance to break the cycle.

Meaningful body image promotion encourages women to reject the tyrannical and reductive thin-ideal portrayed in the media, and to understand that pursuing a healthy lifestyle for its own sake is much more rewarding than obsessing about dieting and weight loss. After all, “thin” doesn’t translate to “healthy.”

For example, the Health At Every Size (HAES) movement is based on the understanding that weight does not determine health, and that exercise and good nutrition are beneficial, whether or not they result in weight loss. Instead of using BMI, HAES advocates using more specific measures, like blood pressure and cholesterol, to determine one’s health status.

Instead of relying on body dissatisfaction, HAES teaches us to draw motivation from positive sources, like the desire to explore new hobbies (yoga, archery, kickball), to achieve new goals (run a 5k, learn to surf), or to enjoy the flavor and feeling you get from nourishing your body with healthy foods. This is the kind of lifestyle change that keeps people engaged and motivated for the long haul, and it will keep us healthier, whether or not we’re overweight. Also, it’s fair to say that by letting go of the “impossible dream” of one day looking like the (photoshopped) people on the cover of magazines and by learning to accept and love our bodies as they are, we’ll be happier too.

This type of holistic approach—incorporating positive body image, mental health, physical activity, and good nutrition—is actually sustainable because it promotes an understanding of “health” as a lifelong process rather than a set of restrictions or punishments to be lifted once you reach that magic number on the scale.

We know that there are no health benefits to negative body image. So why would we limit the scope of obesity prevention to exclude the potential benefits of positive body image?

Encouraging positive body image does not “promote” obesity. Rather, it helps people let go of the shame, fear, and unsustainable weight loss behaviors that are keeping them trapped in a state of bad health.

The MBTA should not allow advertising from crisis pregnancy centers

The MBTA is where you’ll usually find ads for Jamba juice and Jansport backpacks, local research studies, and public health campaigns. Currently, though, much of this highly-coveted space is occupied by ads for Daybreakinc.org, an anti-abortion crisis pregnancy center. The ads don’t tell you that Daybreak has an anti-abortion agenda; they claim to offer “compassion,” “empowerment,” “hope,” and most inaccurately, “options.” This is in fact the major criticism of crisis pregnancy centers—that they misrepresent themselves as neutral parties. They are not, and they should not be allowed to advertise their heavily-biased and manipulative services on the MBTA.

The point of a crisis pregnancy center (CPC) is to keep pregnant women from having abortions, often by delaying them with offers of pregnancy tests and ultrasounds until it’s too late. What is truly sinister about CPCs is their use of untrue or misleading information to scare women away from choosing abortion, with false claims such as: abortion causes breast cancer, abortion is psychologically damaging, abortion can lead to sterility, and birth-control pills cause abortion. A 2006 Congressional investigation found that 87 percent of the centers surveyed provided false or misleading medical information.

Daybreak is guilty of this type of misinformation, although they are careful not to appear so on their website. It’s no wonder they are covering their behinds—legal action has been taken against CPCs in a number of states regarding their deceptive advertising in New York, California, Ohio, Missouri, and North Dakota.

According to their website, Daybreak claims to provide “accurate information about pregnancy, fetal development, lifestyle issues, and related concerns” as well as offer “accurate information about abortion procedures and risks.” They say “our advertising and communications are truthful and honest and accurately describe the services we offer.” But when you dig in deeper, you will find a sample if misleading and just plain untrue “facts” on their website:

  • Daybreak claims: “[Plan B] It may alter the uterine lining which prevents the fertilized egg from implanting, resulting in an early abortion.” (This is wrong—the dissolution of a fertilized egg is NOT “early abortion.”)
  • Daybreak claims: “Complications may happen in as many as 1 out of every 100 early abortions,” when according to the Guttmacher Institute, “the risk of abortion complications is minimal: Fewer than 0.3% of abortion patients experience a complication that requires hospitalization.”
  • Daybreak claims: “Women who have experienced abortion may develop the following symptoms: guilt, grief, anger, anxiety, depression, suicidal thoughts, difficulty bonding with partner or children, eating disorder,” when the American Psychological Association’s Task Force on Mental Health and Abortion reported that “the best scientific evidence published indicates that among adult women who have an unplanned pregnancy the relative risk of mental health problems is no greater if they have a single elective first-trimester abortion than if they deliver that pregnancy.”
  • On the particularly appalling “For Men” section of the Daybreak website, they write: “Many women who have had abortions report that they were waiting for their boyfriends/husbands to stop them. Some even say that they sat on the table hoping the father of their baby would ‘rush through the door to rescue me and take me away somewhere safe.’” (Um, citation needed?)

I’m not trying to make the argument that free pregnancy counseling is a bad thing or that the people at Daybreak are “bad” people, but pregnancy counseling, or any counseling for that matter, should be unbiased and informative. No where on the Daybreak MBTA ads are women informed that the the “free pregnancy counseling” is actually anti-abortion counseling, and that is dishonest, manipulative, and ultimately wrong. Women facing unplanned pregnancies need to know all their options, without the implication that one is better than another, and they need real medical information, not the “facts” listed above.

The MBTA is currently under fire for proposed fare increases and service cuts. They may be desperate for funds, but that does not excuse this moral misstep. CPCs are a growing threat to women’s health and the MBTA is the last place Bostonians should be exposed to anti-abortion propaganda.

“Shame and Blame: Facing the Unintended Consequences of Health Messaging” on Huffpost

Today my op-ed on shame and blame in health campaigns was published on the Huffington Post. Check it out!

Shame and Blame: Facing the Unintended Consequences of Health Messaging

A solemn black and white poster shows a picture of an obese girl with copy that reads: “Warning: It’s hard to be a little girl if you’re not.” Another poster displays a woman’s naked legs with her panties around her ankles and the word: “She didn’t want to do it, but she couldn’t say no.” The first is part of the Georgia “Strong 4 Life” campaign to prevent childhood obesity; the other is part of the Pennsylvania “Control Tonight” campaign to reduce excessive alcohol consumption. Though the campaigns are unrelated, they have one thing in common: disregard for the effects of shame and blame — the frequent unintended consequences of health campaigns.

The promotion of health and social welfare is one of those noble causes that attracts people who want to “do good.” Physicians are taught to “First, do no harm,” but health communication professionals take for granted that their work is “doing good” without considering that it might cause unintentional harm. For example, stigmatizing sexually transmitted infection (STI) prevention messages may make people with STIs too embarrassed to seek treatment or too ashamed to tell their sexual partners. Not only can health promotion messages lead to such negative health outcomes, they can also promote destructive social values, like fat stigma and rape culture.

Read the rest at the Huffington Post.