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!

Your fat is not your fault

Your fat is not your fault.

tumblr_lqq3xmd7nw1qky3lio1_500

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.

Healthy Choice™ and healthy changes

I’ve recently taken note of a new ad campaign by Healthy Choice stating, “Don’t diet. Live healthy.” Turns out the campaign isn’t actually that new since the New York Times covered it in September, 2012, but since I didn’t have television until recently, it’s new for me.

I liked this ad as a wellness educator and body image researcher, and as a former dieter and purchaser of SmartOnes Weight-Watchers-friendly frozen dinners, it made me laugh.

Yes, you heard right. I am a former dieter. At the end of 2012, after yet another frustrating year of failed attempts at dieting and weight loss, I made a serious decision. I decided to stop dieting, forever. I cancelled my Weight Watchers Online subscription for what will be the last and final time. It all started last year when I started researching body image and “fat talk” for my dissertation-equivalent Health Communication project. Conducting that research often and unintentionally became “mesearch,” forcing me to examine my own feelings and behaviors with the intensity of a laser beam. It was painful and I did not like what I found.

I learned that I was one of the 90% of students with body image concerns. I learned that body image disturbance, an umbrella term for body image dissatisfaction and distortion (believing you are bigger than you really are), is associated with depression and low self-esteem. I learned that I was one of the majority of women who engaged in “fat talk” — a term coined in 1994 to describe the specific way girls and women talk to each other about the size and shape of their bodies or diet and exercise regimens, typically in a negative or self-disparaging manner. “I’m so fat.” “You’re not fat! If you’re fat, what does that make me?”

After leaning that fat talk is associated with greater body image disturbance and thin-ideal internalization (the idea that skinny=pretty) and coming to understand the way it normalizes and reinforces body image concerns at the societal level, I started paying attention. It was staggering to realize how many of my conversations with other women were about dieting, exercise routines, the clothes we “could” or “couldn’t” wear, how much weight we wanted to lose, the reasons why we hadn’t been able to “commit” to our weight loss plans. I never realized how often I apologized for eating (“I’m sorry but I’m getting a big burrito tonight”) or made excuses for eating (“I ate like nothing all day today so I’m going to get fries”).

I started to learn more about dieting. I began to realize that all dieting is bad. Yes, ALL dieting is bad. Even if you really need to lose weight for medical reasons like heart disease or diabetes, dieting only helps in the short term. Dieting offers nothing that might help you stick to your diet. Dieting doesn’t help once you’ve reached your goal weight. Cleanses and fasts are even more stupid than diets. They’re like douching–completely unnecessary when you’re healthy, and potentially harmful when you’re not.

I have come to believe that dieting is unhealthy. Slowly but surely, I came round to the philosophy behind Health At Every Size. Believe me, it took a while.

I am overweight but not horribly so. I have been this way for most of my life. I have wanted to lose weight ever since I was 10 years old. That’s a long time to want something. So, making the decision to stop dieting and pursue health rather than weight loss is nothing short of worldview-shattering. A complete about face. A completely new paradigm positioned 180 degrees from my former belief system.

This kind of conversion doesn’t happen easily or quickly. I’ve sat and mulled and struggled with these feelings and developing beliefs for a year or two now. Even today I’m still often shocked by how radical they sound to my own ears. Deciding to stop dieting has been one of the most terrifying things I’ve ever done, and I’ve just barely gotten started.

I created a plan for myself. Instead of dieting, I would:

  1. Get active for the right reasons. Find and embrace the pleasure in physical activity. Exercise because it feels good or to meet goals other than weight loss (do 30 push ups, hike that mountain, etc.).
  2. Learn to cook and eat take-out and prepared food less often
  3. Practice mindful eating, listen to my hunger signals, etc
  4. Practice good sleep hygiene (lack of sleep affects the hormones that regulate your appetite and feelings of satisfaction after eating, not to mention the myriad other physical and mental effects)
  5. Cut out “fat talk” entirely; if others around me are doing it I will not participate or change the subject

Truthfully, I started on number five about a year before I made the rest of my plan to stop dieting. Cutting out fat talk turned out be easier than I thought. At first it felt awkward and I didn’t know how how to act or react when friends and coworkers launched into the usual self-put downs and mutual reassurance tango. It turns out that simply not participating or changing the subject works pretty darn well. In a couple of instances, I talked with some close friends about it and my decision to stop. They were receptive and overtime less and less fat talk creeped into our conversations. Overall, I think I am happier for it. Now when I hear fat talk I’m struck by how annoying and insipid it is, and grateful that it’s no longer a part of my social repertoire  It’s been harder, of course, to silence the fat talk that goes on inside my own head, but hey. One step at a time.

This January, I  started the rest of the plan. The first week of diet-free living felt amazing. It was FREEDOM. I felt great to eat something “normal” (non-diet food) and even better to allow myself to NOT feel guilty afterwards. The elation didn’t last long, though, as my insecurities and doubts bounced back with a vengeance. They’re still with me today, louder than ever:

I doubt that I will be able to make any real measurable changes in my weight or my health without dieting. I doubt I will be able to stick to my 5 point plan. I doubt I will be able to be happy if I stay at my current weight, even if I’m super healthy and fit.

I doubt everything regularly, but I’m so committed to building sustainable, healthy habits that will last for the rest of my life that I can’t give up.

It turns out that quitting dieting is the easiest part of making this lifestyle change. A harder part is actually developing and maintaining my new, healthier, lifestyle and the hardest part of all is silencing the doubts and insecurities that make me want to give up or give in to the seeming futility of it all.

I appreciate the message behind Healthy Choice’s latest ad campaign: “Don’t diet. Live Healthy.” I believe it to be a healing message for both individuals and our sick culture. Of course, if it were easy to “live healthy” in America today we wouldn’t have turned to dieting in the first place. And as great as Healthy Choice products are (that is, marginally better than SmartOnes and other diet food), frozen dinners are not the answer.