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!

WTF is “lifestyle change” supposed to mean anyway?

lifestyle changeIf you’re like me, you’ve heard the term “lifestyle change” thrown around quite a bit. For example, it was used plenty of times in the comments on my recent post, My Breakup with Exercise. People are always saying things like, “It’s not about dieting, it’s about making a lifestyle change.” But oftentimes one person’s “lifestyle change” is another person’s diet, and vice versa. So WTF does “lifestyle change” actually mean?

Growing up, I first heard my parents use the term to describe a family friend and the healthy changes she made many years ago. Even then I was confused because her story began with everyone’s favorite diet company, Weight Watchers. Even though she no longer follows the program, she continues to practice some of their tips and tricks to maintain her weight, like tracking what she eats, looking for foods high in fiber, etc. A relative told me about a coworker who “doesn’t diet” but just has “plus days” and “minus days”; if she had a “plus day,” she’d compensate by having a “minus day.” To me, this all still sounds like dieting because it involves monitoring your food intake, following food “rules” or restrictions, and placing value judgements on foods or eating habits as being “good” or “bad.” Of course, you might not agree, and that’s okay.

Although the intention is usually good, telling someone to make a “lifestyle change” is problematic because everyone’s understanding of what that means is different. For example, it could mean switching to sugar-free versions of your favorite foods, or it could mean never eating artificial sweeteners ever again. Those of us who struggle with weight and body image often understand the term to apply to eating and exercise behaviors, but for others it could refer to quitting smoking or taking up a meditation practice or switching to paraben-free bath products.

The beauty of the term, though, is that it can mean whatever you want it to mean — whatever makes sense to you.

At it’s most basic level, a “lifestyle change” means making changes to support one’s personal wellness. Did you know that there are actually seven different dimensions of wellness?

  • Physical wellness can include fitness, diet and nutrition, sexual behavior, substance use or abuse, medical care, and sleep.
  • Intellectual wellness can include the pursuit of knowledge, awareness of current events, and the expression or experience of creativity.
  • Emotional wellness can include stress management and relaxation, as well as self-awareness, self-acceptance, and mental health.
  • Social wellness can include interpersonal relationships, social justice, and community service.
  • Spiritual wellness can include your value or belief system (including but not limited to religion), and finding personal meaning, hope, and optimism.
  • Environmental wellness can include the protection and conservation of natural resources, as well as the health and safety of animals, humans, and our own bodies.
  • Occupational wellness can include job satisfaction, work/life balance, and financial security.

It’s helpful to consider of all of these dimensions because it reminds us that neither our worth nor our happiness nor our “wellness” is defined by our appearance, our fitness, or our diet. Part of figuring out what making a “lifestyle change” means to you is figuring out what dimensions of wellness you want to pay more attention to–recognizing that each are equally valid and important in your personal pursuit of health and happiness.

Last year I taught a course on leadership and we used a ranking activity to help students think deeper about their own values. (Mad props to Steve R. for the activity!) I modified it and I think this version could be helpful in terms of figuring out what “lifestyle change” you might be interested in. Below are 50 different things that could be part of making a healthy “lifestyle” change, in no particular order.

 Weight management

 Fitness/ Strength

 Smoking

 Religious belief & practice

 Community Service

 Finances/debt management

  Job satisfaction

 Inner Harmony

 Environmental conservation

 Social Justice activism

 Hope/Optimism

 Stress management

 Animal rights

Being active

  Nutrition

 Vegetarian diet/ vegan diet

 Mindfullness/ meditation

  Sleep

 Creativity/ Creative expression

 Sexual pleasure/sex life

 Family relationships

 Social life/ friendships

 Avoiding processed foods

 Career Advancement

 Romantic relationships

 Pursuit of knowledge

 Alcohol use/abuse

 Medical care

 Sexuality/ gender identity and expression

 Self-care/ Self-compassion

 Awareness of current events

 Political involvement

 Mental health

 Avoiding artificial sweeteners

 Body image

 Reducing intake of chemicals in bath/beauty/cleaning products, etc.

 Intuitive eating/mindful eating practice

 

 Self-acceptance

Avoiding artificial growth hormones in meat/dairy

 Drug use/abuse

 Community engagement

 

Experiencing new things/places

Eating less sugar/high fructose corn syrup

 JOY!

FUN!

 Eating whole grains

 Work/life balance

 Hobbies/skill development

 Gratitude

 Eating local/food sustainability

 

 Intimacy

Okay, here’s the hard part. Here’s the link to download and print it out: Defining your Wellness Values Chart

  1. Cross off the 10 that either a) you’re already satisfied with, or b) that are least important to you right now. (Remember that this doesn’t mean these things are unimportant, just that they are less important to you, right now, than the remaining 40.)
  2. Now cross off 10 more (30 remaining). Give yourself a time limit.
  3. Now cross off 7 (23 remaining). Take a quick break and then come back to it.
  4. Now cross off another 7 (16 remaining).
  5. Cross off 6 more (10 remaining). This is getting tough, huh?
  6. Cross off 5 more (5 remaining).
  7. Circle the most important wellness element to you at this point in time.

I just did this activity and it was really freaking hard, but I narrowed my top 5 wellness elements to: building fitness/strength, improving family relationships, self-acceptance, intuitive eating, and reducing my intake of chemicals, These are the areas I want to focus on to improve my overall “wellness.” So, for me, a “lifestyle change” means working out, accepting myself the way I am, finding more ways to make meaningful and positive connections with my family, listening to what my body wants, and staying away from processed foods and chemicalized bath and beauty products.

The thing about changing your lifestyle is that it has to be something you actually WANT to do. Wanting to lose weight because you struggle with body image is not the same thing as wanting to change the way you eat. For example, the person in that scenario might experience more success and actually feel better by choosing to focus on positive body image and building self-esteem.

Only you know what a “healthy lifestyle” means for you. And if you’re not sure yet, perhaps this activity will help.

Let me know how it goes! I am hoping to try this with my students next year, and your feedback will be super useful.

 

 

One Year of Not Dieting

In December, 2012, I made a New Year’s resolution to stop dieting. Forever. I’m proud to say that I have kept my resolution and for the first time in my adult life, I have gone a whole year without tracking a single Weight Watchers point. Why? Because dieting does not work for me.

Each time I committed to dieting I would lose weight and then, whenever I needed to focus my energy on other goals (like grad school) or went through a stressful time, I would gain it all back plus more for good measure. In addition to my personal experience, I have been reading a lot about the science of weight-loss and finding that it’s really not so simple as “calories in, calories out.” I could go into more depth about the research and what I believe, but that’s for another post. For now, I’ll share that it is my belief that thanks to dieting, I weigh much more than I would have had I just left my body alone.

Here are some reflections after a full year of not dieting:

Image1. Fat talk is everywhere. People who are concerned and self-conscious about their eating habits (read: most people) insist on ruining every meal you have together by exclaiming how unhealthy the food is or reassuring you that they never eat like this at home, etc. etc. At first it was hard to stop fat talking, but now – a year after breaking the habit – I find it profoundly annoying and intrusive because I’m still expected to join in. What I choose to eat at any given time is none of your business. I don’t need to justify or explain my choices to anyone, and I certainly don’t need to apologize for my choices.

My decision to stop dieting was, in some ways, a promise to stop judging myself every time I ate some food. But thanks to all the fat talk everywhere, I became hyper aware of how much everyone else is judging themselves or others based on the food they eat. If you are trying to retrain your brain not to associate these negative judgments with food, it’s really annoying to hear everyone else do it constantly. It starts to feel like everyone’s out to sabotage you – or at least your next meal.

2. Real food tastes amazing. Have you tried non-diet yogurt lately? Or coffee with milk and actual sugar? Holy crap. Turns out, food doesn’t have to taste like a chemical sundae. The other day I was eating a big, fresh-baked chocolate chip cookie that was given to me at a work training. And believe it or not, I couldn’t even finish it. Can you remember a time when you were not able to finish a diet cookie? Those things are about as filling as a celery stick and they taste like cardboard. And even though they taste like cardboard, you end up eating the whole box anyway because you’re so hungry and it’s either the cookies or a salad, but you’re so goddamned sick of salads and your bowels are a wreck because Weight Watchers prizes foods high in fiber and apparently the secret to weight loss is pooping all the damned time. So basically, you’re sitting there, choking down cardboard cookies, mentally exhausted from decision fatigue over whether or not to eat the cookies, feeling like a total failure because you ate the cookies, and wondering if anything makes any goddamn sense in this world anymore.

Dieting! Huzzah!

3. I am finally learning how to cook. I was never that interested in learning to cook, and dieting made cooking really simple to avoid. After all, it is much easier to buy pre-made, processed foods with the nutrition facts and portion sizes clearly labeled than it is to cook a dish and figure out how many Weight Watchers points it is if you used 3 sprays of non-fat cooking spray and substitute non-fat greek yogurt for everything else that might possibly contain fat and my god how does this bland, sorry excuse for food add up to 16 points per serving when there are no goddamned calories in it?

You know what I did instead of cooking? I ate Lean Pockets. Lean Pockets. If anyone wants to know the deep, dark truth about how low dieting can bring you, just tell them “I know someone who actually ate Lean Pockets.” Now that I’m not dieting and focusing on other healthy goals (like not eating so many chemicals) I am learning to cook. So far this year, I have learned to cook African sweet potato peanut stew, chicken marbella, stuffed tomatoes, mini Greek-style meatloaves with arugula salad, brussel sprout breakfast hash, sweet potato spinach mac and cheese, black bean enchiladas, escarole and orzo soup with turkey meatballs, and more! And even though most of these dishes didn’t turn out perfect and I had to do a lot more cleaning up, every single one was better than a fucking Lean Pocket.

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Yep. I made this.

I’m beginning to be able to eat more intuitively. I used to be just like Louis CK.

the-meal-is-over-when-i-hate-myself

Party food was the worst; if there was a bowl of chips or tray of mini quiches in the room, those savory treats would just not leave me alone. I’d be thinking about how many I could have, and once I’d had those, how many more I could have, and when I could have them again. Now, I am much less obsessive about food at parties. I have some if I want some – and more importantly, I know that I can have them if I want them. Now, I can actually stop when I don’t want them anymore. I actually don’t want them sometimes! It doesn’t sounds like a big change, but it feels super different. It’s like I’ve been granted a restraining order and I am no longer being harassed by bowls of chips.

Of course, this is a slow and gradual process. I still overeat sometimes, by accident and also not by accident. Still, I have started to be more in tune with how food makes my body feel. I’ve realized and accepted the fact that certain foods make me feel bad and other foods make me feel good. That may sound obvious, but while dieting my stomach was always off (so much fiber, why???) and so I focused on ignoring my body’s signals, cravings, and reactions rather than listening to them. Until recently, I didn’t know that mozzarella cheese turned my stomach or that big servings of meat made me feel gross. I knew what full felt like, but I didn’t really know what “satisfied” felt like. I never felt satisfied when I was dieting because I was never satisfied. How can you feel satisfied when you’re eating weird, calorie-free versions of food instead of actual food? Now that I can recognize satisfied, and enjoy that feeling, it’s easier to stop.

5. I haven’t lost weight. Yet. I won’t lie. I was really hoping that after I stopped dieting, my body would revert back to whatever it “naturally” would have weighed. That didn’t happen. Let’s be real. After years of dieting, the initial freedom to eat all the things was so novel and exciting that I definitely ate all the things. Unsurprisingly, I gained a little bit. (I stopped weighing myself when I stopped dieting so I am blissfully ignorant of the numbers.) This part has been hard and disappointing. But after more reading and reflection and discussion with health professionals, I’ve been reassured that this takes time. Longer than one year. After all, I’m just beginning to eat intuitively. I’ve also started working on my relationship with exercise – something just as complicated as my relationship with food. It’s a process, and I’m still at the beginning of that process.

I do have hope that as I develop new, healthier relationships with food and exercise, my body will respond accordingly. In the meantime, I’m working on my body image. I’m learning to let go of the idea that being thin will make me happier or my life better. I am accepting the fact that I will never be a size 4, and exploring the possibilities of being happy, fit, and confident with my body as it is.

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After a year of not dieting, I am confident that I’ve made the right choice. I feel healthier in body, mind, and spirit. I’m excited to discover where another year of not dieting will take me. And most of all, I’m grateful to finally be in touch with my body.

As it happens, my body is exhausted and telling me to just post this already and go to sleep. And I’m going to listen to it.

*** Edit ***
I made these. Enjoy.

Weight Watchers 1

Weight Watchers 2