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!

My Breakup with Exercise

In November, I met the amazing Ragen Chastain at a conference. She was the keynote speaker and blew the minds of college health professionals about Health at Every Size. During one of her talks she explained that many people are currently experiencing a “bad breakup with exercise.” That phrase was a gift to me – I finally have the  words to describe my fraught and complex relationship with exercise.

I was never an overly active kid. I loved to read, play with plastic dinosaurs, and find salamanders in the woods. I hated gym class. I did not like sports. Nor did I like hiking or cross-country skiing, my parents’ favorite activities. Once I hit puberty my body became soft and pudgy and my dislike of physical activity was no longer just a personality trait – it became a flaw. It became an indicator of my laziness and bad attitude, or at least, that’s how my parents seemed to interpret my spirited protests. I quickly understood that I was being forced to go hiking because I was fat. My mom encouraged me to go to the gym with her. I felt out of place there and embarrassed. My presence in this dark, smelly, scary adult space was punishment for being a fat and lazy kid.

I didn’t touch exercise again until my junior year of college. My university required everyone to take a certain number of gym credits and I signed up for a step aerobics class I had heard good things about. I loved it. The instructor was an athletic female coach who was all about strength and fitness, not about appearance. She wore a giant t-shirt and long, baggy gym shorts. I started coming to the gym a few times a week and doing the elliptical machine, crunches and pushups. I signed up for Pilates and a strength-building classes even though I had already fulfilled my Phys Ed requirements. It felt good. It was a happy time for me. I finally was developing some positive experiences with exercise.

In 2009, I moved to Boston to begin my first full-time job.I got myself a gym membership. I started doing Weight Watchers with a coworker, and religiously tracked every morsel I ate. I signed up for personal training. I went to the gym at least 5 times a week. My sessions at the gym now lasted about 2 hours. I would start with 15 minutes of cardio on the elliptical to warm up. Then I would do 30-45 minutes of strength training. Then I would do 45 mins-1 hour of cardio – rotating between the elliptical, stairmaster, and bike. Then I would stretch for 20 minutes. For a month or two, I added another 15 minutes of ab work each night before I went to bed. I turned down offers to go to dinner or evening events in order to go to the gym. I knew that I needed at least a 3-hour block of time to do my regular workout, shower, and change; there was simply not enough time to do anything else on a weeknight. I had no hobbies to speak of, besides working out. I did this for about a year.

Everyone thought I looked great. I lost 25 lbs and fit into size 8 pants for the first time since high school. For a brief period, you could actually see my ab muscles when I flexed. I could wear really short shorts. I ate mostly processed frozen dinners, raw vegetables, and Greek yogurt (no time to cook). I got compliments from friends, coworkers, and my family. Guys asked me for my number. My parents no longer chided me for my behavior; now they were asking me for tips. They soon signed up with personal trainers themselves.

I was down to 145 lbs, but I was convinced that I needed to get to 125. I believed that was considered “normal weight” or “healthy weight” for a woman of my height. I was excited and happy about the changes I felt and saw in the mirror, but I in no way considered myself “done.” I was in the best shape of my life, but I still thought I was fat. And according to my BMI, I was technically still “overweight.”

This too can be yours! Just eat hardly anything and exercise 2 hours a day for the rest of your life!

This too can be yours! Just eat hardly anything and exercise 2 hours a day for the rest of your life!

Then I started grad school. I was working full-time and taking a full course load at night. Suddenly, there was no time to go to the gym. I had night classes and homework. I still tried to go as often as I could, but if I wasn’t able to complete my full 2-hour workout, it felt like failure. A waste. Moderation was simply not in my vocabulary. My new body was slipping away.

Soon I become so mentally exhausted that I had no room left for tracking Weight Watchers points. I had no time to go grocery shopping. I started living off of cafe sandwiches, takeout, and Red Bull. My beloved trainer experienced some health problems and had to retire. The trainer assigned to replace him was a douchebro jock who kept talking about getting me a “hot bikini body” and I hated him. Eventually, I stopped going to the gym altogether. And, naturally, I started to gain weight. Like so many people, I ended up gaining more than I had lost.

Three years later, I am the heaviest I’ve been in my life. My parents have expressed their concern, and I have pushed back on their well-intentioned but incredibly painful statements with every ounce of spirit in my body; I will not feel like a worthless fat girl again. And no, exercise is not so simple as “Just do it.”

For most of 2013 I was sedentary. I had multiple false starts as I tried to “get back into the gym.”  Each time I returned, there was a new manager at the personal training company who would spot me on the elliptical and approach me, saying “Congratulations on taking the first step towards a better you!” or some bullshit like that.

I wanted to punch them every time. I am already a better me. I have hobbies now. I have friends. I have a life.

Then the manager would encourage me to try personal training because “beginners always need someone to show them how to do things properly.”

“FUCK YOU, I am NOT a beginner,” I would think.

“If you only knew me when…” And then my anger would dissolve into shame. I was embarrassed at failing so spectacularly.

But looking back on it now, I wonder how could I have done anything else but fail. My Biggest Loser-esque workout regime was extreme and unsustainable. Dieting was unsustainable. My abs were unsustainable. And no matter how thin or muscular I got, I always thought I was fat. I always needed to lose more. I was never not unhappy with my body. Losing weight did not improve my body image whatsoever.

In 2013 I vowed to stop dieting forever and began the long process of making peace with my body. Though I was making progress on the eating and body image fronts, I was still having a really hard time with exercise. Friends would say, “Couldn’t you just go to the gym for like 20 minutes? Couldn’t you just take the stairs? That’s better than nothing!” The thought of going to the gym for 20 minutes or taking the stairs was foreign and confusing. How could you do anything worthwhile in 20 minutes? I would never get my abs back by going to the gym for 20 minutes. I would never lose 40 lbs by taking the stairs. It became obvious that thinking of physical activity in moderate and sustainable terms was going to be extremely challenging for me.

I spent a lot of time thinking of ways to get active that would be fun and sustainable. I didn’t come up with any radical new ideas. There was yoga and hiking, which I have learned to like now that it isn’t mandatory and I can choose to do it on my own terms. But I haven’t found a yoga studio I like yet and hiking is difficult to do on a regular basis when you live in a northeastern city. I kept coming back to the gym – the first place I ever really enjoyed exercise.

But I was, as Ragen deftly stated, going through a bad breakup with the gym. The gym had ghosts of my thinner self in every mirror. The gym was full of people who would assume I had never worked out before. And I still never had enough time to do the kind of workouts I felt were necessary. “Do it right or don’t do it at all” would echo in the back of my head.

I took my time. I thought about things. I let myself get comfortable with tenets of Heath at Every Size. I practiced self-compassion. I forgave myself for “failing” and gaining weight. But most importantly, I worked on letting go of the idea that I could someday be 125 lbs or “get my abs back” or achieve the extreme physical transformation I did back in 2010. This has been, and continues to be, the hardest part. There is a very real sense of loss involved in abandoning the idealized, aspirational vision of yourself that’s been in your head since you were a teenager.

Then I agreed, for the first time in my life, to participate in a fundraiser stair climbing challenge. I knew this would force me to get back to the gym, and it did. The stair climb event is two days away, so last week I forced myself to return to the gym for the first time in many months.

Walking in the door was really hard. I could barely finish my first 20-minute cardio workout on the cross trainer. Five days later, I can do 30 minutes without too much difficulty. I think it’s amazing that my body can adjust back so quickly after so long. I am grateful for its strength and responsiveness. I suppress the faint urges to pull my scale out of storage.

This time, I’m trying to commit to realistic goals. 25 minutes. 30 minutes. Mostly cardio, with some Yoga Meltdown or free weights every now and then when I want to work on building strength. No more than 45 minutes per workout, 3-4 days a week.

Workouts that will help keep me active and give me the health benefits I’m looking for, but won’t consume me. Workouts I can squeeze into my busy life without having to sacrifice other hobbies or time with friends. Workouts that have absolutely nothing to do with losing weight or achieving a “hot bikini body.” Those are the kind of workouts I am aiming for now.

I’ll have to wait and see how it goes, but I’ve got a good feeling about this “moderation” thing. Maybe it could work for you too.

Size 14 and that’s okay.