thou shalt be thin: obesity hysteria and the eating disorder epidemic

This ad for Yoplait Light reduced-calorie yogurt, which I saw on TV last Sunday night, was supposedly pulled from circulation. The National Eating Disorder Association petitioned General Mills because the ad promotes a mindset associated with eating disorders. Instead of negotiating every bite of food, anxiously calculating if we've earned the right to eat a dessert, as this woman does, how about asking ourselves, Am I hungry? And maybe, even if we're not particularly hungry, if it's not habit or routine, and it's food we really like, how about enjoying a small slice of cheesecake?

Whether or not this one ad continues to air, advertising that perpetuates the message that eating is bad - but buying our product is good - is legion. When I wrote about eating disorders in the 1990s, several therapists referenced current ads and said, "That is an advertisement for exercise bulimia." (Exercise bulimia is another term for compulsive exercise, the attempt to purge food consumption through excessive calorie burning.) Eating disorders are closely linked to advertising and consumerism, as companies constantly play on our insecurities about body image, seeking to induce us to buy, buy, buy.

This recent ad controversy brought to the surface something I've thinking about for a long time. In a culture obsessed with a belief that most people weigh too much and are too large, what happens to people already obsessed with weighing less and being thin? Put more simply, as we fixate on obesity, what happens to people with eating disorders?

Society's obsession with body size received a fresh veneer of legitimacy when it became accepted wisdom that an "obesity epidemic" now threatens the health and lives of Americans and Canadians. Obesity, we have learned, is an alarming health risk. Being fat causes terrible diseases, those diseases take a terrible toll on society, and we can reduce the risk of disease if we reduce our weight. Body shape and size are now seen as predictors of health - even though the evidence does not support that claim. (More on that below.)

This accepted wisdom has given rise to new heights of fat-phobia. One website counts 18 weight-loss-themed TV shows worldwide, and while some of those listed are no longer running, newer shows such as CBC's "Village on a Diet" have taken their place.

Healthy eating and regular exercise are both important to maintaining good health. Public education about healthy eating and exercise choices is a very worthwhile goal - and making healthy choices affordable and accessible to all people should be a societal priority. But it's not.

At best, the cultural obsession with body size takes the form of brow-beating people to change their behaviour, never an effective model. At worst, it's all about shame and humiliation, and perpetuating stereotypes of people our culture declares unattractive. Meanwhile, the constant emphasis on weight-loss likely fuels the very unhealthy quest for thinness that dominates so many lives.

Everyone must lose weight

I want to share something I overheard at the gym, a scene that seems so cliched, you may think I am inventing it, but I assure you I heard exactly this. Two women and a little girl, the daughter of one of the women, were getting ready to swim. None of them were heavy by any standard. The women were thin and the girl had the perfect shape of a healthy, active child. She was, I'm guessing, around 8 years old.

The women were talking about dieting. One said, "I only lost one pound this week." The other replied, "I was so good all week, but I didn't lose anything."

Then the girl said, "I was good, too. I think I lost weight."

Both women immediately said, "You don't have to lose weight," and "You don't have to worry about that."

That's the right response, but I wonder if those women are aware of the damage that they've already done. They are both thin - yet both are dieting, tracking their weight, and referring to their eating as "good" or "bad". As a recovered obsessive dieter, I recognize that talk and all it implies. These women are probably always trying to push their weight a bit lower. They have tremendous trouble losing any weight because they have no extra weight to lose, so they end up thinking and talking about their eating habits a lot. Some of that talk takes place in front of this girl. The girl sees what her mother looks like, knows her mother is dieting, and internalizes the message that when we look like that, we should diet.

Like all children, that little girl learns by example what is expected of her. Even someone as thin as her mother must lose weight.

And of course this girl, like all children in our culture, is bombarded with images that thin is beautiful and fat is ugly. She receives those messages from hundreds of sources over the course of her lifetime. But a girl who grows up in a home with a lot of talk about weight loss and dieting is at greater risk for acquiring a distorted body-image and an eating disorder.

And what about the women themselves? They may, like so many women, struggle with constant restriction, guilt and recrimination. I never fully appreciated the burden of weight-obsession until I liberated myself from it.

Here's another snapshot from the gym. I noticed a card where members could sign up to participate in Live Right Now, CBC's healthy-living program, which at times is an extended commercial for their principal sponsor, President's Choice (the brand of a major Canadian supermarket chain). Upon closer inspection, I was taken aback to see that the card was a "weight loss pledge" - not a pledge to go to the gym more often or to eat a healthier diet, but a pledge to lose weight.

This is a YMCA, mind you, where the emphasis is usually on health, rather than weight. By my observation, most people at this gym don't need to lose any weight. Losing a few pounds will not decrease their risk of heart disease, diabetes or cancer; in fact, a few extra pounds may extend their lives. So why should members pledge to lose weight? What will a weight-loss pledge do, except make people feel bad when the promise goes unfulfilled?

Perhaps for some people, being challenged to lose weight will lead to more healthy eating and exercise habits. But if the goal is healthier habits, why not say that? Why put the emphasis on weight loss?

This speaks to the central myth behind the so-called obesity epidemic. Fat doesn't cause disease. Unhealthy eating and lack of exercise are risk factors for diabetes and heart disease; weight and size, absent other factors, are not.

Body size is often associated with unhealthy eating and a sedentary lifestyle, but not always. One person eats healthfully and has an active lifestyle, but is considered overweight. Another person sits at a desk all day, eats junk food, and watches TV all night, but is thin. The active "overweight" person is at lower risk for heart disease and diabetes than the thin couch potato.

Fat phobia and our genetic potential for weight gain

We live in a fat-hating world.

Body size is the last frontier of ridicule. Progressive Torontonians gleefully bash their city's Mayor Rob Ford over his appearance - as if there aren't enough real reasons to criticize the union-busting, environment-hating, racist mayor - and those of us who object are self-righteous curmudgeons. We are socially conditioned to find fat people unattractive, to the point where many believe that attraction to larger people amounts to sexual deviance. We associate fat with laziness, and a slew of other negative traits. Fat people are unsightly and should keep themselves hidden. (My mother tells me it "doesn't look nice" when heavy women wear tank tops or shorts. Apparently heavy women should be uncomfortable all summer because the sight of their large limbs might offend someone's eyes.)

One reason fat-bashing is considered acceptable is the underlying assumption that people can choose whether or not to be heavy - a belief that if fat people just tried harder, they could be thin. For the vast majority of heavy people, this is not so.

It's been proven - many times, over many different studies - that weight is only slightly less malleable than eye colour. You can change your weight for short periods of time, but your body will eventually return to its old shape, the shape for which it is genetically programmed. Anyone who permanently keeps off significant amounts of weight must either obsess on her weight for the rest of her life, or is genetically predispositioned to be thin, and the weight gain was a temporary condition.

I realize this may seem counter-intuitive, since people in first-world countries are heavier now than they were 50 years ago or 50 years before that. Our median weight has increased. But so has our median height: each generation is, on average, taller than the previous one. Try blaming that on junk food and video games.

The fact is, as more people have adequate access to nutrition, their bodies are able to express their full genetic potential to store fat. This has been proven again and again. For a good summary of the evidence in this regard, see Gina Kolata's groundbreaking (and highly readable) book, Rethinking Thin, which I wrote about here.

What else has been proven many times over? Diets don't work. Whatever current eating program is being promoted - low-fat, low-carb, high-protein, food combining, whatever - it will always yield the same results: temporary weight loss, followed by larger and more stubborn weight gain.

In which I briefly place my own experience in this context

Full disclosure: I'm overweight. Not obese, but heavy, a result of my hard-won decision to stop dieting and enjoy eating, combined with my funky metabolism, likely caused by fibromyalgia.

I was somewhat chubby growing up, but not fat. For example, I was never teased for being heavy and never called fat. (These days I notice that the trolls who hang around wmtc and JoS try to insult me with fat name-calling. It's interesting how anonymous men play that card, assuming it is hurtful.)

Twice - once in university and again in my early 20s - I gained a significant amount of weight, and both times lost it through heavily structured diets. The second round of dieting set me on a path of diet addiction and obsession with the scale that lasted more than 10 years. Writing an article on compulsive exercise for Seventeen magazine, then later a book, I discovered my own disordered thinking about food. I worked with a nutritionist therapist to learn how to eat again. And none too soon. Once I had fibromyalgia, my body changed radically, and I began to slowly and steadily put on weight.

Now I eat, I exercise, I'm healthy, I'm overweight, I'm happy.

I include this information because when one writes critically about obesity hysteria, readers tend to make assumptions. You are free to ask me questions about my own experience if you want.

Fat is a capitalist issue (apologies to Susie Orbach)

The combination of these two powerful myths - fat causes ill health, and fat is a personal choice - allows us to take an individualistic, anecdotal approach to what is, in reality, a societal problem. Just as we blame people for their own poverty and cling to the belief that a positive attitude can "beat cancer", the personal-choice approach alleviates the need to create systemic change, or even to commit social resources to the issue. (Social resources? My taxes aren't going to help lazy fatties keep their hands out of the potato-chip bag!) A morbidly obese woman on a TV show is supplied with a personal trainer, time to exercise, healthy food and a support network. Et voilà, she loses weight! If she can do it, you can do it. (But you'll have to do it on your own.)

Clearly, individual choices matter - in all things in life, and certainly for our health. But we don't all have access to the same choices. The single greatest predictor of health is not a choice. It is poverty. Poverty is the strongest predictor of virtually every measure of health: infant mortality, low birth-weight, incidence of disease, risk of being a victim of violent crime, chances of surviving serious disease, age of death.

Weight, too, is inextricably tied to poverty and class. People with higher incomes have more access to fresh, healthy food, and more time and opportunity for exercise. If you doubt that affluent people have more discretionary time than poor people, think about how many tasks you can pay others to do for you. If you never pay others to work for you - no dry-cleaning, lawn care, child care, dog care, sewing, painting, repairing, cooking, shopping, researching (because, perhaps, you are saving for your retirement), I hope you will recognize that as a choice of privilege rather than a fact of survival.

Poor people's diets are often full of empty, unhealthy calories, and their time is more constrained by the need to constantly stretch every dollar. Do you know what a "food desert" is? Food deserts are found in every North American city. They are neighbourhoods without fresh, healthy food choices, where the purchase of healthy food entails lengthy and expensive treks, often on several methods of public transit. Why do food deserts exist? Because poor people aren't good consumers. Low-income neighbourhoods are not good profit-generators, their residents don't have disposable income, so quality supermarkets don't set up shop there. Such is the insanity of food production and distribution in a capitalist system.

We can collectively exhort fat people all we want, but until we decide to eradicate poverty, the weight - and more importantly, the health - of large segments of our society will not change.

In The Social Determinants of Health: The Canadian Facts, researchers Juha Mikkonen and Dennis Raphael write:

The primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living conditions they experience. These conditions have come to be known as the social determinants of health. This information – based on decades of research and hundreds of studies in Canada and elsewhere – is unfamiliar to most Canadians.

Canadians are largely unaware that our health is shaped by how income and wealth is distributed, whether or not we are employed and if so, the working conditions we experience. Our health is also determined by the health and social services we receive, and our ability to obtain quality education, food and housing, among other factors. And contrary to the assumption that Canadians have personal control over these factors, in most cases these living conditions are – for better or worse – imposed upon us by the quality of the communities, housing situations, work settings, health and social service agencies, and educational institutions with which we interact.

Improving the health of Canadians requires we think about health and its determinants in a more sophisticated manner than has been the case to date. Social Determinants of Health: The Canadian Facts considers 14 social determinants of health:
1. Income and Income Distribution
2. Education
3. Unemployment and Job Security
4. Employment and Working Conditions
5. Early Childhood Development
6. Food Insecurity
7. Housing
8. Social Exclusion
9. Social Safety Network
10. Health Services
11. Aboriginal Status
12. Gender
13. Race
14. Disability

My friend Dr. J has covered this issue much more thoroughly, in his excellent post Fat phobia, the "obesity epidemic" and the medicalization of inequality. He points out that "much of the 'obesity science' is arbitrary" and the oft-repeated claim that obesity contributes to "300,000 deaths a year" in Canada is a myth, practically plucked out of thin air.

Not only does the supposed problem "fat = unhealthy" not stand up to scrutiny, but the supposed solution of lecturing people to "stop eating fat" doesn't reduce weight or the supposed obesity-related illnesses. The Women's Health Initiative followed 50,000 women for years, telling one group to eat a low-fat diet while the control group followed their usual diet. The results: "Women assigned to this eating strategy did not appear to gain protection against breast cancer, colorectal cancer, or cardiovascular disease. And after eight years, their weights were generally the same as those of women following their usual diets." Despite the simplistic call for "good lifestyle choices", people can choose health in the same way that they can choose housing, income, working conditions, the food they eat, the air they breathe. In the market, people's ability to make choices depends on their socioeconomic condition.

Where does this leave people with eating disorders?

Dieting is a multi-billion dollar industry, feeding our insecurities to sell us snake oil. If dieting actually worked, the industry would put itself out of business. The diet industry thrives on failure, and that's easy to do, since failure is a fact of dieting. Big Pharma, too, is always part of the picture. As Kolata demonstrates in Rethinking Thin, diet studies never lack for funding, as the pharmaceutical industry quests for its Holy Grail: the magic weight-loss pill.

Researching an article, I once tracked the after-school ads on MTV. A full one-third of ads marketed weight loss - either through diet plans, exercise equipment, low-calorie food, or meal replacements - while another one-third sold junk food and sugar-laden beverages. The rest were for cars and electronics. And in between ads, there was a parade of impossibly thin women and artificially pumped-up men. The picture is pretty clear. It's almost a mandate for eating disorders.

By any count, millions of North Americans struggle with eating disorders. But all estimates must be low, as the behaviour almost always takes place in secret. Unless someone goes off the deep end, she (or, increasingly, he) may not show up in any statistics. People who are sexually abused are more likely to have eating disorders than the general population; eating disorder diagnoses are often lost as seemingly more pressing problems like substance abuse and self-injury are dealt with. In fact, both cutting and eating disorders are addictions.

The best known expressions of eating disorders are anorexia and bulimia, but most eating-disorder behaviours overlap, meaning people are likely to engage in several: restricting, purging, exercising in harmful ways and to an unhealthy degree. Eating disorders, like many mental and emotional issues, are best seen on a continuum. The girls and women who starve themselves to death or near-death are at one end of the spectrum, but less obvious "disordered thinking" about food and body image is incredibly widespread; the conversation I overheard at the gym is a typical example.

For the last 20 years, eating disorders, body dissatisfaction and diet obsession have been appearing in younger and younger children. With boys, it's often associated with supplement use, exercise (especially weightlifting) obsession and binge eating; with girls, it's often associated with restricting ("dieting") and purging.

To me, it seems obvious and inevitable that the current anti-fat hysteria must be increasing the prevalence of eating disorders. We already believe everyone is too heavy and eats too much. How can we also believe millions of people are too thin and eat too little? Better to just ignore that, and keep telling everyone they're too fat.

From the National Eating Disorders Association (stats with sources downloadable as pdf:

In the United States, as many as 10 million females and 1 million males are fighting a life and death battle with an eating disorder such as anorexia or bulimia. . . . Because of the secretiveness and shame associated with eating disorders, many cases are probably not reported. In addition, many individuals struggle with body dissatisfaction and sub-clinical disordered eating attitudes and behaviors. For example, it has been shown that 80% of American women are dissatisfied with their appearance.

• For females between fifteen to twenty-four years old who suffer from anorexia nervosa, the mortality rate associated with the illness is twelve times higher than the death rate of ALL other causes of death.

• Anorexia nervosa has the highest premature fatality rate of any mental illness.

[A 2003 review of the literature showed:]

• 40% of newly identified cases of anorexia are in girls 15-19 years old.

• Significant increase in incidence of anorexia from 1935 to 1989 especially among young women 15-24.

• A rise in incidence of anorexia in young women 15-19 in each decade since 1930.

• The incidence of bulimia in 10-39 year old women TRIPLED between 1988 and 1993.

• Only one-third of people with anorexia in the community receive mental health care.

• Only 6% of people with bulimia receive mental health care.

• The majority of people with severe eating disorders do not receive adequate care.

[From public opinion surveys on eating disorders:]

• Four out of ten Americans either suffered or have known someone who has suffered from an eating disorder.

Dieting and The Drive for Thinness

• Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives.

• Girls who diet frequently are 12 times as likely to binge as girls who don't diet.

• 42% of 1st-3rd grade girls want to be thinner.

• 81% of 10-year-olds are afraid of being fat.

• The average American woman is 5'4" tall and weighs 140 pounds. The average American model is 5'11" tall and weighs 117 pounds.

• 46% of 9-11 year-olds are "sometimes" or "very often" on diets, and 82% of their families are "sometimes" or "very often" on diets.

• 91% of women recently surveyed on a college campus had attempted to control their weight through dieting, 22% dieted "often" or "always".

• 95% of all dieters will regain their lost weight in 1-5 years.

• 35% of "normal dieters" progress to pathological dieting. Of those, 20-25% progress to partial or full-syndrome eating disorders.

• 25% of American men and 45% of American women are on a diet on any given day.

• Americans spend over $40 billion on dieting and diet-related products each year.

There you have it: "Americans spend over $40 billion on dieting and diet-related products each year." The branding of Fat as Public Enemy #1 generates massive profits, confirms our stereotypes, and absolves us of the need to create real social change. No wonder we refuse to admit that it's simply not true.

* * * *

Special shout-outs and hat tips to my friends Dr. J of your heart's on the left and Julie Devaney, health and disability activist, creator of My Leaky Body. I had a difficult time selecting a quote from Julie's relevant post, so please just go read the whole thing: The Body-Shaming Epidemic.