From time to time I come across people saying that Health At Every Size and/or Fat Acceptance is “anti-science”.
People who say that tend to be making at least one of two mistakes.
1) a. Not knowing the science of why weight loss is so difficult for humans to maintain. At this point I’ve been reading FA/HAES, and mainstream news articles supporting it, long enough that facts like “a weight-reduced person who weighs 150 lbs will have a lower metabolism than a never-fat person weighing 150 lbs” seem like basic, elementary stuff to me, yet I’ll come across people like Rebecca Watson who are generally pretty up on their science who seem to be completely unaware of it–or of the other, probably much more important biological mechanisms that cause people to put weight back on. For a fairly detailed summary of them in one article, see Tara Parker-Pope’s The Fat Trap.
b. They may also not be comparing apples to apples. Some people in Fat Acceptance do make statements that aren’t scientifically accurate. If you compare all of Fat Acceptance to the best, most science-oriented of writing on weight-loss, sure Fat Acceptance will look less scientifically accurate. Duh. If you compare all of Fat Acceptance to ALL pro-weight-loss stuff… I mean, come ON. Cleanses? Detox? Wheat belly? Food combining? Volumetrics? COME. ON.
Plus, see the 1) a.–a lot of people who are fairly scientifically knowledgeable will be completely unaware of reasons besides “they go back to their old habits!” for weight regain, which seems like pretty important knowledge to have if you’re going to discuss weight loss. At least Fat Acceptance people generally know what a set point IS, even if they may not be able to debate the finer points of whether we should really call it a set point or a settling point, whether and how it can be altered, etc. I see plenty of pro-diet people make basic mistakes like conflating a strong genetic influence within an environment to a strong genetic influence across environments (“if BMIs went up in the last few decades and it wasn’t due to genetics, genes must not have much to do with who gets fat in our country today!”), or citing short-term studies of weight loss as proof that people can lose weight permanently (Rebecca Watson AGAIN [I’m picking on her because she’s a relatively-recent example], apparently I can’t link to individual comments, but CTRL+F for “There were only 25 participants in that trial, and they were in the clinic for only 10-12 weeks.” and read the comment just above it) as well.
Pro-weight-loss people have more than their share of cranks (an example via Rebecca Watson!), but people who disagree with them don’t think of their cranks as representative of their side–but they do think of our cranks as representative of our side.
2) You may notice, if you have read to the end of The Fat Trap, that Tara Parker-Pope’s answer for herself is not, “Well, time to do HAES.” It’s, “I’m gonna keep trying, and try to be philosophical about it when I fail.” That’s because, and this is the more important of these two points, deciding whether to do HAES or any of the numerous weight-loss plans or keep eating the Standard American Diet IS NOT A SCIENTIFIC QUESTION. It is NOT the same question as “Which diet is the healthiest?” Not even people deciding to lose weight are necessarily asking themselves “Which diet is the healthiest?” or even “Which diet is the most effective at losing weight?” (I certainly have known people to follow the Atkins diet in order to lose weight who did not believe that it was a healthy diet in general–though their hope was that the unhealthiness of Atkins would be balanced by weight loss, which they naively assumed would persist after they returned to a normal diet.)
How many people arrange everything in their lives, without fail, to be the absolute healthiest possible? Leaving aside whether the causal connection leading from BMI to health is strong, nonexistent, or present-but-greatly-exaggerated, people make decisions all the time about when to try to minimize a health risk and when it’s not worth bothering about. People who work the night shift are not anti-science. People who work 80-hour-work-week jobs are not anti-science. People who sometimes get drunk on the weekend are not anti-science. People who ride on motorcycles instead of in cars are not anti-science.
Similarly, if I decide that since the canine Lyme disease vaccine may not be super-effective and most dogs who test positive for Lyme disease are asymptomatic, and my income is too low to justify the expense, so I don’t get my dog vaccinated for Lyme disease, that doesn’t mean that I’m an anti-vaxxer anti-science person. (In reality, my dog is vaccinated against Lyme disease.) If I choose to get a Subaru instead of a Prius because I kinda need four-wheel drive, that doesn’t mean I’m a global warming denialist.
People are allowed to make judgment calls on how much energy they want to sink into a given health project, and what way of approaching health will be the most resource-efficient and give them the most bang for their buck. They are allowed to decide that focusing on getting the right amount of sleep, eating a balanced diet, getting a decent amount of movement, and drinking moderately are the things they should focus on for their health, and focusing on weight loss too would be a higher investment of resources with a lower rate of return. (To be fair, many of the “HAES is anti-science” people will admit this point, but as a general reminder) They’re also allowed to not focus on health at all!
closetpuritan 
I haven’t yet read that Skepchick post (kind of dreading it), but I do think we kind of do a bad job in FA and HAES circles distinguishing between moral, ethical, and personal decisions and scientific arguments. Like most people, when we make decisions that are entirely personal and based on our own priorities, or based on ethical judgment calls, I think we often reach for scientific arguments to lend them a veneer of “credibility,” which is actually not necessary. I see people do this all the time in denialist movements – they’re basically making a personal judgement call (“I don’t believe in X because I just don’t”) and then dressing up that judgement call with pseudoscience to try to convince other people and make themselves seem authoritative. Frankly, I think it’s wrong to do that, and it’s dishonest. And at the same time, practically everyone does it, and I don’t think HAES and FA folks are any worse at it than other people. We do have some scientific evidence on our side, particularly the evidence that intentional weight loss dieting does not work in the long-term, and a baby amount of evidence that a non-diet approach isn’t harmful and can help people — but a lot of people are not equipped to fully understand the evidence (myself included, probably – scientific evidence is usually nuanced and complicated) and in discussing it, they make all kinds of mistakes in their zeal to get across what is essentially a moral point: That fat people have the right to exist, to have autonomy, and to prioritize their health in whatever way makes the most sense to them. My main point is that fat people have the right to eat “normally,” without dieting, if they want to. That is not a scientific argument; that is an argument based on basic human rights.
Anyway, I’m glad you write about this stuff because it’s been on my mind a lot lately.
I’m glad I’m continuing to be useful! 🙂
I do think we kind of do a bad job in FA and HAES circles distinguishing between moral, ethical, and personal decisions and scientific arguments.
Yeah, I think you’re right.
The link between the science and the personal decisions, etc. is kind of interesting to me, with how it’s played out for me personally. I don’t think the science changes much of what I actually do; before encountering anything from the fatosphere I knew how my mom had struggled with trying to lose weight/maintain weight loss, and knew that even Weight Watchers told her that it was hard to keep weight off once you’d put it on. (The explanation they gave at the time was that you had built the fat cells already, and, balloon-like, they would deflate with weight loss but then re-inflate with weight gain.) I basically figured that I would never have enough motivation to radically change my eating, and would tinker around the edges a bit, but not much. I still have a bit of a soft spot for The Omnivore’s Dilemma because for whatever reason it helped encourage me to pay more attention to hunger and fullness cues, which I would get even better at after learning about HAES. I already knew before learning about HAES that exercise mitigated the risks of high BMI and started doing it more after a spell when my weight crept up. My point is, HAES/FA didn’t really change what I was doing WRT eating/exercise, it changed how I felt about what I was gonna do anyway. And what also did not change was how I felt about being mean to/shaming fat people*. BUT without encountering HAES/FA I wouldn’t be blogging about it or encouraging other people to focus on health behaviors other than weight instead of weight. (But not in a getting-up-in-their-business type of way. Ragen Chastain deserves credit for popularizing the underpants rule, whatever people think about her other writing.)
*Even though I myself use “shaming fat people doesn’t help them lose weight!” a lot, I feel like it’s kind of sad to use it. Like “torture doesn’t work!” That’s true, it doesn’t! That’s not the main reason why we shouldn’t do it!
Okay, I finally read the Skepchick. I just want to say that, while I agree with a lot of her points, but I think she may be oversimplifying some of the scientific evidence about really, really complex issues that still have a number of open questions (like the link between obesity and type 2 diabetes – a link that I acknowledge exists and is quite strong, and also something for which my understanding is that the entire causal mechanism has not been definitively worked out re: insulin resistance. I’m sure I need to brush up on this, but my current understanding is that there is not a 100% definitive etiology for insulin resistance, and more that there is a very strong association with obesity and some plausible mechanisms proposed.) I find it troubling when people make statements like, “This is absolutely without a doubt completely untrue.”
Yeah, any time someone uses language with that much certainty, my hackles go up.
Yesterday I was procrastinating, so I decided to track down that reference from Linda Bacon about insulin resistance possibly contributing to weight gain, rather than the other way around. It is based, basically, on a statement made, and a model of insulin resistance proposed, by Peter H Bennett in a letter to the editor (not a study or article) of the journal Diabetologia in 1986. It is kind of a weak-sauce reference and I haven’t found much or any evidence to support it, though Peter H Bennett is a very well-respected researcher in this area (he’s the Pima Indians research guy who’s done a ton of work on why populations like this develop diabetes when their diet and lifestyles rapidly change.) I would love to write him and find out how he would respond to this idea now, given that nearly 30 years and numerous research studies have passed since he originally mentioned the idea that insulin resistance may cause weight gain.
Interestingly, I delved a bit into the insulin resistance literature, because it’s been a long time since I worked in diabetes (I used to work with some hot-shot endocrinologists who sort of kept us on the cutting edge of what they were up to), and I found lots of interesting arguments about ectopic fat accumulation, adiponectin, and most recently, the concept that people with a more expandable and adaptable fat pad, who are able to lay down new subcutaneous adipose tissue without much fuss or physiological strain, may actually be less prone to metabolic syndrome than people whose fat pads are not as adaptable and easily expandable (usually associated with having more visceral and less subq adipose storage) and who may therefore end up with more ectopic lipid accumulation in key organs (like the liver and skeletal muscle) and possibly this could be the mechanism leading to or exacerbating insulin resistance.
I thought it was an interesting hypothesis, though of course it would be interpreted by the media as “There are good fat people and bad fat people, and the bad fat people look like THIS and get diabetes!!!1!” but still worthy of investigation.
Thing the first: I advocate for Fat Acceptance because I think fat people, regardless of the state of their ability and health, deserve to be treated with the same respect as everyone else. That isn’t science, that’s just not being an asshole.
Thing the second: I went over and read the Skepchick post and was disappointed but not surprised at the lack of nuance there. For someone who calls herself a skeptic, there wasn’t much critical thinking or knowledge of contradicting literature. (I’m sorry, I just can’t with the First Law of Thermodynamics weight loss folks, like our bodies are idealized heat cycles.) I also found it disappointing that she ignores the lived experience of folks who go to the doctor for whatever and get prescribed weight loss instead. I suppose someone needs to publish it so it can be Official Science.
I would love to see the literature firmed up on this topic, but it’s tough. Lots of smart folks are going to have to ask lots of good questions and fight against a lot of “everybody knows” in order to let the scientific method do its thing. (And gather lots of data. Good data.)
Anyway, as usual you’re making excellent points here and this is an interesting companion to Michelle’s post that I read earlier today. Maybe we don’t practice FA and HAES because science. Maybe there are better reasons, not so logical.
Thanks!
You are right that one of the big problems in obesity research is people not asking certain kinds of questions and therefore not doing certain kinds of studies. (I just came across another example of people missing things because they didn’t think to ask a basic question, because everybody knows that women trade beauty for wealth when selecting mates.)
And in the meantime, we’ve got to do the best we have with the information we’ve got.
All right, I went away and thought and came back after I realized my last post was mostly just an angry response to the skepchick post (I was typing as I read the comments.) It was frustrating because I definitely recognized it as coming from a place of privilege, “Listen, I lost 20lb by just not putting so much in my face, maybe you fat people should try that instead of constantly lying about how much you eat.” She would say I’m putting words in her mouth, I guess I am. Setting that stupid post aside now.
For me, a really important aspect of FA is recognizing that people are allowed to make choices that don’t necessarily prioritize their health. The health uber alles perspective is at its core ableist and problematic. Even if being fat is a choice (which is fully debatable) that doesn’t mean hating fat people is ok when they don’t meet an arbitrary standard for health.
And mental health is health, too. For those of us whose relationship with food has been disrupted or was never great to begin with, giving up a weight loss focus can be freeing. If I’m still fat but I’m free from obsessing about food, that may be a acceptable tradeoff for me.
Standard health indicators and quality of life aren’t the same thing, and we’re all trying to negotiate a balance.
I was frustrated by that, too. Basically it sounds like her personal experience with weight loss (you know, anecdata!) has coloured her view of the concepts behind HAES.
I was thinking this morning, as I woke up, what are the reasons I defend HAES? And basically it boils down to these points:
*Evidence-based reasons*
-Fat people definitely have higher health risks than people in the “overweight” or “normal” BMI categories (very strongly supported by literature)
-Weight loss is rarely maintained long-term (the literature is very strong on this point, even from researchers who would prefer not to admit it)
-Fat people can, and a large swath of them are, metabolically healthy (the literature is also very strong on this point)
-There is some evidence that a HAES approach improves the health of fat people, or at least does not cause them harm, compared to a weight loss approach (the literature is still in its infancy here, but is generally promising)
-Fat stigma exists and may do harm to the health of fat people (literature is moderately strong on the existence of fat stigma, and still in its infancy on the harm stigma causes in terms of real health outcomes)
*My own personal ethical reasons*
-I don’t think it is ethical to prescribe weight-loss as a first-line, or in many cases, SOLE line of treatment for fat people experiencing health issues, given the failure rate
-I don’t think the fact that fat people experience higher health risks makes it acceptable to treat them like a burden on society – every demographic has a different risk profile, and it is ableist to value people differently based on their health or health risks
-I think HAES is a more ethical approach to first-line treatment for fat people who are concerned about their health, even though I think weight loss should remain an option as well for people who have given informed consent and for whom the risks of remaining where they are outweigh the risks and likelihood of long-term failure of weight loss
What I think has happened here is that, frankly, most lay people writing on the internet about HAES and FA don’t really grasp the science and make extremely oversimplified arguments about it. I think there is also a tendency to black-and-white thinking on this topic – if you’re against HAES and FA, you buy into rhetoric that fatness is 100% a disease, and 100% controllable through behaviour, and that fat people who aren’t trying to lose weight are an intolerable burden on society. On the other hand, if you’re FOR HAES and FA, you buy into rhetoric that fat people are JUST AS HEALTHY as thin people, and that there are NO INCREASED RISKS associated with having a higher BMI, and that weight loss NEVER works long-term for anyone, and that weight loss NEVER produces health improvements.
I think those arguments deserve to be rebutted, and if people like Linda Bacon are making sloppy arguments, they also deserve to be rebutted and corrected. But I also can’t really sign on to Rebecca’s statement that HAES is “infested with pseudoscience.” No, it’s “infested” with a lot of people who are passionate about not being discriminated against and not feeling like worthless losers who don’t deserve to have the most basic bodily agency, and in their zeal to defend themselves and fight against what is really a devastating form of discrimination, they misunderstand, simplify, and twist what the scientific evidence says. Most of them have zero connection to the skeptic community and might not have good experience in critically examining scientific ideas.
But most of those arguments are not coming from ASDAH (remember, the organization who LITERALLY trademarked HAES to protect its actual definition, and who Rebecca never mentioned in her post, and which definition she seemed to completely misapprehend) or researchers like Linda Bacon. I would actually value a skeptical analysis of “official” arguments and statement, but that Skepchick article is not it.
I agree with all those reasons for supporting HAES!
In addition, although as far as I know there hasn’t been much study of the nocebo effect as it relates to BMI, specifically, I think that repeatedly telling people that they are unhealthy because they’re fat is likely to have a strong nocebo effect, as well as maybe getting them to internalize, “I’m not a healthy person, therefore I do not do Healthy Person Things,” and therefore making it less likely that they’ll do healthy behaviors.
And the whole overaggressive treatment in medicine thing is becoming a bit of a hobbyhorse of mine. I read another article about that recently. It doesn’t talk about BMI, but to me it seems like the takeaway paragraph really applies:
“Allowing the medicalization of normal variations in physiology to be transformed into “treatable conditions” is leading to unintended consequences. We’re spending billions of dollars on treatments that might not, or don’t, work. We’re making people worry when they don’t have to. And we may be causing actual health problems in the process.
“As Dr. Tarini puts it, “Our job as doctors is to make sick patients healthy, not to make healthy patients sick.””
***
And of course, even the people who are in the skeptic or scientific community aren’t always good at critically examining ideas, especially if they’re coming from a community or philosophy that you’ve already written off as “infested with pseudoscience”, which leads to, e.g. fairly well-established concepts like adaptive thermogenesis being dismissed because of course those HAES must have just not noticed that smaller people need fewer calories.
Thanks for this. Those posts by Rebecca Watson were really irritating, particularly the 1st Law stuff G highlighted. (I don’t have anything intelligent to add, just thanks).
Thanks!
The post started out more as an expansion on a conversation I had had elsewhere rather than the Rebecca Watson post, but because she’s better-known, Rebecca Watson was a better way to make the point that many people who have a good general understanding of science will make the mistakes I talked about.
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