Too Much Public in My Public Health

Things you can tell by looking at a fat personA recent study looked at he public’s willingness to accept legal strategies when it comes to public health interventions found that:

There was much support for strategies that enable people to exercise healthful choices—for example, menu labeling and improving access to nicotine patches—but considerably less for more coercive measures, such as insurance premium surcharges. These findings suggest that the least coercive path will be the smoothest and that support for interventions may be widespread among different social groups. In addition, the findings underscore the need for policy makers to involve the public in decision making, understand the public’s values, and communicate how policy decisions reflect this understanding.

I have a number of concerns around this, but first and foremost I think that we need to be sure that public health is about making information and options available to the public, while taking care not to make the individual’s health the public’s business.  When we reward and punish people for “health”  and “healthy behaviors” we create an environment that ignores the complexities of health, dis/ability, and individual circumstances creating an environment of shame and blame that are the precise opposite of the goals of public health. It also encourages people to deputize themselves into the “health police” which only serves to exacerbate these issues since, like drivers who think that everyone who drives more slowly is an idiot and everyone who drives faster is a maniac but their driving is perfect, these people tend to suggest that  “their” health practice is “Juuuuuust right.”

Before we break this down let’s look at some of the premises of this study.  The first issue is the danger of taking a vote on how we treat people in public health.  I’m not saying that studies like this shouldn’t be done, but I think we should be careful of how we interpret the results.  Public support for public health measures is not the same thing as evidence-based public health and even if 99% of people supported charging people more for health insurance based on how they look, that still wouldn’t make it right. The other questionable premise is the fact that this study mentions  a study from 2000 that showed the nation’s three leading causes of death to be tobacco use, poor diet and physical inactivity, and alcohol consumption.

I’ve not read that study so I don’t have a comment on the findings, but it is important to note that poor diet and physical inactivity are NOT the same thing as being fat/obesity, though the interpretations of the public health methods study seem to readily conflate the two which always brings scientific rigor into question.  Body size is not a behavior or a set of behaviors, it is not a diagnosis, it is not a disease.  This kind of thinking does a disservice to fat people by promoting weight stigma and suggesting that one cannot have a healthy diet and be physically active while still being fat which is demonstrably incorrect.  It also does a disservice to thin people suggesting that if you are thin your diet must be “healthy” and you must be doing the “correct” amount of physical activity which is also demonstrably untrue and dangerously misleading.  Public health interventions that are focused on body size are extremely problematic and wholly unnecessary to an actual conversation about public health. We’ve already talked about that. 

I think it’s fine to present people with information (including the evidence to back it up and the limitations thereof) and I think it’s fine to work hard to give people access to options like the foods they choose to eat, movement options that are both physically and psychologically safe, and affordable evidence-based healthcare.  I think that we should do that while being fiercely anti-shame in all of our messaging and  remembering that nobody owes anyone else “health” or “healthy habits” by their definition or any other, that health is multi-dimensional, complicated, and not entirely within our control, that the rights to life, liberty and the pursuit of happiness are inalienable and not size, health, or healthy habit dependent, and that nobody is obligated to choose to try for the longest life and ideally public health should be about giving everyone the same access to information and options and then allowing them to make their own choices.

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Published in: on March 20, 2013 at 12:27 pm  Comments (21)  

21 CommentsLeave a comment

  1. While I agree with everything you just said, I fear that things are not going to go that way. We are moving on down the wrong road. I am seeing more and more news reports on the “obesity crisis” and how we’re costing more money, we’re uninformed and don’t understand nutrition and exercise (oh please, most of us could write a book on the subject), we’re lazy, etc., etc. And need I say the name, Michael Bloomberg again? He is dangerous.

    I have contacted the Coca-Cola Company to protest their “anti-obesity” advertisement, which sends my blood pressure through the roof. I have contacted Fox News to protest the running of the Coca-Cola ad. I contacted a local radio talk show host for calling overweight people “Fatty Fat Fats” (and he had the nerve to tell me I was comparing apples and oranges. People like me, with genetic issues, could not control what my body did – Fatty Fat Fats are the ones that eat what they want and don’t care. What? Who the hell can tell the difference between the apples and the oranges just be looking at them? And either way, Fatty Fat Fats is just wrong! I told him that too – didn’t work!).

    All of this is to no avail. I feel like I’m beating my head against a brick wall. Can you tell I’m frustrated? I have a headache now!

    To be the object of a society’s prejudice and loathing is not an easy way to live! I am so tired of it!

    Thanks for all you do Ragan. I, for one, surely do appreciate you!

  2. I am also totally fed up with the healthists & the efforts by government, media, etc. to dictate how individuals live in our bodies. My body belongs to me & how I live in it is my business, no one else’s. I am 63 & disabled, yes, because I was born with cerebral palsy, but my overall health has always been very good & I have had far fewer medical expenses than some thin people half my age. I intend to live as long as I live on my own terms.

    I come from a family of mostly fat, long-lived women in particular, & some long-lived men as well. My family members have not lived according to what is considered ‘right’ or ‘healthy’ & in fact I most likely come closer to that than any of my relatives. They have lived their own way, on their own terms. My maternal grandmother was ‘non-compliant’, like another grandmother I saw referred in another comment on another post; she loved chocolate, real butter, bacon & other fatty meats, was not fond of exercise, loved being waited on & being taken for rides. She loved life as much as I do & enjoyed things so much, as I try to. She also lived to be 90 years old. I love bacon, butter, & chocolate as well, though I do exercise a lot more than she did. We shall see if I am as lucky as she was, because, make no mistake, overall health & longevity are mostly a matter of good genes & good luck. And I will keep reiterating that fact to any nanny who dares try to tell me how to live.

  3. You’re so right about public support not being the same as evidence-based health measures! After all, the public overwhelmingly supports putting calorie counts on menus. The general consensus is that this will make people thinner because they will be suddenly made aware that there are more calories in the pasta alfredo than in the half portion house salad with a vinaigrette dressing on the side.

    What it actually does? Well, when I go to a restaurant that lists the calorie counts of all the dishes, I have one of three reactions based on my mood and my emotional strength going in. Either I:

    a) spend a lot of time and mental energy on finding a way to tune out the numbers and order what I really want to eat,

    b) get defiant and deliberately order something extremely high-calorie whether I want to eat it or not, or

    c: start feeling myself get sucked back into diet mentality and try to find something that marks me as a ‘good’ person trying hard to change my natural body, no matter what I know perfectly well this will do to my health, both physical and mental.

    I can only imagine how much worse it must be for someone who spent a lot more time and effort dieting than I did, or who – and this is what REALLY terrifies me – is battling an eating disorder. How triggering is it to walk into a restaurant and see the numbers in black and white when you’re trying to recover from anorexia?

    And yet every time I bring up how these little legends in the menus trigger me – and as I said, I don’t have an eating disorder and never did, plus I spent a lot less time following diet culture than a lot of readers of this blog – the response I get is invariably ‘yes, but it’s better for you because you can stop overeating so much.’ It’s that ‘yes’ at the beginning that always gets me because it doesn’t indicate that they agree or even that they heard my point.

    It’s one thing to have the information available for those who request it. I, for one, would find it helpful to be able to ask for information about carb counts to help my husband manage his diabetes, and I have a good friend with celiac’s who could really use more help finding the gluten free stuff. Discreet handouts that people could request for a variety of purposes – and sure, I have no problem if one of these handouts is about calorie counts for those who feel the need because they are in charge of their underpants just as I am in charge of mine – could have benefit because then people could get the information they specifically feel the need to have without being bombarded with the shocking fact that there are (GASP! CONSTERNATION!) calories in the milkshake.

    You know what? Sometimes it’s hot and I just want a damn milkshake. Sometimes I’ve had a hard day and cheesy noodles or a baked potato stuffed with bacon and sour cream sounds comforting. And sometimes I just want a salad not because it’s the low-cal option, but because crunchy raw vegetables sound utterly blissful to me. But if I can’t escape seeing the calorie counts, my decision is not based on what I want to eat, but on whether I am more concerned in that moment with conforming or rebelling… and that’s very, very bad for my health.

    • Couldn’t have said it better.

      I’m currently trying to fit in my switch from PT to an exercise program at my PT office and I’m having a scheduling issue. I do not wish to work out with the other workout “groupies” who generally show up during my regular PT time. Their discussions of food and weight loss are triggering to me. I recently went out and got a milk shake from a fast food restaurant on my way home from PT because I craved one terribly after their discussions. I cannot remember the last time I ordered a milk shake.

      Mind you, these are the people in the exercise program, not the trainer monitoring the group. The trainer is understanding of my position and promised no weigh ins and that the work would be to promote strength and flexibility so as to mitigate future injury. I may end up having to go in the middle of my work day so as to avoid the weight loss crowd.

      • Not that there’s anything wrong with a milk shake…. they just generally aren’t my thing. Neither am I much for fast food. Not to say I never dine on their food. :-)
        I’d appreciate it if they all just let me eat what I want, give me information should I request it, but otherwise leave me alone!

    • I personally appreciate having the calorie count readily available, and would also like access to the nutrition facts and ingredient list. I know you support those things being provided on a case-by-case basis, but I’ve been dealing with autoimmune and intestinal issues since I was a teen and I’ve always felt weird and annoying (to my companions and the servers/restaurant workers) when I have to ask for more information about the food. It holds everyone up, turns the topic of conversation towards diets, makes some people feel uncomfortable, and makes me feel like I’m being neurotic. I’ve received hurtful comments too, which I think were meant to be half-playful. I no longer need info about the specific ingredients because my stomach and intestines are so much healthier and more flexible with what they can handle, but the calorie count gives me a good idea of whether or not I can handle a dish, or how much of a dish I can eat without getting sick later (I think I don’t tolerate large meals well because I no longer have a gallbladder). Probably like many people here, I know the calorie/fat/carb counts of many raw ingredients, but it is difficult for me to try to figure out how rich a dish is just by looking at it or reading a description. And the intuitive eating thing fails in this regard, because I don’t find out that I’ve eaten too much until the food has left my stomach and passed through my small intestine, which could be hours later. I hate being the weird person in the group, so I either default to salad and chicken (and sometimes underestimate the calories and end up starving later), or I try something new…and often end up sick. :(

      Of course, I’m not saying I’m entitled to a nutritional analysis, especially from smaller restaurants. But the big chains can easily provide a nutritional analysis, because their food is scientifically designed and mass-produced (and because they are rich). Perhaps at sit-down restaurant chains, they could tuck a thin paper booklet inside the menus. Or they could use tablets for their menus, and you could just tap a menu item to see all the ingredients and nutrition info (the tablets could also easily provide custom “safe food” lists for people with dietary restrictions). That way the info won’t bother people who might be triggered, and I won’t have to feel weird asking for it.

      I do understand what you mean by being triggered though. Analyzing what I eat is usually triggering. It can be tricky to use nutritional info as a tool for better health, without it spiraling into disordered eating. Maybe that’s one reason I avoid eating out. I don’t have to plan or count anything at home because I cycle through the same meals, and already know what/how much agrees with me.

  4. I agree with your comments. One important fact and that is if someone else if paying for your health care, e.g. taxpayers, or anyone else for that matter, will have a say in your health care. There isnt much that can be done about it other than teaching the taxpayers that being fat is not what they believe it to be. They need to know we are not a “burden” to them or their pocket books.

    • I fear that teaching taxpayers that being fat isn’t what they believe it to be is going to be as hard as getting taxpayers to understand the welfare system and that people don’t just get pregnant and refuse to work so they can get food stamps and be lazy. Until they’ve been in the situation of having a load of prejudice and stigma laid at their feet over something that is not entirely in their control, they are going to be hard to convince.

    • No, they don’t get “a say in my healthcare.” they can lobby to their congressmen and women about how their tax dollars are used, but they get zero say in what my doctor does once I’m in her office. As it stands (unless some laws have been passed I didn’t know about) having taxpayer funded medical care does not mean someone else is making decisions about your care without your consent or agreement. You go to the doctors, they have you sign a Medicaid waiver (which states that anything not covered by Medicaid will need to be paid by you, but that you are well within your rights to request any treatments and/or tests available, but the burden of payment falls on you or any other insurance you may hold). and then you see your doctor. Both times I’ve been pregnant I’ve had state funded Medicaid specifically for prenatal and pregnancy care, my doctor has advised me of things that were covered (I.e. certain prenatal tests done to determine if the baby has specific disorders, like Down Syndrome, or Cystic Fibrosis), and the things that weren’t(such as more specialized genetic tests that are not covered by any insurance, let alone Medicaid) so I could make an informed decision, but in the end the decision was mine and no one else, not even my doctor made any healthcare choices for me without my consent. What taxpayers, heck what everyone needs to be taught is that someone else’s health is not their business, they don’t get to determine who costs more money or who is worthy of care. They don’t get to make judgements about someone based on some BS arbitrary nonsense like body size and think that qualifies them to make health decisions for that person. Having Medicaid or Medicare does not nullify your right to privacy and it doesn’t make your health public property.

      I apologize if I seem angry, it’s not directed at you or your post but at society at large and the people who do hold the belief that having Medicaid means you’re now some kind of public property and you aren’t allowed to make any of your own decisions.

      • I totally understand and did not take your post as angry ‘at me’. I agree with you completely. I get so frustrated at the presumptions by individuals in general about what they percieve as open for them to control.

  5. I had one more reason to hate my ex-husband last week… (He has inoculated our son w/a moderate case of orthorexia & his own brand of fat phobia)
    We were on Spring Break, went out to breakfast at IHOP where we were confronted w/calorie counts printed on the menu for each & every item… My (very thin, fast-growing 14 yr old) teenager not only didn’t want to order his favorite Smokehouse breakfast combo, he was reluctant to order ANYTHING! With a lot of fast talking, I finally convinced him we were going to be hiking around all day, he needed a good breakfast, so he finally ordered his combo. Don’t need the nannying from IHOP, thanks very much. I’m sure I would gain more success complaining to corporate headquarters than my ex, however ;-)

    • I know the fact that Z is THIN is absolutely irrelevant (don’t get me started on the crash diet the father of one of his best friends inflicted on the poor child – yes, he lost weight, then as we all well know, he gained it back w/a few lbs to boot!) – but I wanted to point out that Z is not a recalcitrant toddler or a youngster fixated on a handful of “acceptable” food items.

    • I don’t think hiking burns anywhere near as many calories as you think it does.
      1340 calories in that combo. Hiking burns 150-180 calories per hour. That’s roughly seven and a half hours of hiking to make up for that breakfast. Persuading your child to engage in gluttony is not the same thing as advocating HAES. I’m guessing this is a troll post though. (“Look, fat people force feed their kids!!”)

      • WTF Sparrow Heart??!!??
        I don’t even know how to respond to that – the point I was TRYING to make was despair over the orthorexia my ex-husband is imposing on our son. A normal active teenager would need close to 3Kcalories/day. I don’t consider it “gluttony” to eat a hearty breakfast – & yes we actually WERE hiking around for the rest of the day.

      • Although he doesn’t need to “make up for that breakfast.” From what I understand of HAES, calorie-burning isn’t a typical goal. That sounds a bit pro-weight-loss to me, as does the use of the word “gluttony.” Wanting your kid to eat breakfast is natural; the important thing is that he didn’t want to and shouldn’t be forced to eat if he’s not hungry (intuitive eating).

      • You’re right, you do sound like a troll! Val is obviously concerned about her son and wants him to have a healthy attitude about food. No need for a healthy, active young man to end up with food issues. If this society would leave people alone, we would all be a lot better off!

      • Are you serious? There was nothing about force feeding her son there, nor is eating a large breakfast before hiking “gluttony”. YOU sound like a troll, and I am very surprised that this was let through considering the triggering language.

    • I also want to point out that orthorexia is an actual mental health diagnosis, not just a more official-sounding way of saying “health nut.” If you feel your son actually has an ED, I’d recommend taking him to a doctor or psychologist. If you’re just using “orthorexia” to mean “health nut” in the same way that people sometimes use “OCD” to mean “neat freak” (which is also not okay), that’s a bit ignorant and casually ableist.

      • Yeah he’s almost to that point Maddi – he’s policing every morsel that goes in his own mouth as well as mine, to the point that I had to threaten to take away privileges if he didn’t stop the commentary about MY dietary choices!
        I would probably have more luck influencing him by asking his football coach to give “the team” a health & nutrition lecture – an adult male whose opinion he values & respects…

  6. Things are getting rough here… I’m going to take a break.

  7. You’re absolutely right that the public shouldn’t be voting on health measures. This is a very, very dangerous precedent that goes way beyond the fat panic – personally, I want public health measures to be based on evidence, thank you very much. The vaccine debate gives an inkling of how bad things can get when popular public opinion clashes with scientific consensus.


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