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Welcome back to Food Psych Weekly, the newsletter where I answer your questions about intuitive eating, Health At Every Size, disordered-eating recovery, and the anti-diet approach.

This time it won’t be me answering, it’ll be guest writer (and my wonderful admin assistant!) Julianne Wotasik, who I think is a great person to address this week’s question because of her personal experience of navigating life and the healthcare system at the high end of the BMI chart.

Julianne Wotasik is a virtual executive assistant with almost 20 years of admin experience. She runs A-Team Virtual, an admin team that provides assistance to a wide variety of clients, including many in HAES-related fields. She is also a queer fat activist who has a long history of community building and advocacy, from working individually with people struggling with weight stigma, to organizing events, to behind-the-scenes collaboration with other activists. She lives in Los Angeles, CA with her fiancée Ragen and their two adorable little dogs.

She’ll be answering a question from a reader named Rosanne, and just a quick Content Warning (CW) for use of the “O-word” and discussion of weight-stigmatizing content in the question and answer. Rosanne writes:

Hi Christy, Thank you so much for all the positive, encouraging, and tenacious work you are doing! I have learned a lot already from your podcasts and have begun taking your Intuitive Eating Fundamentals course.

As a registered dietitian myself, I have been very much rooted in a traditional dietetic education and career, in that there is a focus on "healthy foods" and weight loss for patients/clients as a means of diet education and counseling. I read Health at Every Size after I discovered your podcast and am so eager to embrace the HAES and intuitive eating approach in my future work in behavioral health nutrition.

There is one piece, however, that I am still struggling with as it relates to HAES, that I have yet to find some good clarification on—hoping you can shed some insight on it. My question is this: if everyone can in fact achieve health at every size, how do I make sense of that considering larger-bodied individuals who fall in the "morbid obesity" category, such as individuals who are upwards of [X] pounds? I realize that the term "morbid obesity" is weight-stigmatizing in itself, so I use this merely to express what conventional medicine deems as part of this classification.

I truly want to embrace HAES, however, I can't help but reference past patients I have encountered who have had significant physical health struggles that can in part be attributed to their weight. I also think of the show My [X]-Pound Life. I realize this is a TV show, and some of the actual reality of these individuals' lives may not be captured. In that show, you see a very stark picture of physical ailments that are faced even with just getting out of bed or bathing. I want to believe in HAES, and I realize it is counter-intuitive and hypocritical to advocate for health at every size, but only up until a certain weight. I'm just looking for some help in adjusting my perspective and possibly offering up some research that supports embracing the health "as is" of this population of larger-bodied people.

Thank you so much!

Thanks for this great question, Rosanne, and before Julianne answers, here’s our standard disclaimer:

These answers are for informational and educational purposes only, aren't a substitute for individual medical or mental health advice, and don’t constitute a provider-patient relationship.

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​Julianne’s Answer

I appreciate you asking this question. As a woman who identifies as superfat (the term I and many others in the fat-liberation community prefer to stigmatizing BMI labels), I am often on the receiving end of these questions and attitudes from healthcare providers, so I’m glad to have the chance to address this.

There’s a lot to think about here. The first thing is the idea of “morbid obesity.” You are totally right that it’s a stigmatizing term, but it’s way beyond that. It’s a term that was literally created to pathologize fat bodies—as Christy explains in Anti-Diet, a bariatric surgeon came up with the phrase, perhaps to help grow the market for his work by attributing myriad health issues that may well be caused by other things to body size. (Also, fatphobia in general has a basis in white supremacy and anti-Blackness; I recommend Sabrina Strings’s Fearing the Black Body and Da’Shaun Harrison’s Belly of the Beast to learn more about that.) Because the O-word has become a medicalized term, it tends to sound “official,” but we always have to remember that even if some fatter people have more health issues than some thinner people, we can’t make the assumption that it’s because of our body size, or that trying to make us into thinner people is the solution.

Body diversity is natural, and bodies of all sizes have challenges. For instance, there are health issues/challenges associated with being tall, but we don’t try to make those people short to solve them. We accept the fact that there is no safe, evidence-based way to make a tall person shorter, even if it might change the health issues they face. We accept that they are the height they are, and we know the best thing for healthcare professionals to do is treat them at that height and focus on how to best support them rather than fantasizing about a way to make them shorter. Why aren’t superfat people treated in the same way when it comes to their weight? I am toward the highest end of the weight spectrum in humans, and Shaquille O'Neal is toward the highest end of the height spectrum in humans. Both of us deserve compassionate, evidence-based medical care that focuses on how to best support our health—not how to change our body size.

You mentioned “past patients … who have had significant physical health struggles that can in part be attributed to their weight.” We need to consider that the health challenges faced by superfat people could very well be caused (and exacerbated) by fatphobia, yo-yo dieting, and lack of access to the same healthcare that thin people get. Almost every healthcare practitioner a superfat person sees immediately becomes obsessed with their size and changing it, rather than focusing on how to support their health, so they are often not given the care they need and deserve. Even if you, your patient, or their doctor believes that their health struggles are due to their weight, that doesn’t make it true. Thin people can get all the same health issues as fat people, so there is no reason to assume that a health condition is caused by weight or could be cured by weight loss. It’s far more likely this is just flawed “everybody knows” thinking and is not grounded in fact.

I also want to talk about the concept of “health.” There is a tendency, especially in the U.S., to treat “health” as a simple concept, when it’s actually complicated and multi-faceted. It’s individualized and changes over time. The book Health at Every Size does not say that “everyone can in fact achieve health” (by whatever definition). There are people of all sizes who have health issues and mobility challenges, some they’re born with and some that develop later in life for many reasons. The difference is that when those people are thin, their health and mobility aren’t blamed on their size, and they’re more likely to get supportive care than a lifetime prescription for yo-yo dieting.

So HAES is not about making everyone “healthy” by any definition. Instead, it’s about the fact that truly health-promoting behaviors are a far better predictor of future health than body size is—and those behaviors aren’t just about food and exercise! Adequate sleep, strong social connections, and reduced stress have been shown to have a major impact on well-being, along with social determinants of health including the experience of oppression. Even more important than focusing on individual behaviors is the need to end oppression (including racism, fatphobia, ableism, healthism, homophobia, transphobia, etc.) and bring down barriers to healthcare.

For superfat people like me, barriers include having to rely on medical practices that were created based on research that didn’t include or consider people my size, a lack of access to healthcare (from the most basic levels, e.g. properly sized blood-pressure cuffs and gowns, to critical treatments and tools, e.g. MRIs, surgical tables, and best practices), and practitioner bias that can cause our providers not to listen to or believe us. We are constantly given the message (even though the evidence doesn’t support it) that weight loss is the only answer to our health issues, when in fact there are evidence-based treatments available.

To me the real question is: how many of the “challenges” around being in a fat body would be mitigated if superfat people were treated like human beings deserving of compassionate, easy-to-access, evidence-based healthcare? Instead of trying to make us thinner, what if healthcare providers just tried to care for us?

As numerous studies over many decades have shown, at best intentional weight-loss attempts fail about 95% of the time, and those odds actually get worse for superfat people. However, weight-neutral behavioral interventions have been shown to be more effective for people of all sizes. In a recent study (CW: BMI numbers, weight-stigmatizing language), researchers Glenn Gaesser and Siddhartha Angadi looked at 225 different studies and meta-analyses and found that behavioral interventions show far more success in improving fat people’s health, and carry far less risk, than intentional weight-loss attempts.

Unfortunately, instead of going with the evidence and supporting health and mobility for fat people, healthcare has pushed the idea that the fatter you are, the more acceptable it is to subject you to dangerous surgeries and medications. The field of “obesity medicine” is built around the idea that it’s worth risking the lives of fat people—especially superfat people—to try to make us thin. Imagine how it feels to sit across from a doctor, someone who has the power to help you or harm you, and know that they think your life is expendable because of the way you look. They don’t see you as someone who is loved and valuable to this world, they just see your fatness. This is the experience for most superfat people with many of the healthcare providers they interact with. It’s wrong and needs to change.

That brings me to the TV show My [X]-Pound Life, which I think is an exploitative abomination. It cherry picks and specifically produces stories that allow voyeuristic views into experiences of superfat people that fit in with people’s stereotypes of our lives. If there was any reality to that horror of a show, it would have to have a heavy focus on the terrible way superfat people are often treated by people in general and healthcare providers in particular. As it is, the show does nothing but exploit people like me for views and advertising money. Well, that, and convince other people that the life of a superfat person is, as they suspected (thanks to stereotypes), full of sadness and dread. This simply is not true. There are many superfat people who live happy, fulfilled lives. I don’t think a show about my quiet life with my loving partner, adorable dogs, and supportive family where I spend my days running a business, loving my friends and family, and enjoying little adventures that often include petting goats, would get very good ratings. Because viewers unfortunately are far more interested in a show that exploits vulnerable people. There just isn’t much of a market for a balanced view of what life is like for people at the highest end of the weight spectrum.

I can tell you that the best things I ever did for my mental and physical heath were to stop trying to change my body size, let go of the shame I had around any health or mobility challenges that I have now or might have in the future, and avoid working with any healthcare practitioner who sees me as a “lost cause” without weight loss.

I think the most important thing about working with superfat people, including those of us with health and/or mobility issues, is to let go of the idea that you can help us by making us into thin people. Instead, ask us about our actual goals: do we want to increase our health or our mobility, fight the oppression we face, etc.? To increase our well-being, the best, most evidence-based path is health-promoting behaviors without any regard to our weight. If there is an issue with mobility, think about what you might advise for a thin person in the same situation—maybe working with a trainer or physical therapist on strength, stamina, and/or flexibility. If we are trying to fight against our oppression, it can be really helpful to connect us with resources within the fat-liberation community, rather than giving us the impression that we should change ourselves to suit our oppressors. There is no size limit on appreciating our bodies and supporting them based on our own priorities and the path that we choose for ourselves.

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Podcast Archives

In Episode 207 of Food Psych, Health At Every Size medical doctor Louise Metz joined me to discuss why weight management has no place in evidence-based medicine, how our current medical system can get in the way of providing compassionate care, why it’s actually not necessary for doctors to weigh their patients, how physicians can shift their practice to be more weight-inclusive, and so much more.

Plus, I answered a listener question about dealing with digestive symptoms.

​Check it out right here, and be sure to subscribe to the pod so that you get weekly reposts of fan-favorite episodes (plus the occasional bonus episode) while we’re on hiatus, and new episodes once we return.

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Here’s to healthcare without diet culture,

Christy