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Marion Nestle, a nutritionist at New York University who spent last spring at UC Berkeley, is not so sure. She contends that the Health at Every Size approach is a potentially messy one, since biological risk plays a major part in the development of health problems: "If an overweight person is unlucky enough to be predisposed to Type 2 diabetes, then being overweight is not a good idea." And while Nestle allows that many overweight people may be healthy, she believes that "lots more are not." She pounds her weight-loss mantra into the pages of her recent guide What to Eat. "Eat less, move more, eat more fruits and vegetables, and go easy on junk food."
But Nestle admits that following her own instructions is quite a challenge for most Americans. "We live in an environment that promotes eating more food, in more places, at more times, and in larger portions," she said. "We now have tons of research showing that nobody can resist overeating in that kind of environment."
Perhaps surprisingly, given their stinging critique of an entire sector of the US economy, people such as Nestle abound in the world of publishing. But that's not the case with their counterparts. University of Colorado School of Law Professor Paul Campos tackled such issues in his 2004 book The Obesity Myth: Why America's Obsession with Weight Is Hazardous to Your Health. Getting it published, however, was no simple feat. Campos easily acquired a top-rate agent, but no major publishers would touch his manuscript. Only after nabbing tons of attention from an article he wrote in The New Republic did publishers start biting. "It was a long struggle of a year, but it resulted in a huge amount of media coverage, and now people are paying attention," he said. "For a while, people like Marilyn Wann and Glenn Gaesser and I were lonely voices in the wilderness. Now there are a lot more of us."
Gaesser, who collected three degrees from UC Berkeley and now directs the kinesiology program at the University of Virginia, had an even more hellish time when he attempted to sell an antidiet book a decade ago. "The only reason a few publishers bit was that they were somewhat fascinated by the idea of a book about fat being overstated as a health problem being written by a thin person," he said. In fact, before Gaesser's agent even agreed to represent him, she asked about his weight. "She said if I were fat I'd just be viewed as a fat person rationalizing his existence, with an ax to grind."
By his own admittance, Big Fat Lies: The Truth About Your Weight and Your Health flopped when it was finally released by Ballantine in 1996. "It probably set some kind of publishing record for the ratio of most media attention to least sales," he said. Reporters gobbled up Gaesser's controversial ideas, but puzzled-looking patrons consistently approached him at book signings and asked, "Where's the program?" Gaesser calls it an exposé people weren't ready for. Still, it changed his life, sparking more than 150 lectures all over the world, and countless interviews. Calls still come from journalists nearly every time a major obesity study is released, which he considers a good sign even if his published quotes usually consist of a one- or two-line rebuttal.
Yet Gaesser has serious doubts that the Health at Every Size approach will be co-opted by the mainstream any time soon. "Aside from medical issues, you have our culture, which is absolutely intolerant of body fat," he said. "Even if you say, 'My blood pressure is fine,' someone will reply, 'But you're still fat. I can't stand the way you look.'"
Linda Bacon, an El Cerrito-based nutritionist who conducts research at UC Davis and teaches at San Francisco City College, is far more optimistic. Her agent is currently shopping her recently completed book, which will be the first focusing specifically on Health at Every Size. Bacon's publishing effort comes on the heels of a two-year study she codirected, the results of which were published last year in the Journal of the American Dietetic Association. Bacon and UC Davis Professor Judith Stern instructed half of a group of 78 women to consume less, exercise more, keep a daily food diary, and pay frequent visits to the scale. The rest of the women were told to eat according to internal hunger cues, reflect on how certain foods made them feel, consider what obstacles were keeping them from being more physically active, and attend a support group stressing self-acceptance. Each group met weekly for six months and monthly for six more months, with a follow-up a year later. Some 58 percent of the dieters dropped out during the first year, compared to only 8 percent of the Health at Every Size group. And at the two-year mark, any successes achieved by the dieting group (including, on average, an initial 5 percent weight loss) had vanished. The nondieters, however, managed to maintain a major increase in activity level, lower blood pressure and cholesterol levels, and heightened self-esteem even though they didn't lose weight.
"It's not about having better control, or denying yourself, but about paying attention to signals and respecting your body," Bacon said. "I believe this approach is sustainable."
Now, for just a moment, suppose that science did prove that fat people will suffer horrifically debilitating diseases and keel over well before their time. Does that make it okay to discriminate against them? Where is the rationale for limiting their ability to do what they want while they're still alive?
Fat acceptance as a civil-rights issue is the basis upon which the Oakland-based National Association to Advance Fat Acceptance was formed in 1969. In recent years, the organization has had some growing pains, but treasurer Frances White said ambitious new efforts lie ahead. "In the past, a lot of our work has been reactive," she said. "Now we're more interested in being proactive." At its annual convention in August which White refers to as a "family reunion" the association, which fully embraces Health at Every Size, announced a plan for drastically reduced membership fees and the launch of several major initiatives.
A legal advocacy program will educate attorneys about size discrimination, push for legislation, and create a nationwide database of attorneys willing to take on such cases. Association members, including White, Wann, and Burgard, were instrumental in the San Francisco City Council's 2000 adoption of an ordinance banning weight and height discrimination in housing and employment. Only Santa Cruz, the state of Michigan, and Washington, DC, have approved similar guidelines. Two additional databases also are in the works: One will invite members to rate how well various businesses accommodate people of size, and the other will be a list of fat-friendly health-care providers.
As doctors have come under increasing pressure to do their part in solving the so-called obesity epidemic, the relationship between doctors and fat patients has become increasingly contentious, activists say. For many larger people, being in the same room with a doctor is about as appealing as ripping off a hangnail. Pat Lyons, the program director of WomanCare Plus, an Oakland nonprofit that aims to improve large women's access to health care, said she knows firsthand how physicians often treat their heavier patients, because she's been one all her life. They often have one cure for any ailment a patient describes. Headache, sprained ankle, sore throat? Lose weight!
"I've been the same weight for twenty years, but in doctors' computers I'm listed as having a weight problem," lamented Lyons, who coauthored with Burgard the country's first fitness guide for large women back in 1988 and is often credited with launching the Health at Every Size philosophy. "I still have to deal with doctors who think I should lose weight, even being as empowered as I am."
Carrying excess weight is definitely unhealthy in one sense, Lyons has found. That's because heavier women are often less inclined to seek medical care. A major study she helped conduct of nearly five hundred obese women found that the more a woman weighed, the more likely she was to delay pelvic exams, Pap smears, and mammograms. Women who dieted often were also less likely to go to the doctor. In addition, Lyons' team surveyed more than one hundred doctors and nurses. Most reported having received little, if any, training on treating larger patients, and indicated that it was more difficult for them to do.
The change Lyons is seeking in the medical arena is not rocket science. She merely wants doctors to address fat patients' medical concerns in the exact same way they'd handle those of thin ones. In other words, physicians should use all the diagnostic tools they have at their disposal. "It's the sense that 'I know everything about you when I can see your body fat,'" she said. "They need to stop making assumptions."