Healthy At Every Size?

Read first, then decide.

Today I saw a 12 yr old girl, I’ll call Gabrielle, whose weight was off the charts. She was referred by her doctor, supported by her concerned parents. And here's what I told her, because I believe it to be true.

Her place on the weight chart is likely the right place—for her. Since the age of 2 yrs she has paralleled this curve at just above the 95th percentile, (in spite of being only 5 ft tall, much shorter than average), resulting in a very high BMI. She is an active, healthy girl—more active than most thin girls and boys I see, with no apparent suggestion of health issues. She eats well—appropriate portions, as I'd expect for her need, a healthy balance of foods, including those I'd call "junk" food, and she eats the same when she is alone and when with others. In other words, she’s got a healthy relationship with food. Most importantly, she feels good about herself, and the last thing I wanted to do was add mental health issues to any perceived, but non-existent risk of physical health issues.

Gabrielle is one of several patients I’ve seen recently, fitting this description. Some individuals are larger than average size, some smaller, kids and adults, males and females. And we should not assume that’s a problem, as several bloggers are sharp to point out. Health At Every Size, The Fat Nutritionist and others enlighten those who don’t know better, who don’t ever question their assumptions, that large people can be healthy, fit, and in fact happy.

End of story? 

Not quite. The key word is can be. While we cannot and should not assume that an individual’s weight is causing them medical or emotional problems, there are overweight individuals who are not healthy or comfortable at their size, for whom weight loss may help. I question the belief that striving to lose weight, in all cases, is bad. And I am not talking fad diets, mind you.

I am not simply projecting here. I speak on behalf of the patients I have seen over my 25 years of practice. Just as we cannot assume that they’re distressed at their current weight, we cannot assume they are very comfortable or healthy at their state of health and size either.

There are kids, and adults, like Gabrielle described above—always large, but healthy and fit. Many are self-accepting, many self-loathing, perhaps due to society’s discrimination and learned messages they need to unlearn. And I do my best in my sessions to convey this very message, that they are just fine as they are—their eating, their activity and their weight. I am not addressing these “Gabrielles” in the remainder of this post.

Rather, I am speaking about those for whom obesity, or the degree of obesity they are living with, is not their norm, the men and women who have gained weight outside of their comfortable and usual weight range. This includes individuals struggling with compulsive overeating, as well as those without any emotional baggage. It applies to those who no longer take time to meet their needs for exercise, or who might have suffered an injury, which forced a decrease in activity, without adjusting their food intake. I’m describing those who don’t know how to prepare a healthy meal as well as those who eat many meals out, juggling the modern life of working and parenting, soccer practices and carpooling. And those who minimally eat throughout the day, only to eat excessively at the end of the day.

I am not judging them, merely conveying what I hear from them day in and day out. They put off travel because airplane seats feel too tight, and European cars fail to accommodate their size. They want to be off the medications they now take daily, for hypertension, high cholesterol and joint pain. They want to be free of their sleep apnea and their heartburn. 

Sure, there are plenty of normal weight people, thin even, who also develop such conditions (count me in—thin with high blood pressure). But as a population, increased weight increases the odds of developing such conditions. The damage to their knees may be already done, but it is easier to move a body with a lower mass versus carrying surplus weight, particularly when you’ve got pain.

I’m not picking on the obese. If you read any of my posts you’d clearly see my philosophy. Similarly, I do not believe there can be health at every size at the low end of the spectrum. While not all slim individuals have eating disorders, (some are naturally thin, always were and always will be) I can tell you that a low body weight that contributes to loss of menstrual periods, low body temperature, a very low pulse, distorted thoughts and preoccupation with food similarly would benefit from a change in weight. 

And if you think these individuals are immune to society’s judgment, think again. There is equally little sensitivity to those struggling with weight issues on this side of the spectrum. Yes, sometimes the very people who preach size acceptance are all too quick to dismiss, insult and disregard the opinions and insights of someone who is thin, simply because they are thin.

A rabbi friend once said jokingly “Anyone who is more religious than me, is a fanatic. Anyone less religious, a heretic.” Sometimes that’s how I think we all behave around the issue of weight. It’s fine if you are my size, but thinner or fatter we accuse of needing to change and have a difficult time accepting.

Ultimately, the primary focus should not be on losing weight. Yes, even for those who truly care to lose weight, for whom a high BMI was not the norm. Rather, they need to address their behaviors and experience tangible benefits—a sense of accomplishment, having set a realistic goal and achieved it; better sleep; better endurance; better concentration; less irritability by honoring their body’s need for fuel; and a better relationship with food. As these changes occur, weight loss also follows.         
Where do you fit in all of this?

Does your activity need to be addressed? Are you even at a healthy enough place to be exercising? What modest goal can you set that you’ll be able to achieve?

Do you allow yourself to eat when you need to? Or do you push this to the limits, thinking you are too fat to be eating? Everyone, 
regardless of her size, needs and deserves to eat throughout the day.

Do you give yourself permission to eat foods you enjoy? Do you even remember what those foods are? Or are you so stuck following everyone else’s rules (including your own), absorbed from years of dieting and denying yourself?

Yes, allow yourself to eat whatever you’d like—no single food makes a person fat. And have it when your body needs it—when you are hungry, any time you are hungry. But learn to have just as much as you need (do read through the many older posts that address this topic).

In fairness, the palpable anger I feel from those who blog about fat acceptance is understandable. They have been mistreated by our society, including those that should know better, such as the medical community. They include those, like Gabrielle, for whom weight loss may be inappropriate. They are repeatedly told to change, when change is truly not necessary.

But let’s not over generalize. There are also those overweight individuals who would like nothing more than to be accepted for who they are but have medical conditions that may be assisted with weight loss. And they deserve to be supported on their journey to a healthier place.
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