Barriers to Treatment

“Weight: What’s Fat, What’s Not, What Can We Do About It”

Barriers to Treatment: A Patient’s View

A speech by Lynn McAfee to the National Institutes of Health Seminar
June 4th, 1998

This is such a distinguished group of people, with so many initials after their names, I feel I should tell you a little bit about my credentials since I have no initials. First, and most obviously, I am a 505 lb woman who is disabled by her size. I’ve been an advocate for fat people since 1970, but as you’ll see I’ve been a fat person all my life. (Showed slides.)

Here’s a picture of me on my first diet. I’m 3 weeks old. Really. I was taken to the doctor because I was growing too fast, getting too tall and too fat and crying continuously for more food.

Here’s a picture of me at age 7 with my first boyfriend. By the way, it’s a myth that we are not attractive to the opposite sex. I remember the moment this picture was taken. I was on amphetamine cocktails, so what looks like the joy of childhood is actually me being very hopped up. Two years later I tried to kill myself because I couldn’t lose weight, and I couldn’t imagine a happy future as a fat person.

Here’s a picture of me around age 22 or 23. I was sticking my finger down my throat twice a day and I thought it was a great weight loss plan. But, as you can see, it didn’t work.

As an advocate for fat people, I am in the rare position of knowing what every weight between 0 and 505 feels like, every issue we face at every weight. So please remember that when I speak, I speak not only for and about supersize people, but also for those who are all sizes of large.

“Barriers to treatment” as a topic implies that there is an effective treatment for obesity, and we are now beginning to understand that is not really the case. After years of telling us that small weight losses are useless, now we’re told that a maintained loss of 10% is the best we can hope for. “The 10% solution”, which came suspiciously soon after it was publicly admitted that dieting is not a successful remedy for overweight or obesity, may indeed have health benefits but it does not confer the social benefits we all seek.

Being fat in this society, whether you’re called “overweight” or “obese”, is penalized in every way imaginable. We have a higher rate of poverty, and those of us who are working are discriminated against in the workplace to the tune of $6700 a year per family less income. We are less likely to marry: studies show that as marital partners we are ranked below embezzlers, cocaine users, and shoplifters. We complete fewer years of education. We are accepted at elite universities less often than equally qualified thin applicants and even when we attend college we receive less financial aid from our own families.

The economic consequences of discrimination affect the way we view even a medically beneficial weight-loss intervention. Often the most successful, perhaps even the only successful, long term weight loss programs take place in academic, psychotherapeutic settings. We are unemployed and underemployed at a high rate, we are the working poor, and we are often uninsured. For many, our meager resources cannot be stretched to pay for these expensive treatments. And remember, it is clear that the emphasis must be on the maintenance of weight loss in order to have a health benefit, so we’re talking about a lifetime of care and financial expense.

Cost is one of the least-talked about issues; it seems assumed that we should gladly pay any amount, and keep paying it throughout our lives, for this small weight loss. And people are not always honest with us about cost. The Center for Science in the Public Interest has shown that Jenny Craig’s famous “Lose 20 pounds for $20” slogan should really say “Lose 20 pounds for $1,000”. And it has yet to be proven that commercial weight loss programs are in any way effective. Weight loss techniques developed in academic settings may not even be reproducible in the commercial programs.

Exercise is an important health-producing behavior and is critical to weight maintenance, yet the barriers to exercise are nearly insurmountable for many. Taking a walk after dinner may be good exercise in the suburbs, but in my urban neighborhood any fat person out after dark has “victim” written in glowing neon on their forehead. Child care resources are scarce, even if one had the money for them, and time is every bit as scarce in a society where many poor people routinely work two jobs to support themselves and their families.

Another barrier to exercise is the self-judgment and fear of ridicule we expose ourselves to when we expose our bodies in public. I can remember weighing 165 pounds and refusing to go bicycling because everyone else was wearing shorts and I felt they would laugh at me if they saw my fat thighs. I remember weighing about 200 lbs and making excuses so I didn’t have to go hiking with a group of my friends because I was afraid I would walk too slowly and they would become exasperated, and perceive me as inferior to them.

If you’re not at the top of the exercise pyramid, if you’re not among the fittest, you are made to feel less than good enough, worthy of rebuke and self-recrimination. Is it any wonder that we avoid exercise?

Compounding the problem is the fact that we have linked exercise and weight loss. In the water aerobics classes I organized, I always got people when they started a diet and lost them when they stopped dieting, usually because they became unable to continue what is, at least in the short term, the deeply masochistic act of caloric reduction. We need to disentangle exercise and weight loss. Exercise has a health benefit regardless of whether or not one is engaged in weight loss or maintenance. People should learn to exercise because it is something good we do for our fat or thin bodies.

Many of us hate our bodies so much we think they don’t deserve to feel good or to be taken care of. We are reluctant to see our physicians for any reason because we are often the victims of severe prejudice, we are verbally assaulted, and our symptoms, any symptoms, are ascribed to our weight. First there’s the weigh-in, the dreaded scale. Then, it is often implied that because we are fat, we are responsible for our own ill-health and so not deserving of treatment. It’s no wonder that in a study of health care workers, 32% of women with a BMI of 27 or more reported that they had delayed or avoided health care based solely on their concerns about being weighed. Yet for all the concern over the morbidity and mortality of fat people, little or no effort is made to address this human component.

And how could we expect our health care providers to be unprejudiced when prejudice pervades every part of the system. Even the American Heart Association feels comfortable in displaying their ignorance in Public Service Announcements that advertise their contempt for fat bodies.

So trust is a major barrier to care. In this category, I would also place the increasing skepticism fat people have regarding the pronouncements of various government health agencies, including the FDA and the NIH itself. Redux and fen/phen have made fat people skeptical of the ability or desire of the FDA to protect them, although those of us who attended the Advisory Committee hearings know that is not the case.

I am also greatly troubled by the upcoming NHLBI Obesity Treatment Guidelines that change the cut-off for overweight from a BMI of 27 down to 25. Suddenly, 29 million more of us are considered overweight although we haven’t gained a pound! Although these are evidence-based guidelines, there is absolutely no evidence of any change in mortality at BMIs 25 and 26. None. So if we’re not going to benefit from a longer-life, who does benefit from changing the cut-off for overweight?

Pharmaceutical companies will be at the FDA’s door the day after these guidelines are released, looking to move downward the weight at which people can get diet drugs. That’s another 29 million potential lifetime buyers of a drug.

Since we’re now over 54% of the population, we should expect more research money for obesity. Now this is a very good thing, I’m very much in favor of more research, especially on the basic biology of the weight maintenance mechanism, but this is not the right way to get that money. This kind of “end justifies the means” approach is a return to the paternalism all of us, especially women, have fought against for years.

Although there are considerable barriers to treatment, I feel strongly that we should continue to work on more effective treatments. But we can no longer accept the scorched earth self-esteem practices that old weight loss treatments espoused. We are worthwhile whatever our weight. Our bodies are to be respected, they must be viewed as aesthetically admirable, and our efforts now must also concentrate on improving health at any weight.

Someday, perhaps we will all be thin. Maybe then we will discover that being thin does not automatically confer happiness; that whatever one’s body size we can’t live forever; and that there is value to all human diversity – even size diversity.


Facts & Figures
Health At Every Size
Take Good Care of Yourself
Good Nutrition
Long Term Diet Failure
Thinness Obsession
Barriers to Treatment: A Patient’s View (currently open)
Medical Advocacy
Prescription Politics
Unbiased Research

Healthy Weight
Food & Exercise
Non-Diet Approaches
Feminism & Weight
Eating Disorders
Body Image
Men’s Weight

Eating & Exercise