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.
