Beginning to Weigh in on the Linda Bacon/Lucy Aphramor Paper

In Weight-Loss Maintenance on February 28, 2011 at 2:34 pm

The great thing about procrastination in blogville?  If you wait long enough other people do big chunks of your work for you.  I have, for some time now, wanted to post my impressions of the Linda Bacon/ Lucy Aphramor treatise, from January 24th of this year, Weight Science:  Evaluating the Evidence for a Paradigm Shift.  The shift they speak of, of course, is away from a weight-loss centered medical model to one of Health at Every Size, or HAES (trademark pending).  It is a densely referenced essay, with only eleven pages of narrative followed by 178 footnotes filling nine pages of their own.  Those footnotes deserve fair inspection and at least some random verification to make sure the authors are interpreting properly (a daunting task), and that has held me up some.  However, to critique such a treatise as this, it is only fair to start with a summary, and I thank others for coming through for me, brilliantly.

From the size acceptance community we have a lovely essay from Living 400lbs, and we have Big Fat Blog’s earlier quickie post on the topic. 

Since we can expect the size acceptance community to embrace a paper promoting HAES (which is rooted first in size acceptance), I found it more heartening to see that Canada’s preeminent obesity expert, Dr. Arya Sharma, not only posted a thoughtful summary of his own, but he ended by saying he is keeping an open mind on the topic.  This from a man whose bread and butter entails (where he deems appropriate and judicious) recommending bariatric surgery for his patients.  Unsurprisingly, he has a much rosier impression of the evidence-based benefits of bariatric surgery than Bacon and Aphramor or others from the size acceptance community who publish in journals.  (To my lay eyes, this debate is stuck in a state of limbo, these-scientists-say-X/but-these-others-say-Y.  And few scientists are creating studies that cover a significant time period, which should be required if they are to break the tie by the weight of their evidence, credentials or the consensus of their colleagues.)  

Possibly more important than Dr. Sharma’s post itself, however, are the comments.  Linda Bacon, herself, responds.  Wow.  Moreover, Dr. Barbara Berkeley jumps into the fray (as do a few of her supporters).  And from the size acceptance community, we see the influential voices of Deb Lemire (President of the Association for Size Diversity and Health) and Bill Fabrey  (founder of NAAFA and continuing size acceptance advocate). 

I am disappointed that Dr. Sharma didn’t acknowledge the comments, and I hope he recognizes that while the post was important, synthesizing the important comments (and ignoring some of the others) may be more so.  In as much as HAES v. Intentional Weight Management becomes a conversation, and not dueling manifestos, his post may be progress toward a broader, more dimensional understanding of human adiposity by influential people of differing vantage points. 

HOORAY!  I cheer!  Let those of us in the peanut gallery bust open the champagne!  (A fruit-based carb product, unlike that shady grain-based beer.)

Now that the summary is out of the way (no thanks to me), later this week (or at such time as I am not distracted) I will address a few of the strengths and weaknesses I see in the Bacon/Aphramor research.  I will try to make sense of the pencil notes I wrote in the margins, and give my thoughts on some of the footnotes I chased down.

  1. What’s very meta is that I was just thinking about writing in my blog about your blog and others in the “maintaining” vein.
    I’ve often tried to have a foot on both sides of this fence.
    I’m someone who sees herself as a maintainer (of an around 40 pound weight loss for around 10 years now) and also a HAES-er (as I’m still Class III Obese), and someone who also does a little uncomfortable dance with myself when my weight crawls up as well as a little happy dance when my weight finds itself at the lower end of my comfort zone.
    I think the key words that I need to remember are “mileage varies.” Mine. Yours. I’ve used the car analogy when talking about myself and having type 2 diabetes — I like to think of myself as an zippy low-maintenance compact I’m actually a high-maintenance vehicle — one that is totally worth the effort to maintain — but still not the kind of car that you can just put gas in and go.
    So, for me, learning what kind of fuel and how far and how fast to go, and what other maintenance is needed — that’s been totally valuable. I encourage others to do the same. I’m no mechanic — I don’t know much of anything about YOUR car, but I’m happy to tell you what I’ve learned about mine.
    And I think we can learn from each other. Be a community of learners. Rather than fussy, annoying windbags — if that’s the alternative — blowing hot, stale air on each other.
    Have I mixed enough metaphors yet?

    • You have done a great job with your metaphors, AW. And I too have often used the car metaphor. The thing that really bugs me most is that people routinely accept that two Buicks can get different milage, but we humans, who are vastly more complex as machines than mere cars, and whose fuel is also complicated — well, we all process 3,500 calories to the pound, and that’s all there is to that. Huh?!

  2. One other thing — I think that there’s an idea floating around that HAES means that you accept yourself and suddenly everything is okay — your health problems disappear, the sky fills with light and harp music, butterflies land all around you. That’s not what I think HAES is about.
    For me, Health at Every Size (and I’m truly not crazy about the name) means that I get to define what health means for me at whatever size I am. If I gain weight — what does health mean for me? Does it mean I have to lose weight to be healthy? Does it mean I don’t have to change a thing and still get to expect my health to be exactly the same as when I weighed less? Neither of those fit for me.
    For me, HAES is about placing my own values around health at the center, and then letting the chips fall where they may. If I decide that for me, eating sugar rather than abstaining from it makes me happier, and I know that has consequences for me with regard to my weight but I’m still able to manage my diabetes very well while eating it within reason, then I’m the one who gets to make that call. I get do call the shots about how much I exercise, how often, and what I eat and when. And I think you also have determined that you get to call the shots about eating and exercise and you are only accountable to yourself, not the size-acceptance movement or the NWCR. So, in that sense, we’re more similar than we are different.

    • The confusion around HAES is because so many different people claim it and define it differently. It is also confused with intuitive eating and with Size Acceptance. Each of these concepts is related, but not synonymous. One is an approach to eating (which can be consistent with HAES or can be abused into a diet mentality) and the other is a political movement (which can be complemented by practicing HAES, but can also stand on its own). HAES is a philosophy — some would say medical philosophy others would say wellness philosophy. Your definition of HAES is interesting but probably too vague for Joe and Jane Public.

      I think it’s especially helpful to separate HAES and Size Acceptance. You don’t need to practice a particular wellness philosophy in order advocate for social justice, and the Size Acceptance movement doesn’t need to be alienating anyone.

  3. i’m glad you are looking closer at this report, Debra. another rational voice in the discussion almost always raises the level of discourse by calling into question the rhetorical blindspots and implicit biases.

    @Acceptance Woman: I’m glad you “call the shots” about your health issues and respect others’ right to do the same. Now, if *we* could only get the field of options to open up for more people who want to improve their health but do not have access to the means (knowledge, support, resources, care…).

  4. You know, HAES has a lot of logic on its side but not a lot of research. This is because nobody wants to fund research that may end up concluding that it’s okay to be fat. That’s why so much of the evidence in favor of HAES is actually from anti-obesity studies that draw conclusions that appear to contradict their data. The weight centered paradigm is well established and difficult to challenge from within the system. Still, it has to be done if we’re going to get to the truth.

    • If nothing else, the Bacon-Aphramor paper shows how much research there is still to do. The papers they cite as specifically HAES-focused were only in obese women, sometimes with an eating disorder history. No studies focused on HAES in men. No studies focused on people with diabetes, PCOS, hypothyroid or a history of heart disease.

  5. Debra, I’m looking forward to your critique of the article. My own post was sorely lacking in critical insight, in part, due to a lack of time but also because I was so excited to see a scholarly piece of work that questioned the axiom that fat is bad. There are so few voices that dare question the blanket assumption that you are by definition unhealthy and will definitely get sick because your BMI is over 24.9, no matter what your actual health status is.

    The fact of the matter (and who am I to tell you this??) is that it’s all so much more complicated. On both sides.

    OK, I’ll stop ranting. I’m waiting…

    • Ah, NewMe, I apologize for not mentioning your post too. A fine one at that, and a contributor to my thinking process, no doubt. Woof.

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