Bo Po Expo
26th March 2023
This is the speech that I, Jo Money, wrote in preparing for the Bo Po Expo in Melbourne March 26th, 2023.
No doubt on the day a very different presentation was actually given based on the tangents I went off on in the moment! And I probably ran out of time!
Introductions
Firstly I would like to acknowledge that we are on; and I work on, the lands of the Wurundjeri people. I would like to acknowledge the elders past, present and emerging. It is a privilege to hear and learn from their stories and wisdom.
I would like to acknowledge the many privileges that I hold. I am white, cis gendered, straight, able bodied. I have had access to education, higher education and the means and support to create my own business.
My greatest privilege is the gift of seeing clients. For 19 years I have had the privilege of holding space for the most amazing individuals who have opened their souls to me. Shared their lives, experiences, fears. So many things I've learned as a human, and all I have learnt as a clinician comes from the brave people who have come to me to work on their relationship with food and body, to explore their diet and body trauma and to heal from this.
I exist in a small fat body. I was a fat child and a fat teenager. I'm a small fat dietitian. AND I acknowledge that my experience pales in comparison to others who exist in a body that is larger than mine and that hold other marginalized identities.
I stand here to share the wisdom I have learnt from the privilege of hearing their stories. I take this platform using my privilege as a health practitioner to advocate for change. To support everyone in this room to know - it isn't them. To educate that you deserve better and to plant some seeds of how to demand change. Know that I will be advocating ongoing with individuals, with health practitioners, within the education systems I can, within the health care teams I am part of and in time many other health practitioners. I will support those with lived experience to take this platform when they can. And I will not push anyone to speak and share their story if they don't want to. It is not your responsibility to do the emotional labor of educating others.
The world we live in is fucked. Cruel. The stories I hear of how people are treated; especially in the medical system, based on the assumptions of their body, are heart wrenching. And they all deserve space, air time and validation.
I suspect that this experience is common in the people present today. It is not ok that you were treated that way. It was not ok that basic human decency went out the door and that assumptions and ‘well meaning concern’ was used in a veiled attempt to cover basic verbal abuse.
Health care practitioners have caused harm, myself included. I acknowledge the harm I have caused. I will also continue to cause harm in ways I don't understand yet.
I, and others, strive to learn from the people we support, holding lived experience as our greatest teacher. We are listening, we are reflecting on our practice and we are sorry for the harm we have caused. We will continue to work to do better to support you.
But you're not here to hear me talk about me.
I am here to offer something for you so let's move forward.
All humans deserve to be treated with respect, compassion and kindness; especially in the vulnerable situation of seeking health care. Let's look at how you can support yourself to seek that.
Let's start with linguistics.
The word fat can be jarring. In this cultural soup we exist in, filled with oppressive systems that degrade and control us in a myriad of ways; the word fat has historically been used as a slur.
I choose to reclaim the word fat. To use it as the neutral descriptor that it is intended for. To simply describe size - with no positive or negative connotations.
I support those who have reclaimed this word in their own process of exploring the injustices that have impacted them. I support those that are not ready to use the word also.
I acknowledge the hard emotional labor of the fat activists that have come before and continue to work; that have allowed me to feel safe in the use of this word.
I appreciate not all who are here today are ready to use the word fat when describing their own bodies and may still find the word sticky in their mouths when using it to honor others wishes.
That is ok. Everyone is in their own process, at their own stage. There is no rushing the personal and confronting exploration of the systems that oppress people based on body size around us and how we have internalized this and weapoise it against ourselves.
Anti fat Bias and health care
We all exist in diet culture, the belief system that “worships thinness and equates it to health and moral virtue,” The origins of this run deep (much too deep to explore and cover in this forum).
The western medical system is in bed with diet culture; they have been since the beginning. Weight bias, assumptions based on weight and the stigmatizing interactions as a result of this are rampant in the medical and health care system.
People may experience assumptions about their health based on their appearance, they may not feel believed, they may be disrespected, probably offered unsolicited weight loss advice. The bias of health care practitioners and the system can lead to stigma in the form of microaggressions, lack of chairs to accommodate all bodies; up to gate keeping life saving surgery.
Why is health care infused with anti fat bias:
Teaching
Practitioners are taught through a weight centric lens - where health is blamed on the individual and body weight is blamed as the cause of all health evil. The practitioners in the health care system are human; they exist in the same culture soup under the same systemic oppressions.
I swing between compassion for them as individuals that they are performing what they were taught and haven't drunk the kool aid yet - and fiery anger and frustration that they arent listening to the people who are so brave to share their experience and advocate! They aren't reflecting on and learning from the experiences with the clients they see and they aren't reading the overwhelming evidence that health is complicated - mostly influenced by social factors out of individuals control and continuing to focus on weight loss is causing harm!
Perpetuating long held internalized bias
We all have bias, it is our responsibility to reflect on this unlearn and relearn. This is a concept that most in health care are not even aware off! People with privilege are the ones that are able to access the education, have the time to study to succeed and attend long placements; and systemic bias and stigma is not addressed in their learning. I acknowledge I am making sweeping statements and not all people in caring professions fall in to these categories or perpetuate harm! Just a large chunk!
Poor research
Research around weight and weight loss is held to a different level of scrutiny for some reason. It is not examined and challenged in the same way as other health care research. There are confounding factors, small intervention groups and small outcomes that are over inflated in their impact.
Lazy medicine
Harsh but true. Assuming that all ill health is due to size is lazy. It fails to consider the impact of the social determinants of health. There are some situations where we know weight or fat mass may exacerbate this - there is no evidence based intervention for changing the body that is long term and does not cause harm! SO how can we ethically recommend this!
Health care professionals need to listen to their clients, validate their experience and think creatively about how they can support them - what they can offer! A great place to start is for them to reflect on - What would I recommend for someone in a smaller body with the same presenting problem.
Big pharma ($)
Billions and billions of dollars are going into the pursuit of weight loss each year!
Big pharma is paying for the research! Drug reps are winning and dinning the GPs.
In our practice we can always tell when the drug reps have been to see the GP around us for lunch and a chat about their new offerings! We have a wave of clients experiencing further harms, confused and overwhelmed!
*Louise at Untrapped has great content around this!
So let's look at the facts:
Please note this, like all information, is generalised from empirical evidence and is not meant to be alarming - simply some more ideas to challenge the long held message that individuals are exposed to in the healh care system. And explain some of the grossly inaccurate assumptions. Know that individual risk is nuanced.
Weight stigma is associated with a 60% increased risk of death - Independent of BMI! (1).
The impact of the weight stigma experienced by people in fat and higher weight bodies has a much greater impact on their weight itself!
BMI is an outdated tool, never intended to be used on an individual. BMI tells us nothing about an individual and their health status.
People in all body sizes experience diabetes, cardiovascular disease and other lifestyle diseases.
- They are not caused by weight or eating particular foods.
- They are caused by a complicated mix of things - the biggest contributors being genetics and age! Things we can not control.
People who experience stigma in health care avoid the medical system leading to delayed diagnosis and poor health management.
People in higher weight bodies avoid physical activity.
People in higher weight bodies have poorer mental health!
How could they not - the anti fat bias is enacted as stigmatizing interaction in the health system lead to all of these negative outcomes - not the individual or the body itself!
Yet - the overwhelming message is - If you just lost weight, 5-10%, it would improve your health and outcomes. I call Bull Shit! And how do you propose this happens without perpetuating the same harm?!
I always reflect there that we can't untangle the interventions, increased activity, different food choices, that are often associated with weight loss interventions. Is it these changes in activity that leads to improvements of clinical outcomes, secondary reward of weight loss, feeling safe in a world that vilifies you? I suspect that any improvement recorded in the research is a result of these other factors that are not isolated for examination seperate to body weight changes and the weight loss its self is not the cause of improvements. We also know that health behaviours interventions improve health outcomes regardless of changes in body size.
What I do know is that people blame themselves when they try to comply with the messages they have been told their whole life to be smaller - and it doesn't work!
You are not broken - the system is!
Not all bodies are meant to be small! All bodies - all the parts of bodies - exist on a spectrum. Some are meant to be tall, short, large feet, small feet, brown hair or blond. Some bodies are genetically designed to be big. And this is not an indicator of health!! We know this from countless studies. But more importantly we know that from people!
So many people have been referred to me over my career for ‘weight loss’ as their BMI is deemed too high. When I sit and talk with these people together we find they are perfectly healthy, happy, functioning, no increased risk of anything! The only thing the referral contains is the weight bias of the referring GP. I have had the pleasure of supporting these clients to understand that the system has failed them - not the other way around.
The fallacy of weight loss and health outcomes
Body size is not an indicator of health.
Fatness is not the cause of all illness.
You can improve health without focusing on weight loss.
What about if there are health things going on, elevated BGL or cholesterol?
We can’t assume it is related to just size - as we have reviewed, experiencing weight related stigma can lead to this, as can weight cycling and thought there may not be strong evidence I suspect the physiological impact of trauma on the body! . Mostly it is probably a reflection of genetics, age and stress!
Yes, at very high weights there is a higher association (no proven cause and effect!) with poorer outcomes.
- We can’t determine exactly what is the cause - the body itself, experience of living at a higher weight or the history of weight cycling that has most likely occurred.
- There is no evidence based intervention that leads to long term weight loss. And we know the interventions offered cause harm and increase weight cycling and stigma which are associated with poorer health out comes.
And this is such an important point. Billions of dollars has been spent researching weight loss interventions. Causing so much harm to so many people.
And the results are - there is no intervention that leads to long term weight loss. At 2-5 year follow up 97% of study participants have regained the weight plus more. ( the magical unicorn that sustains weight loss - when we review their ongoing practices of calorie counting, weighing food and rigid exercise plans - sounds a lot like an ED to me!
There is a special type of bias in the medical community for weight loss research that is not scrutinized to the same levels as other research. ( another whole topic of conversation we can't have here).
So even if practitioners believe that weight itself is contributing to poor health - there is no evidence of an intervention that leads to long term weight loss.
We know that the attempts at weight loss leads to weight cycling - which is known to impact on physical health. Increases the risk of disordered eating, eating disorders and poor mental health. Reinforces the weight bias upheld in our cultural system and puts the onus of health on the individual and doesn't acknowledge the social factors that impact health.
So, how can anyone ethically recommend weight loss?
Thinking about social factors that influences health; less than 25% of our overall health is determined by behavioral factors including diet, exercise, smoking, and alcohol (2). Our health is impacted by genes and biology, social cultural characteristics and (access) to medical care.
So what can we control?
When we look at the data - at what we have control over that decreases our risk of illness and death.
- Moderate alcohol
- Smoking
- Eating plant foods ( fruit and vegetables - regardless of what else you are eating.
- Movement and activity ( something that you enjoy and is sustainable and probably doesn't need to be as much as you think)
- Social connectedness.
So, it's not your fault. There is nothing wrong with your body. I am sorry you have experienced bias and poorly informed health care.
So what do you do?
How do you navigate interactions in the health care realm?
Be well informed
Reading, listening and learning about the harms of diet culture and weight centric health care.
Learn about weight inclusive affirming options for care and find practitioners that identify as weight inclusive.
Weight inclusive Health Australia has a list of practitioners
Association for size diversity and health professional list
Know that weight inclusive, body inclusive, social justice oriented, non diet, HAES aligned practitioners are who you are looking for. (try googling the terms above).
Ask for recommendations from peers who you identify from or if you find one typ of practitioner who fits the bill ( say a dietitian) but you need another type of practitioner ( say a physio) - Email and ask! It's a small community who appreciate how hard navigating the system can be!
You may not have any disordered eating or eating disorder history or currently - but a tip - eating disorder specialist practitioners who identify as being weight inclusive, non diet will be great support and will also support general health.
Learn from the lived experience. And fill your Social Media feeds with people that look like you! .
Nicola Salmon (fat positive fertility)
I am being a bit lazy ( and running out of time - so see links to others lists of content creators!! )
See below options for books, content creators, podcasts and more.
Please note these resources are due for an update and we would LOVE suggestions from you to add! And Yes, these are eating disorder focused resources, and I don't in any way think that size is any sort of indicator of disordered eating - the resources include a wide range of resources and my ED work involves so much work around naming and exploring anti fat bias they all ended up mixed together!
Resources for supporting children and teenagers
Gender diverse/ Trans and disordered eating resources
Podcasts
She’s all Fat and check out She’s all Fat Extensive Resource list
Empirical Evidence - See reference list below
A Resource to Share with health care Practitioners!
Find your community and supports
FB groups:
-Curvy AU
-Lacey Jade
-Fat Yoga
-Plus size buy swap sell communities
National association to advance fat acceptance
How to build fat positive community (US based)
Association for size diversity and health
Medical Students for size inclusivity
Practical tools to advocate for yourself:
Know that once you have one weight inclusive practitioner on your health care team they will help advocate for you, if you would like, with your other health care practitioners.
To save me re creating the wheel - insert her a wonderful article written by my good friend Nina Mills:
How to advocate for weight inclusive healthcare
HAES Health sheets- links to printable self advocacy cards to use with health providers
And Ragen Chastain who is just an amazing human and advocate in this space has some amazing resources.
Cards to use at the doctors office
Helpful phrases at the doctors office
Ragen Chastain has a collection of video workshops that are informative and empowering.
And Finally,
I don't expect all of the harm to be healed for listening to me introduce another way of looking at health for 30 mins. Take time to process any feelings that are coming up.
You may still have feelings about wanting to change your body and That is ok. There is no judgment here. Just compassion for trying to live in a fatphobic culture. It is ok to hold the incongruence of trying to move towards self compassion, supporting yourself without a focus on changing your body and having thoughts of body change.
How could you not feel that way? You are a good learner and have internalized the messages around you.
Today I offer you an alternative way to think about things. I offer you information so that you have truly informed consent so that you can be fully informed in making decisions for your own body. I support your agency and I support full body autonomy.
References:
From slide:
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- Sutin AR, Stephan y, Terraccioano A. Weight Discrimination and Risk of mortality. Psychol sci.2015 Nov: 26 (11): 1803-11.
- Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319-326. doi:10.1111/obr.12266
- Roberts, K. J., Polfuss, M. L., Marston, E. C., & Davis, R. L. (2021). Experiences of weight stigma in adolescents
- with severe obesity and their families. Journal of Advanced Nursing, 77, 4184– 4194.
- https://doi.org/10.1111/jan.15012
- Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to
- health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.
- doi:10.1155/2014/983495
- Bacon, L., & Aphramor, L. (2011). Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal, 10(1), 9. https://doi.org/10.1186/1475-2891-10-9
- Forhan, M., & Salas, X. R. (2013). Inequities in healthcare: A review of bias and discrimination in obesity treatment. Canadian Journal of Diabetes, 37(3), 205–209. https://doi.org/10.1016/j.jcjd.2013.03.362
- Fothergill, E., Guo, J., Howard, L., Kerns, J. C., Knuth, N. D., Brychta, R., Chen, K. Y., Skarulis, M. C., Walter, M., Walter, P. J., & Hall, K. D. (2016). Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity (Silver Spring, Md.), 24(8), 1612–1619. https://doi.org/10.1002/oby.21538
- Guidi, J., Lucente, M., Sonino, N., & Fava, G. A. (2021). Allostatic Load and Its Impact on Health: A Systematic Review. Psychotherapy and Psychosomatics, 90(1), 11–27. https://doi.org/10.1159/000510696
- Hunger, J. M., Smith, J. P., & Tomiyama, A. J. (2020). An Evidence-Based Rationale for Adopting Weight-Inclusive Health Policy. Social Issues and Policy Review, 14(1), 73–107. https://doi.org/10.1111/sipr.12062
- Leong, S. L., Gray, A., Haszard, J., & Horwath, C. (2016). Weight-Control Methods, 3-Year Weight Change, and Eating Behaviors: A Prospective Nationwide Study of Middle-Aged New Zealand Women. Journal of the Academy of Nutrition and Dietetics, 116(8), 1276–1284. https://doi.org/10.1016/j.jand.2016.02.021
- Mensinger, J. L., Tylka, T. L., & Calamari, M. E. (2018). Mechanisms underlying weight status and healthcare avoidance in women: A study of weight stigma, body-related shame and guilt, and healthcare stress. Body Image, 25, 139–147. https://doi.org/10.1016/j.bodyim.2018.03.001
- Puhl, R. M., Lessard, L. M., Larson, N., Eisenberg, M. E., & Neumark-Stzainer, D. (2020). Weight Stigma as a Predictor of Distress and Maladaptive Eating Behaviors During COVID-19: Longitudinal Findings From the EAT Study. Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine, 54(10), 738–746. https://doi.org/10.1093/abm/kaaa077
- Rothblum, E. (2018). Slim Chance for Permanent Weight Loss. Archives of Scientific Psychology, 6, 63–69. https://doi.org/10.1037/arc0000043
- Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16(1), 123. https://doi.org/10.1186/s12916-018-1116-5