In the weeks since my HuffPost Highline feature on fat-shaming came out, I’ve been inundated with readers’ stories of how weight stigma affects their daily lives.
One reader told me he rarely gets overtly bullied by strangers, but their unsolicited diet advice feels even worse. Another said she leaves the room when her colleagues start talking about their new diets, because it’s only a matter of time before a woman smaller than her describes herself as “huge.” These stories of interpersonal discomfort permeate workplace and social settings, and can have serious, even deadly consequences. In perhaps the most alarming story to hit my inbox, a reader said her doctor refused to give her an MRI after she complained of chest pains, telling her to lose weight instead. Years later, when she finally talked him into giving her the test, he found a 12-pound tumor in her chest that required surgery to remove.
These personal stories, in aggregate, match a growing body of research showing that fat stigma is severe, pervasive ― and utterly overlooked by America’s public health institutions.
In an effort to circle back to some of the findings I didn’t get to include in the article, I asked Patrick Corrigan, editor of the journal Stigma and Health and author of The Stigma Effect, to help explain them. Corrigan has been working on discrimination-related issues for more than 20 years and has developed a program, “Honest, Open, Proud,” that helps members of minority groups resist and cope with stigma. He told me what’s unique about fat-shaming compared to other forms of discrimination, when to confront it and why everything we’re doing to fight it isn’t working.
How do fat people differ from other minorities as far as stigma is concerned?
In stigma research we often talk about “visible” minorities, like ethnic groups, and “invisible” minorities, like people with mental illness or living with HIV. Visible minorities have to navigate a world that sees them and makes judgments instantly. Invisible minorities have to determine how and whether they want to disclose their status.
What’s interesting about fat people is that they’re a little bit of both. People see you and make judgments, but you also have to disclose your wants and needs and your individuality. What you’re demanding is equality and the recognition that bigotry is interfering with that.
As a gay guy, it sounds to me like you’re talking about a form of coming out, that moment when you choose between “I’m gonna bring this up now” and “I’ll let this one slide.” Why is it good for people to tell others what they need?
The first reason is that keeping secrets is terrible for you. We know this from the gay community and from people with mental illness. Even people who get negative reactions after they choose to come out report they they’re glad they disclosed in the long term.
For fat people, of course [coming out] looks different. There may be practical things they’re afraid to bring up, like the ways a joke is hurting them or a physical space that’s not designed for them. Or maybe they’re just tired of tiptoeing around their weight all the time and want to talk about it openly.
Another reason for disclosure is that, at the broader level, it helps reduce societal discrimination. We know that weight stigma is pervasive, and anything you can do to talk about it with your family or friends can help turn that tide. The more people who do that, the better.
One thing I can’t get over is that weight stigma appears to be getting worse, even as more people can be defined as fat.
The real significance of the term “minority” isn’t about numbers, it’s about power. Another huge group that still faces discrimination is women. Depending on how you count, they’re about 52 percent of the population. Or older Americans ― we’re all going to end up there, and yet the elderly are discarded in our society. So to me, a “minority” isn’t what we think of statistically. It’s just a group that’s seen as different or outside of the norm, and we’re trained to think that’s bad.
One of most stressful things about stigma, it seems to me, is the ambiguity. Was that waiter rude to me because I’m fat? Or is he rude to all his customers? You go back and forth being angry and then asking if you have a right to be angry. What do you tell people trying to figure out if what they’re experiencing is actually stigma?
Nobody gets it right 100 percent of the time. A huge component of resisting stigma is replacing the feeling of being unempowered with a feeling of being empowered. Prejudice and discrimination rob you of opportunities. Employers take away jobs, landlords won’t give you a place to live, health care providers don’t offer appropriate standards of care. When you push back against that, when you speak for yourself, you’re taking some of that power back. Standing up won’t solve the stigma in that interaction, but it gives you a sense of control.
That’s why it’s important to find communities where you can talk about these experiences. You have to give yourself permission to get it wrong once in a while. A community is where you can have these debates without anyone questioning your right to them. It’s hard work to constantly be explaining basic fundamental issues to people.
What do we know about when people should confront discrimination when it’s happening?
I used to be against confrontation. The idea was, if you’re a minority and you start pushing back against discrimination, you’re going to entrench those discriminatory beliefs. But based on research we’ve seen in the African-American community, we’ve learned that confrontation that’s empathic and educational really can change stigma.
The other interesting thing we’ve found is that, for example, if a white bystander sees someone say “All black people are lazy,” and he jumps in to say “No they’re not,” he has a much bigger impact on a white person than the black person does.
That sounds like an argument for allyship, that thin people should start standing up for fat people a lot more.
It’s one of the many reasons for allies: You’re limiting the number of spaces where someone can say derogatory things.
What else do we know about reducing stigma at the societal level?
We know the most about what doesn’t work. Education is ineffective, for example. Explaining to people all the genetic and hormonal contributors to obesity doesn’t change their attitudes.
We also know word games don’t work. In Asia, they’ve tried renaming schizophrenia to reduce the stigma, and it’s had no impact on the public. People say, “I don’t care what you call it, they’re all just nuts.” Those debates also lead to word policing. You call it one thing and I call it another thing, and now we’re arguing about the vocabulary, but we’re not dealing with any of the underlying assumptions and finding out where we truly agree or disagree. It’s a huge waste of time.
If efforts at the institutional level don’t work, do we have to do this individually?
The way we reduce stigma is interacting as peers with lived experience. The more interactive, the better. Meeting someone who doesn’t fit the stereotype and getting to know them well is crucial. I need to be close enough to a fat person to know that they play piano or go hiking or are grumpy on Mondays or whatever else I can add to that one characteristic. Media representation can help with this, but it’s the personal relationships that matter.
For fat people, this is harder because we have this whole zeitgeist around thinness and health. We have growing positive media representations, but they’re drowned out by the negative representation that being thin is imperative and that any of us, if we’re weak enough, could become a fat person. That’s one of those fears that has to be confronted person-to-person.
Which, of course, is even more work for fat people.
One of the tragedies of stigma is that it’s always the people most victimized by it who have to do the work of solving it. Even though it was never their problem to begin with.
5 Weeks to Your Best Body Ever: What to Eat
Does the CICO Diet Work for Weight Loss?
Take a deep-dive into the weight-loss forums on Reddit and you’re bound to come across the CICO diet.
One user who had been following CICO for two months and shed 20 pounds wrote, “For years I actually thought that [losing weight] required vigorous exercise, and eating nothing but tilapia, broccoli, and spinach. How wrong I was.”
In a separate thread, another user shared, “CICO will work regardless of what you’re eating. Junk food, healthy food, fancy food, cheap food. It doesn’t matter. CICO is essentially the only thing that matters when it comes to weight loss.”
But many experts have a different take on the eating strategy, and argue that CICO is just another name for a weight-loss myth that refuses to die.
So what is the CICO diet?
The acronym stands for “calories in, calories out”; and the underlying theory—which is by no means a new concept—is that to lose weight, you simply need to consume fewer calories than you expend each day on physical activity and vital functions (such as breathing and keeping warm). Proponents of CICO argue that it doesn’t necessarily matter what you eat, as long as you create a daily calorie deficit.
“At the core of it, it’s true that calories will rule things when it comes to weight loss,” says Dawn Jackson Blatner, RDN, author of The Superfood Swap. “If you’re eating just a ton, you’re not aware of calories, you will not be successful. That is true in the most crude, raw possible way.” But, she adds, calorie counting is only a tiny piece of a much bigger picture.
What CICO gets wrong
The problem with the CICO mentality is that it reduces weight loss to a calorie equation, when not all calories are created equal.
“We now know that the quality of the calories you consume—as well as the macronutrient balance and timing—all impact metabolism, satiety, and how your body utilizes calories,” explains Cynthia Sass, MPH, RD, Health‘s contributing nutrition editor. For example, 300 calories from a blueberry muffin made with refined flour and sugar does not affect your body the same way that 300 calories from cooked oats topped with almonds and blueberries do. “[CICO] is an outdated way of thinking,” Sass says.
You also have to consider how food choices affect your body beyond weight loss. “Eating all junk, but keeping it low-calorie, will still wreak havoc on things like your skin, your mood, your gastrointestinal functions,” Blatner says.
Mira Ilic, a clinical dietitian at the Cleveland Clinic, adds that certain macronutrients are important for things like tissue repair, and muscle recovery and growth. “If you’re doing strength training and other physical activity as part of your healthy routine—which also boosts your metabolism and helps with weight loss—you’re doing yourself a disservice by not thinking about the food you’re putting on your plate,” she says.
So can you lose weight just by keeping CICO in mind? “Sure, it’s possible,” Ilic says. “But would I recommend this to my patients? Definitely not.”
Sass adds that she has seen clients lose weight after increasing their total calorie intake—or break through a weight-loss plateau by altering the quality, balance, or timing of their calories, without reducing the total amount. To sum up: “It’s not as simple as a math equation,” she says.
A better way to watch your calories
For the average woman who wants to lose weight, Blatner suggests aiming to consume roughly 1,500 calories a day: “That number might be a little bit up or down, depending on whether you’re taller or shorter, or how much you exercise,” she explains, “but 1,500 calories is a great starting point.”
However, instead of tallying up the calories from every single food you eat, Blatner recommends practicing “calorie consciousness.” Look at your plate and ask yourself, Do I have a smart carb, protein, healthy fat, and vegetables? Then ask yourself, Do the portions of each look reasonable? And do vegetables take up the majority of the plate?
“If you look at your plate and you have what you can guesstimate is a half-cup of a grain, that’s going to be roughly 150 calories; if you see a reasonably sized piece of protein, it’s likely about 3 ounces, or about 150 calories,” Blatner says. “And if you see a lot of vegetables, topped with just a little bit of fat, like a drizzle of olive oil, you’re probably adding up to about a 400 to 450 calorie meal.” Developing this kind of calorie awareness can help you get a good balance of nutrients to nourish your body, while still staying on track to lose weight that stays off.
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Supplements May Have Hidden, Unapproved Drugs
More than half of U.S. adults take dietary supplements, a category of products that include over-the-counter vitamins, minerals, botanicals, amino acids, and enzymes. But the supplement industry is only loosely regulated by the Food and Drug Administration (FDA), and a new study is shedding light on just how many of these products contain unapproved and potentially dangerous prescription-strength drugs.
Even though the FDA only inspects a small percentage of the supplements sold in the U.S. every year, the agency issued warnings about 776 different products that contained “undeclared, unapproved pharmaceutical ingredients” between 2007 and 2016, according to the study published this week in JAMA Network Open.
Experts have been warning about these problems in the pharmaceutical industry for years, but this is the first time FDA warnings have been quantified to show the extent of the problem.
More than 98% of the FDA’s warnings over this period pertained to supplements marketed for sexual enhancement, weight loss, or muscle building. Most commonly, the FDA found traces of the drugs sildenafil (the generic name for Viagra); sibutramine (a weight-loss drug that was taken off the market after it was linked to heart attacks and strokes); and synthetic steroids or steroid-like ingredients.
Other hidden drugs include antidepressants, laxatives, and stimulants. Some of those drugs have not been approved—or have been banned—by the FDA, and have been linked to serious side effects including suicidal thoughts, abnormal bleeding, and seizures.
In addition to those top three categories, the investigation also found unapproved ingredients in 14 supplements marketed for joint pain, muscle pain, osteoporosis, bone cancer, sleep issues, gout, or prostate health.
Overall, the FDA sent warnings to 146 different supplement companies. More than 150 of the products cited in these warnings (about 20%) contained more than one unapproved ingredient, and 28 of them were cited in two or three warnings more than six months apart. In other words, even after these companies were warned once, they continued selling adulterated products—often with new unapproved substances detected the second or third time around.
The study authors concluded that the drugs found in dietary supplements “have the potential to cause serious adverse health effects,” either from accidental misuse, overuse, or interaction with other medications, supplements, or existing health conditions. They also point out that hidden pharmaceutical ingredients may be one reason why supplement use is associated with 23,000 emergency department visits and 2,000 hospitalizations in the United States each year.
The study also shows that the number of tainted supplements reported by the FDA has increased over the years, and that they include both products purchased via international mail shipments as well as those for sale in the United States. (Just today, a weight-loss supplement was recalled due to detection of a hidden drug.) “Adulteration with active pharmaceutical ingredients does not happen by accident,” the authors wrote in their paper, “and poses a serious public health risk as consumers unknowingly ingest these drugs.”
Pieter Cohen, MD, assistant professor of medicine at Harvard Medical School, wrote an editorial that accompanies the new study. The number of adulterated products highlighted in this study was “no surprise at all,” he tells Health.
“We’ve known for years that companies have been putting drugs into supplements, and we thought there might be 100 or 200 of those kinds of products,” he says. “As time has gone by, every year more and more products have been seen.”
Dr. Cohen says the new study also highlights just how few of these products were ultimately recalled by the FDA. Even if they were, it may not have made much of a difference: His own research shows that following FDA recalls, supplements with unapproved ingredients are often still available for purchase, and consumers remain unaware of their potential dangers.
The U.S. government isn’t currently doing enough to guarantee supplement safety, Cohen wrote in his editorial, and Congress should reform the Dietary Supplement Health and Education Act of 1994 to require stricter testing and enforcement policies.
In the meantime, he says, it’s largely up to consumers to be informed about the potential risks and benefits of supplements. He agrees that products marketed for sexual enhancement, weight loss, and muscle building pose the greatest risk in terms of hidden drug ingredients. Supplements used for more general health and wellness (like multivitamins or fish-oil capsules, for example) are less likely to contain dangerous drugs, he says—but that doesn’t mean they don’t have their own problems with inconsistent and misleading ingredients.
“They might not be accurately labeled in terms of the dosage you’re getting, or the labels might be misrepresenting the health benefits,” he says. Dr. Cohen says he regularly recommends vitamins and minerals to his patients who have (or are at risk of) deficiencies, but—with the exception of multivitamins and calcium/vitamin D supplements—he tells them to look for single-ingredient products.
“If your doctor tells you to take iron, look for a product that’s just iron,” he says. “If you decide to take black cohosh, look for something that’s just labeled black cohosh—not a mix of ingredients.” He also recommends staying away from supplements that claim to have specific health benefits, since those claims don’t have to be backed up by research.
That’s one of the most important things to understand about supplements, he says. “When you buy a product that says it will help you lose weight or improve your workout, there is no requirement that there’s any evidence in humans that it will actually work,” he says. “That’s where consumers have to be wise about their choices, and should consult with their doctor about what they really need.”
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