"Healthcare for Fat People is Based on the Premise that it's Acceptable to Kill Us to Make Us Thin."

Hello, and welcome to another audio version of Burnt Toast!Today, I am so so thrilled to be chatting with Ragen Chastain, who is a professional speaker and writer, trained researcher, and co-author of The HAES Health Sheets. Ragen is also a multi-certified health and fitness professional, and a queer fat woman. Ragen, thank you so much for being here!RagenThanks for having me. I love your work so much. I’m giddy as a school girl! VirginiaRagen and I have been in each other’s orbits for a very long time. We were talking about something that we worked on where the website doesn’t even exist anymore. RagenVirginia gave me my very first paid freelance work in this space. She was leaving a platform and recommended me, so she’s been supporting my work, and just be an awesome leader in her own right, for a long time.VirginiaThat’s very lovely of you to say. When I first found your work in the mid-2000s you were extremely patient with my learning curve. For folks who don’t know, Ragen created the beloved fat activism blog Dances With Fat. She is now writing a Substack called Weight and Healthcare. So let’s start with that, Ragen. You have this amazing blog, you’ve been doing it forever, you have, I don’t even know, 1000 posts there. What inspired you to also say I need a newsletter?RagenI started Dances With Fat in 2009. There are a little over 1800 posts on there now. In the same year, I started doing talks for healthcare professionals around working with higher weight patients: Best practices, weight, stigma, weight science, health care. I wrote about that on Dances With Fat, but recently I’ve started to do more of that work and to do it at a higher level, and when I’m talking with a VP of a major healthcare group, sending them to Dances with Fat is not ideal, even though I’m very proud of that blog. It’s not quite the the thing that they’re looking for. I knew about Substack and I knew about Burnt Toast, so I reached out to Virginia, who helped give me a sense of how Substack worked. It seemed like a really good platform for this type of work. I got a little logo made from Toni Tails, a little researcher Ragen icon, and then put together some of the posts from Dances With Fat that were classics. Now I’m going to be writing new stuff, as well. VirginiaI sort of love the idea of healthcare CEOs going to Dances With Fat. It gives me a lot of joy. But it’s a smart activism strategy to have it all in one place. We’re recording this, I should say, right after your first launch week. So you’ve been putting up a lot of pieces that I will be linking to forever. You are covering these really fundamental questions that can be kind of exasperating, like, “This question is coming up again?” But for people who are new to challenging this huge paradigm, you do have to start with these fundamental questions and grapple with stuff. One question people often ask is, “Isn’t obesity a disease?” So, walk us through it, Ragen.RagenThis is something that has been coming up more and more, this idea that just existing in a fat body is a chronic lifelong health condition for which people should get treatment. This has been pushed for a while now by people who sell dangerous and expensive “treatments” for weight loss. I first started seeing it happening in the most insidious way, with organizations that claim to be advocacy organizations—like the Obesity Action Coalition—but that are actually well-funded by diet drug manufacturers and weight loss surgery purveyors. For the diet drugs, for example, their product doesn’t work long term. People gain the weight back as soon as they go off the drugs. So the drug companies say, “Oh, well, it’s a chronic and lifelong condition, then we can just keep them on the drugs forever,” which is exactly what Novo Nordisk is doing, and why they’re pushing this so hard right now. It also expands their market to every fat person alive. That helps them with what is their golden goose, which is insurance coverage. They can’t get insurance to cover these things because they’re expensive and because they don’t work. So by saying, “Oh, well, it’s because you haven’t let us do it long enough,” they are expanding their market. But that it doesn’t make any sense, and here’s why: Thin people get all the same health issues that fat people do. So, being thin can neither be a sure preventative nor a sure cure. That’s just not how that works. This idea that if fat people experience a health problem more often than thin people, then obviously their body size is the problem and making them thinner is the solution is not a science-based conclusion. We have to look at what are the confounding variables that could be causing this? And in this case, weight cycling, weight stigma, and healthcare inequalities are well researched for their negative impacts on fat people’s health. And this idea of fat being a chronic condition increases those three things. I want to be super clear, there is no shame in having a health condition. There is no shame in seeking treatment. The shame here is trying to make simply existing a pathologized condition for which people can sell dangerous treatments that risk people’s lives for an outcome that isn’t shown to be positive. It’s actually shown to be harmful a lot of the time. So, the AMA studied this. They had their Committee on Science of Public Health study whether or not being fat should be a disease and the committee came back and said no. And the AMA said, “Okay, well, thanks for your time, but we’re gonna go ahead and declare it a disease anyway.” VirginiaI just want people to really take that in. The American Medical Association’s committee that was asked to study that question, should we medicalize weight higher body weights, said no, the evidence does not support that. And the AMA said, Okay, so we’re gonna do it. RagenYeah, it’s a “let me just take a minute to bang my head on the desk and then I’ll complete this post that I’m writing” sort of situation.It’s important because this seems so science-y and medical-y, right? BMI is an equation and that’s math and math is science. We have these words like “obesity” that pathologize body size, and that can sound really legitimate, right? But then you start digging and learn that Body Mass Index is just a complicated ratio of weight and height that is racist in its origins. Sabrina String’s Fearing the Black Body and Da'Shaun Harrison’s Belly of the Beast are books I recommend to everyone to read about this and other racism and body size intersections. The term obesity comes from a Latin word meaning “to eat until fat.” This is not science. It’s a term that was created to pathologize bodies. It was invented for that purpose. The AMA saying, “Oh, yes, this is this constitutes a chronic health condition or disease,” sounds very science-y until you find out that the actual science had to be ignored to make that happen.VirginiaYes and this “chronic lifelong condition” we’re talking about, the treatments that they are pushing actually exacerbate the condition, because the condition is living with weight stigma, living with social inequities around health care, all of these other issues that these treatments further. Fat is not a chronic lifelong health condition.RagenIt really isn’t. It’s gotten out that intentional weight loss interventions fail the vast majority of the time. The majority of the time weight loss has the opposite of the intended effect, right? People gain back all of their weight and up to 66% of people gain back more than they lost. But the response wasn’t, “Hey, there’s a mountain of evidence that shows that there are better ways to support the health of fat people than trying to make them lose weight.” The suggestion was, “Well, then let’s do it harder, and more and more dangerously.” And that’s what we’re seeing with the pharmaceuticals. That’s what we’re seeing with the surgery. We’re getting healthcare for fat people based on the premise that it is acceptable to kill fat people in an effort to make them thin.VirginiaAnd yet they’re saying we need to get insurance coverage for these things, even though they don’t work. They frame that as an example of the stigma. They’re like, “Look, it’s so misunderstood that the insurance companies won’t even pay for these treatments that these people desperately need.” They don’t see the inherent disconnect there. RagenI’m going to say they aggressively don’t see the disconnect, possibly negligently, purposefully don’t see it. They’re saying, “We don’t want to stigmatize fat people, we just want to eradicate them from the earth and make sure no more ever exist.” That’s not an anti-stigma message. It’s a profitable one. One of the things that frustrates me is the way that they are co-opting the rhetoric of anti-weight stigma, which the fat liberation community has spent so long trying to get out there, and then using that to sell even more dangerous intentional weight loss methods. It is super gross.They are creating weight stigma and then selling their dangerous product as a “solution.” It’s this idea that if you don’t want to be oppressed, you should change yourself to suit your oppressors.VirginiaThat’s what I want my kids to learn: Make the bully like you better.RagenGive them your lunch money, and maybe they’ll stop beating you up! It’s not a perfect comparison, obviously, but as someone who is both queer and fat and who came out in the mid-90s in Texas, I see parallels between that and this idea of just doing whatever dangerous thing you need to do to make yourself straight, so that you don’t experience homophobia; this idea of changing yourself to move yourself out of the oppressed category, rather than fighting oppression. I spent years fighting my body on behalf of weight stigma. Weight stigma is real and weight stigma does real harm, including to me, but now I fight weight stigma on behalf of my body.VirginiaThat’s a really helpful framing. You took one for the team by taking on one of the most common and irritating troll comments around fat activism: That all these fat people are a drain on the system because they’re costing us so much money in terms of tax dollars in health care. This is an argument that hits me really personally, not around weight, but I have a daughter with a chronic heart condition. I wrote a piece for Slate about the fact that we had $3 million in medical bills before she turned three years old. That’s why universal health care is essential, to help families avoid destroying themselves financially to save their children. The number one troll response I got was: “She’s a drain on the system. Some kids aren’t meant to live.”RagenIn the piece I tackle that from two aspects: The reality and then if it were true that fat people are this drain on the system. The first thing I always do when somebody comes at me with this “my tax dollars” argument is I say, “Well, I want to see your yes/no tax list.” They say, “What yes/no tax list?” And I say, “Oh, the one that shows all the things your taxes pay for broken down into what you do and don’t want to pay for, and the interventions you’re involved in for everything you don’t want to pay for.” This isn’t about their tax dollars. This is about trying to find a justification for their fat bigotry. This is what they’ve arrived at that people sort of find acceptable. Like, “Oh, well, I’m paying for their health care.” But that’s what civilized societies do, right? I am paying for the health care of people who jumped out of helicopters wearing skis and people whose attempts to climb mountains are dramatically unsuccessful. I want to do that. Anytime you say, “Okay, this group of people who we can identify by sight is a drain on society and we should eradicate them to make things cheaper for everyone,” you have gone down a bad bad road. This is a straight up eugenics argument. We have to really recognize that. I find that people who want to say this about me don’t want other people to be doing it to them. Whether they are a raw foods vegan or a keto or paleo person, they believe that they’re right, and they are not interested in other points of view. This is where it really starts to break down. Who gets to decide for all of us? If somebody finds that, for example, a raw food vegan diet is the most healthy, do we all have to do that? VirginiaAnd do we all have to do that in order to access healthcare? What do we owe in order to access healthcare?RagenExactly. This is a really dangerous argument that’s being made by people flippantly, in many cases, just to justify discriminating against fat people, just to justify their weight bigotry. They don’t follow it to the end of where that goes. So that’s really dangerous. And also, fat people pay taxes, too. My taxes go to fund a government war on “obesity” that makes my life terrible and has negative impacts on my health. In general, this argument, when you scratch the surface even a little bit, just becomes a thin veil for fat bigotry that is unsupportable by any kind of evidence.VirginiaAnd ableism! It’s saying that the only people worthy of health care are people who are making virtuous choices that we approve of or who won the genetic lottery and don’t really need health care. What strikes me when it’s levied against fat folks is that it’s often because people are blaming people for their body size and assuming that it’s your lifestyle that led to this, as opposed to the fact that people just come in different body sizes. With something like my daughter, you can’t say, “The baby’s responsible for her heart condition, but we still don’t want to pay for it.” Either way, it becomes this ableist thing to say some lives are more valuable because they have this genetic luck. RagenThere are a lot of places where the intersections of ableism and healthism and fatphobia come together, and this is certainly one. One of the things that is also frustrating is that the idea of body size as a choice is obviously really problematic, but even if we believed that that was true, also a choice is playing sports, which cost billions of dollars in sports injuries every year that are completely unnecessary. Research shows that moderate walking gives us the health benefits that can come out of movement, so nobody needs to be playing sports.VirginiaI love this so much as someone who just hates sports.RagenI’m someone who loves sports and who does ridiculous fitness-y things. Just to be super clear, health and fitness, by any definition, is not an obligation, not a barometer of worthiness, not entirely within our control. There is this good fatty / bad fatty thing, so I always want to be clear that completing a marathon or having a Netflix marathon are morally equivalent activities. I’ve done both, so I can tell you for sure. So, it’s not about that, but I enjoy fitness. I’m also aware that when you go to a triathlon or when you watch the CrossFit Games and people have an exoskeleton of physio tape, that’s a lot of injuries that people don’t need to have in their lives, but they’re choosing that lifestyle. Shaq got knee surgery even though he for sure caused his knee problem and was going right back to the lifestyle that caused it. The NFL was created to risk people’s short and long term mental and physical health in the hopes that one day their team will score enough points to get a shiny piece of jewelry. You’re allowed to do that, but let’s not act like it prioritizes health because it doesn’t. This is a whole group of people purposefully not prioritizing their health and the average player is broke by two years out of the league. VirginiaAnother piece I love is where you break down why diets fail. A line that really jumped out to me, in your piece, is “the entire basis of prescribing weight loss for greater health is built on the decidedly unscientific premise that if we make fat people look like thin people, they will have the same health outcomes.” RagenWhen I did my original literature review of weight loss, looking for the best diet, I was still in diet culture, but my background is research methods and statistics and I’d never really researched this. I had been yo-yo dieting for years. I decided to read every study and break it down and find the best diet. What I found was that, as you said, there wasn’t a single study were more than a tiny fraction of people were succeeding at long term, significant weight loss. The thing that really blew me away was that there wasn’t a single study that showed that the people who were successful had better out health outcomes or similar health outcomes to thin people. That study doesn’t exist, in large part because there aren’t enough people who are successful to commission such a study.VirginiaIt’s hard to do research on unicorns.RagenThe National Weight Control Registry tried it, they’ve got 10,000 successes since 1994. There have been over a billion attempts, but okay. What they found were just some commonalities among outliers. 98% of the people who have lost 30 pounds and kept it off for a year ate breakfast. They don’t know how many of the other billion also ate breakfast. VirginiaA lot of us eat breakfast without successfully losing weight. RagenHad I turned in the study plan of the National Weight Control Registry research in my freshman year research methods class, the dean would have been telling me, “There are a lot of majors here and I think you should choose another one because you don’t understand this at a pretty basic level.” We know that cis male pattern baldness is highly correlated with cardiac incidents. So it would be like if they stopped there and said, “We have to get these people to grow hair” And when their initial attempts didn’t work, they were like, “We need more dangerous ways to grow hair! Drugs and surgeries and a war on baldness!” That is exactly what they did when it came to weight and health. They simply stopped and those who didn’t stop are getting ignored. Lucy Aphramor did an incredible paper about the validity of the research within dietetic articles. It’s a great piece and I recommend it for people who are trying to look into this. VirginiaI’m thinking of a doctor I saw when I was six months postpartum and my baby wasn’t sleeping through the night. The doctor was concerned about my weight. She was like, “Oh, well, I walked an hour a day when I had a newborn.” And I was like, “That’s nice for you, but I have a job and two children and I don’t have an hour to walk. If I had an hour to walk, I would sleep.” It’s just not realistic. A friend of mine was just telling me that she’s pursuing treatment for various medical conditions and the guy was like, “Intermittent fasting will solve all your problems.” And she’s like, “I am parenting and working full time, during a pandemic. I have two chronic conditions. Starvation is not a great way for me to go.” The way that diet and fatphobia show up in the healthy habits conversation feels really problematic to me. It ends up becoming another form of shame and stigma. What can we do, as patients, to advocate for ourselves in these conversations? RagenOne way to go is to try to bypass it. My magic question is, “What would you recommend to a thin person in this situation?” Often that bypasses some of the fatphobia and some of the recommending of healthy habits just because they believe if you did them, you would lose weight. I was at a regular physical with a new doctor and at the end he said, “I just need you to do something for me and it’s going to be so hard. So hard. But if you can do it, it is going to change your life.” And he said, “I just need you to start walking ten minutes a day.” And to his credit, ten minutes a day is reasonable! He didn’t say you have to walk an hour, like your doctor said. But I was training for my first marathon and I had done eighteen miles the night before. So I told him that and said, “I’d be glad to do ten minutes a day because I’m going to claw back a lot of time that way, but I don’t think it’s going to meet my goals at all.” And he said, “Look, you don’t have to lie about it if you’re not going to do it.” So one thing to always know is that this isn’t your fault. This shouldn’t be happening. You can’t make a doctor practice ethical, evidence-based medicine. I also teach ego management techniques—because I live in LA, I can fire a doctor a day, and I will, there there are tons of them around—but if someone lives in a rural area and there’s only one doctor, they have different options. So you can say things like, “oh, I’m actually already doing a weight loss diet, and I’ve lost some weight, but it hasn’t really helped.” This doesn’t have to be true, by the way. Then you say, “What would you do for a thin person? Let’s try that as well.” Like, “Sure, I’m gonna take this diet advice you’re giving me and I can’t wait to put food in baggies of certain caloric amounts. I’m super excited. But in the meantime my cousin had this and she was given this medication.” When a thin person gets an evidence based treatment for their symptoms and a fat person gets a diet, it delays them getting that evidence based treatment for who knows how long. Probably forever, because that diet isn’t gonna work. So, unless the doctor says, “Okay, this isn’t working, I’ll give you the treatment,” it can delay treatment forever. The person maybe doesn’t go back. This is just one of the ways that these healthcare inequalities impact fat people’s health. Just to be clear, don’t do the diet. And I also want to be clear that lying to your healthcare practitioner is not ideal. Ideally, you wouldn’t need to do that. The fact is that weight stigma in healthcare forces fat people to make some really difficult choices that we shouldn’t have to make. This is one of them. In the past when I needed care and was not been able to get it, I said, “I already lost 75 pounds. It hasn’t helped at all. What else is there? What else do you have?” That was, in that moment, effective. Suddenly I’m somebody who is compliant and deserves ethical, evidence-based care. But what they recommended was also recommendable ten minutes before, when I was just fat. Our choices are often not ideal.VirginiaIt’s frustrating because you are then stuck needing to play into that “good fatty” stereotype. But if that gets you the treatment you need and it’s a way to preserve your mental health through the shitty ordeal, then it’s worth doing.RagenA lot of privilege goes into this too. Not just good fatty privilege, but like as a white, cisgender, currently able-bodied, currently neurotypical person. For those with multiple marginalizations, for those who are higher weight, these solutions are less effective because of intersectional oppression and because of the greater oppression that higher weight people face. That’s a your-mileage-may-vary-due-to-oppression -situation.VirginiaThe HAES health sheet website that you’ve put together, is a phenomenal resource for folks. Ragen worked with Dr. Louise Metz and Tiana Dodson, who are amazing as well. They’ve put together this whole library of different health conditions and information on the weight inclusive approach to this health condition, as opposed to the weight-loss-centered approach that many doctors take. If you’re preparing for a medical encounter, this is a great place to go and prep yourself for what’s to come. So we’re gonna wrap up with our recommendation segment. It can be about a product anything and experience you’ve had recently so, Regan, what have you got for us?RagenI have for you Latoya Shauntay Snell’s Running Fat Chef podcast. Latoya Shauntay Snell is this incredible, Black, fat, disabled athlete and activist. She put together this podcast with different athletes talking about the intersections of weight stigma and fitness in the athletic world and how to overcome that. I love all of her work, and her podcast is incredible.VirginiaThat sounds phenomenal. I will definitely be subscribing and downloading immediately. That’s an awesome recommendation. Mine is a little more out of left field, given the whole context of our conversation, but very much in the field for the context of my life right now. It is a parenting book I’m finding very helpful called Why Is My Child in Charge? by Claire Lerner. If you have a preschooler or a toddler who is often trying to be in charge of your life this book is great. I am not a big fan of parenting writing, which is weird to say since I get labeled as parenting writer, but it’s true. Melinda Wenner Moyer, who’s a friend and parenting writer I love, actually loaned me her copy because I was texting her about various tantrums happening in the house. Lerner frames parenting as understanding that you cannot control your child’s behavior. So your job is not to persuade them to agree with every rule you make or to get them to change their minds about stuff, but actually to keep providing the framework they need to be loved and nurtured without needing to stay up an hour past bedtime and ruin your life.It actually applies to a lot, like what we were just talking about with doctors, you can’t change their minds either. It’s a useful message for going through life. I’m not here to change other people’s behavior. I’m just here to set my boundaries and set the framework I need to function. It’s been very helpful for me with a certain four year old at the moment. (Virginia Note: I finished the book after recording this episode and sadly, cannot recommend the chapter on mealtimes. But the rest is still great!)RagenI feel like I need to read it for my little Maltese. We named him after three drag queens and he acts like it. Don’t name your dog after three drag queens.VirginiaWe also have a dog whose behavior I cannot control, but I can control the framework. Alright Ragen, where can Burnt Toast fans find more of your work?RagenSo my newsletter is Weight and Health Care. You had mentioned the HAES Health Sheets and then Dances with Fat. I also do a monthly workshop and the one coming up is on dealing with fatphobia at the holidays. We will be talking a lot about how we can’t control their people’s behavior but we can control our reactions and boundary setting. If you go to Dances with Fat, you’ll also find all of my social media and past writing outside of the healthcare sphere. VirginiaAwesome. Ragen, thank you so much for doing this.Thank you all so much for listening to Burnt Toast! Burnt Toast transcripts and essays are edited and formatted by Corinne Fay, who runs @SellTradePlus, an Instagram account where you can buy and sell plus size clothing.The Burnt Toast logo is by Deanna Lowe. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe