Fat is a Feminist Issue and a Health Issue — How Can Women’s Health Advocates Help?

By Ninia Baehr, RN

I ask myself this question every day. As a public health professional, I manage a nutrition and physical activity program to prevent obesity in Montana. As a feminist, I desire women’s freedom from oppression – including what author Kim Chernin called the “tyranny of slenderness.”

Fat is a feminist issue. In Montana in 2009, boys were more likely than girls to be overweight or obese, but they were less likely to believe that they were overweight – even when they were.(1) Although only 16.9% of girls were above a healthy weight, 33.4% thought they were “slightly or very overweight,” and 58.4% were trying to lose weight.(1) Most girls reported that they were trying to lose weight even though, from a health standpoint, most of them didn’t need to. National data from 2007 show that girls are more than twice as likely to go for 24 hours or more without eating than boys are, and nearly three times more likely to vomit or take laxatives in order to lose weight and/or avoid gaining weight.(2) Although the extent to which thinness is seen as a desirable quality varies among ethnic and cultural groups, on average, U.S. society’s emphasis on slenderness impacts girls in a disproportionate and unhealthy way.

Fat is also a health issue. Since the 1950s, scientists have been researching the ways in which obesity leads to illness. We now know that fat cells are not passive storage compartments, but actually manufacture many hormones; some peptides made by fat can create changes in a person’s immune function. In particular, the pathway from obesity to insulin resistance is of intense interest to the public health field, since insulin resistance is the first metabolic problem that appears in many diseases, including type 2 diabetes and polycystic ovary disease.

Most scientists in the Division of Nutrition, Physical Activity and Obesity at the US Centers for Disease Control and Prevention (CDC), agree that excess body fat is an independent risk factor for disease and premature death. Regardless of one’s diet and level of physical activity, the risk of type 2 diabetes increases at a BMI of 25, and escalates as BMI increases. The connections between increasing BMI and health risks also exist for cardiovascular disease, certain cancers (including endometrial cancer and post-menopausal breast cancer), and other health problems. While preventing obesity is the best way to reduce the rates of a host of other diseases, it will be some time before the connections between obesity to specific diseases will be fully understood.

******* The Body Mass Index (BMI) is a weight/height calculation used to approximate body fat content. According to the National Institutes of Health (NIH), a person with a BMI of 18.5–24.9 is considered “healthy,” while a person with a BMI of 25–29.9 is considered to be “overweight”, and someone with a BMI equal to or greater than 30 is “obese.” (To learn more about BMI or to calculate your BMI go to http://www.cdc.gov/healthyweight/assessing/bmi.) *******

So excess fat is not healthy. And obsessing about thinness is not healthy. Some health advocates believe that, although weight is important, it should rarely be mentioned, because doing so may promote negative body images, lower self-esteem, and foster eating disorders. These advocates prefer to focus on promoting healthy eating and increasing the individual’s physical activity.

How do we craft public health messages about healthy weight and fitness that help women and girls of all sizes and cultures? There is no one-size-fits-all answer. Whether or not a woman focuses on her weight, however, engaging in healthy eating and appropriate physical activity can promote health at any size. (The US Dept. of Agriculture offers a fun, free page for tracking and analyzing one’s diet and activity levels at: http://www.mypyramid.gov.)

Some concepts to keep in mind are:

• Depending on one’s culture, the weight that is considered sexy and desirable might be below — or above — what the BMI chart specifies as “healthy”. We need to bring “sexy/desirable” in line with “healthy”. There is much to learn from anti-smoking advocates, who have made enormous progress in changing social norms and behaviors, and improving public health, by shifting cultural perceptions of tobacco use from “cool” to “unacceptable” among many segments of society. These activists engaged groups that have been targeted by tobacco marketers (e.g., youth, people of color) in their successful efforts to develop social marketing messages and counter-advertising campaigns to change the way that smoking is viewed. The same efforts could be applied to weight and appearance.

• Having a BMI in the “healthy” range doesn’t automatically mean that a person is healthy. A person’s healthy weight may, or may not, be the result of a healthy lifestyle. This is particularly true for someone whose weight is impacted by harmful behaviors such as smoking, binging/purging, or using drugs — all of which lower one’s weight and BMI in dangerous ways.

• Being “overweight” may, or may not, mean prioritizing weight loss as a goal. NIH’s guidelines recommend weight loss for women whose BMI is over 25 and who have a waist circumference of more than 35 inches, or who have a BMI over 25 and two or more other risk factors (such as hypertension, dyslipidemia, elevated blood glucose) at a rate of 1-2 pounds per week. The NIH recommends weight loss be achieved by consuming a balanced diet with fewer calories and, ideally, moving more. Otherwise, the guidelines call for maintaining weight at or below the present level, explaining that these overweight patient’s “ health risk, while higher than that of a person with a BMI < 25, is only moderately increased.”(3)

• An overweight individual’s biggest risk may be for further weight gain, since most of us add pounds as we age. Over time, this can add up to a significant amount of weight. The more obese a person is, the more likely she is to face health problems and possibly to die prematurely, so people in the “obese” ranges should talk with their health care provider to assess their risks and set appropriate health goals.

• For some people, losing enough weight to move into the “healthy” BMI range is just not realistic. It’s important to remember that losing even 10% of one’s body weight can produce health benefits for those who are overweight. The CDC recommends six behaviors that may help people achieve or maintain a healthy weight, and that have positive health effects independent of weight.(4) They are:

1. Eating more fruits and vegetables;
2. Increasing physical activity;
3. Drinking fewer sugar-sweetened beverages;
4. Decreasing time spent watching TV and using computers (including hand-held devices);
5. Eating fewer energy-dense foods; and
6. Increasing breastfeeding initiation, duration, and exclusivity.

Easier said than done, especially in today’s society where high-fat foods are in abundance and many individuals lack the time and/or money that can facilitate healthy lifestyles. But, the effort is well worth making. The personal (and financial) costs of obesity-related illnesses are enormous and growing. In the last four decades, childhood obesity has tripled, and most U.S. adults now exceed the BMI’s “healthy” weight. Diabetes diagnoses are soaring, and health experts wonder if this generation of children will be the first to live shorter lives than their parents.

Recent increases in levels of obesity were not caused by changes in our genes. They are, rather, a symptom of how our changing social and physical environments do – or don’t – support our ability to engage in healthy behaviors, especially in lower-income and rural communities. As a result of policies as far-reaching as the Federal Farm Bill (which subsidizes energy-dense foods such as high fructose corn syrup more heavily than low-energy/high-nutrient foods such as fruits and vegetables) or as local as whether your neighborhood’s kindergarten includes daily physical activity, we eat more and move less. Focusing on weight as an individual responsibility has not worked at the population level. Broader changes are called for.

Within almost every institution, there are ways to support healthy eating and active living that will benefit the nation’s health. Schools can remove soda and candy from vending machines. Childcare providers can limit the time spent watching television and increase time spent being active. Government officials can require restaurants to post calorie and other nutritional information. County commissioners can adopt “complete streets” policies that promote walking and biking. Employers can institute physical activity breaks. Congregations can serve healthy options at their gatherings. Grocers can remove candy from the checkout lanes.

The list of possibilities is endless. Advocates seeking these changes may or may not choose to mention weight. Either way, these changes will lead to healthier eating and more physical activity. As people move more and eat better, they may or may not lose weight, but they will certainly enjoy better health.

References

1. Montana Office of Public Instruction. Youth Risk Behavior Survey. 2009 Montana Youth Risk Behavior Survey High School results page. Available at http://www.opi.state.mt.us/. Accessed October 21, 2009.
2. Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Surveillance System. 2007 National Youth Risk Behavior Survey Overview, Atlanta: CDC, no date. Available online at: http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbs07_us_overview.pdf. Accessed October 21, 2009. This is an on-line report. I don’t see any publication date. The site was last modified on September 22, 2009.
3. National Institutes of Health (NIH). Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report (NIH Publication No. 98-4083). Bethesda MD: NIH, 1998, Available at http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf. Accessed October 23, 2009. I don’t know what format you would use but this was NIH Publication No. 98-4083, September 1998. As for location, they don’t say anything, but the NIH is in Bethesda, MD.
4. Centers for Disease Control and Prevention (CDC). Overweight and Obesity. State-Based programs page. No date. Available at http://www.cdc.gov/obesity/stateprograms/index.html. Accessed 1/13/10. Ninia Baehr, RN, is a NWHN Board member and the Program Director for the Montana Nutrition and Physical Activity Program to Prevent Ob