Dear Health Care Provider

Dear Health Care Provider,

No, I am not “willing to reconsider” intuitive eating and Health At Every Size. And by your asking me that, I’m going to guess you don’t have much idea of what they are, so let’s start with a review.

Health At Every Size says that there is so much we can do to maximize health, and none of these have to do with a number on a scale. There’s no evidence that the majority of fat people can permanently become not-fat people, and lots of evidence that say that trying to make them be so is bad for their health. (I don’t care if you’re one of the 5% who could and did lose significant weight and keep it off for more than five years; I am one of the 95%, and I’m perfectly happy to be so, thanks.) So let’s work on the parts of health we can affect; let’s move with joy, and nourish with love, and address things like blood pressure and blood sugars and respiration as needed, rather than letting weight — so poorly correlated with health — dictate everything.

Intuitive eating, a related idea, says that when we listen to our bodies, they’re actually quite good at guiding our food choices. Intuitive eating helps us eat when we are hungry, and stop when we are full. It says to “Eat food. Stuff you like. As much as you want.” It acknowledges the first rule of nutrition (“Eat or die.”). It recognizes that there are more important things than optimal nutrition (no, really, there are), and tells us it’s ok to honor those as well.

These are not only healthy ways of thinking and living (so why would you want me to stop them?), I think they are the only ways for me to be healthy, body and soul, when it comes to food and weight. They are non-negotiable for me, and you need to accept that if we are to have a therapeutic relationship.

You say you might not be the provider for me if I’m not willing to let you do your job.

But here’s what you can do:

You can help my intuition be clearer. You can support my own trust in my body and its signals. You can ask about how well I feel I’ve been in tune with my intuition recently. You can query about whether I’ve had access to fresh, yummy foods recently, and you can offer assistance in increasing that access.

You can help me figure out whether there are any foods in particular that are adversely affecting my health; if there are, you can help me keep in touch with my intuition while replacing that food in my diet. You can help me see the abundance of what I am able to eat and enjoy and nourish myself with rather than feel deprived.

You can help me figure out ways to incorporate the movement I long for into my life. You can trust that I will do that as I am able. You can recognize that laziness is not what is keeping me away from the gym or the track — and you can ask about what is, if you are open to hearing the honest answers. You can offer to brainstorm solutions with me, or alternatives, or simply commiserate my factual, hopefully temporary, inability.

You can help monitor my vital stats: keep track of my blood pressure, and my heart rate, and my respiration, and all the gazillions of lab results you are sent when I visit the vampires. You can talk about what those say about my health, and offer suggestions to improve them, within the context of my life (see above).

You can make sure that there aren’t any obstacles in my way (other than, y’know, my life) to eating intuitively and living healthfully: you can optimize my thyroid replacement dose; you can help monitor my mood and stability; you can investigate other illnesses I might have; you can help me manage my anemia. You can help me get to a place where I have the energy and the body-trust to do my own work.

Saying that I will not “diet” and I will not seek to lose weight is not saying that I do not care about my health, and it is not saying I see you only as a med-dispensing unit. It is not saying anything except that I will not diet, and I will not seek to lose weight. You can still do so many things to earn your title as health care provider. The only thing you cannot do is harass me about my size.

I don’t see why my assertion of this boundary would possibly mean you cannot do your job — unless you see yourself exclusively as a diet pusher and weight loss promoter. No? We should be fine then.

Sincerely,

Arwyn

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32 Responses to Dear Health Care Provider

  1. Arwyn, you rock my world. this is fabulous. I am going to totally print it out baby and USE it.

  2. a nonny mouse

    Oh, wow. This…came at the PERFECT time for me, personally, odd it may seem. Reading this and the strength inside kind of gave my confidence a kick in the butt to get it started upwards. Thank you for being so wonderful. :)

  3. From your post, I don’t have the full picture of what your health care provider said or how she said it. Whatever it was, it obviously wasn’t appropriate and obviously didn’t resonate with you. Two big problems right there. While I cannot critique her specific words or approach specifically, since I don’t have the details, I can share what my doctor does.

    My doctor does weigh me. She looks at the trend in my weight (going up, going down, staying the same). She will note the trend (e.g. “I see you’ve gained 10 pounds since I saw you last) and will then ask questions (e.g. “Are you finding the opportunity to exercise regularly?”) and make remarks about other related health issues (e.g. “Your blood pressure is still at a healthy level, so that is a good sign”). I like that she looks at my weight not as the end goal, but more as one of several factors to consider in assessing my health and figuring out how she can help.

    • Annie — I actually wouldn’t mind weighing as part of an annual check up, necessarily (though I will not agree to it at every visit), and interestingly enough, he didn’t ask me to get on a scale at all. What he did do was look me over and say “I have concerns”, which, actually, feels far worse.

  4. This is awesome Arwyn. totally awesome.

  5. I’m really dreading finding a doctor soon for just about this reason. I’m on pregnancy #4 (two miscarriages) in three years so I’m noticeably heavier than my ‘ideal’ weight. I don’t ever shoot for a weight in the BMI range because it is just flat inappropriate for my body. I’m nervous because I have reached the conclusion that I will never diet again. Period. It is terrible for your body and I’m just not doing it. I’m kind of afraid of getting yelled at. It’s really pathetic that I worry about a doctor treating me badly because I don’t want to do something unhealthy.

    • I’m on pregnancy #6 in three years (4 miscarriages) and have the opposite problem; I lost TONS of weight I couldn’t afford, and don’t know if I can gain enough back in an adequate time frame. :(

      Good luck!

  6. Argh. This is my problem with many health care providers. I am someone who, due to the side-effects of one of these wonderful allopathic medications, was “underweight” for a little while (I am still on the skinny side, but that’s just the way I am). My doctor recommended I increase my caloric intake, which was okay with me, but when I asked what foods would be best in this regard, she suggested meal-in-a-can shakes.

    Okay. I do not “diet”, in that I don’t have a terribly prescriptive way of eating as it relates to my health or my weight. BUT I do limit the foods I eat on principle–not to lose or gain weight, but because I object to the industrial, capitalist, soulless and compassionless ways in which most supermarket food is produced. This is why I sort of take issue with parts of Michelle’s otherwise spot-on post, linked to above. I don’t see Michael Pollan’s primary objective as being everyone losing weight. He has always written about food from a greater ethical perspective. Twinkies are not bad because OMG THEY’LL MAKE YOU FAT!!!1!! Twinkies are still bad, though, because they represent everything that is wrong with our food industry. Same thing with McDonald’s food. Those foods don’t taste good naturally–they have been researched and doctored up and modified to no end in order to take advantage of our bodies’ intuition, with the sole priority of making as much money as possible for the corporations that sell them. In other words, I do love the way a lot of fast food tastes (at least at first). But I do not feel that “if it tastes good, it is good”, because that food has been made to taste good artificially, by people who don’t give a damn about me or any aspect of my well-being. I am not overly compulsive about food rules, and if I’m hungry and the only thing available is processed crap, I’ll still eat it, because I need and want to eat. But my point is, the issue of food rules is rather nuanced, and involves people being patronized from more angles than just the medical one.

    Needless to say, I didn’t take the “nutrition shake” advice. I switched to whole milk and I increased my organic ice cream intake :)

    Sorry for the hijack-of-a-sort. I know you know that we do not live (or eat) in a vacuum.

    • Totally agree here. I recently read Michael Pollan’s book, and it’s inspired me to continue to to try to change the way I and my family eat, not because of weight worries necessarily, but because I want us to eat wholesome foods that nourish our bodies, not empty calories that have been linked to all sorts of diseases that significantly lessen quality of life (I don’t remember the book mentioning much about weight, actually, more over-all health). Luckily, we also live someplace where we have great access to fresh foods, so that helps. ; )

    • maria — as we talked about on Twitter, the thing is, *food itself* is not morally good OR bad. Food can have environmental implications, it can have more or less nutritional value, and the corporations (or, alternately, cooks) behind the food can be evil or good, but *the food itself* is just food. And all food (except noncaloric “foodstuff”, I guess) has nutrition of some kind. Twinkies? POWERHOUSE of gross nutrients like calories and fat. Plus, tasty*. So if the options are between that and something less calorie (aka nutrient) dense, or less tasty, or would take way way more work? Yeah, I can see reaching for the Twinkie. And that isn’t a bad moral choice. It’s just food.

      * I find I can’t eat them anymore because they make me ill and don’t taste good at all, but once upon a time, after moving out on our own for the first time, we’d buy them by the boxful.

      But I do not feel that “if it tastes good, it is good”, because that food has been made to taste good artificially, by people who don’t give a damn about me or any aspect of my well-being.

      I agree, but if it tastes good, it tastes good, and that’s really important in what we eat. Be pissed off at corporations and laws (and the individuals that create and run them) that encourage the manufacture of food that has been created to trick our senses, but to make rules that call individuals good or bad based on whether they eat those foods? Not cool.

      • Ahhh, hi. I keep meaning to come back to this post, and as you can see, I haven’t. I think you’re right about food itself being morally neutral–I take back what I said about Twinkies themselves being bad. My point was more that going on taste alone can be (sadly) misleading in a world of artificially good-tasting food. I wish it were that simple, but it just isn’t. And just to be clear, I never have said (or thought) that individual consumers are bad for the choices they make.

        A quote from Bertolt Brecht has been running through my head recently: “Erst kommt das Fressen, dann kommt die Moral.” (Literally, first comes feeding, then comes morality–figuratively, a hungry person has no conscience). I wonder if this is true. I wonder if it’s a luxury of our privileged, over-industrialized culture that we even have such food choices, that we can even sit here and assign value to this food and not that.

        • correction: I have totally been guilty (at various points in my life) of judging fellow consumers for the choices they make. I meant I haven’t in the context of this discussion.

  7. If I had the guts I’d write a similar letter to my GP starting along the lines of “Dear Doctor, despite your horrified response, yes, I am still breastfeeding my three year old”. Still, at least the great thing about the NHS is that I don’t have to pay to be insulted.

  8. there are times when i feel like body mass does hamper health. times when one weighs more than their body can support and they stop being able to move with joy. but in those cases, the weight wasn’t the problem to start with, and by telling people that they must address, first and foremost, their weight, i feel that GPs are doing more harm than good, oftentimes leading to the very problems they think they’re preventing. :-(
    Thank you for this blog post. I may have to print it off for my next check up. As a woman who for the most part makes healthy eating choices, as a woman who goes to the gym and works out 3-5 days a week most weeks, sometimes more, sometimes less depending on the disposition and health of my children, I take issue with this notion that my size is related to my overall health and moreover, to my worth, which is nearly invariably implied.

    • slee — “I take issue with this notion that my size is related to my overall health and moreover, to my worth, which is nearly invariably implied.Exactly

      And yeah, a high body mass can be a burden, especially in some conditions (though as you point out, those are often the same conditions — such as knee problems or arthritis or etc — that contribute to high body mass in the first place), but until we have a safe, sensible way to permanently reduce body mass in the general population*? Promoting weight loss as a primary treatment is not only ineffective, but, I’d say, immoral.

      *Which, actually, I don’t want. Because there’s nothing wrong with the way I am, and I’d be horrified if we were all told we HAD to use it because it existed, and of course thinner is better.

  9. Who is your healthcare provider, and why are they still your healthcare provider?

  10. For the first time in a very long time [maybe ever?] I have a primary doc who is *amazing* in every way. My weight “issues” – according to my Mom, who I suspect would remember better than I, all started because of comments that my pediatric doctor made when I was a slightly chubby but in every way normal kid. That sent me on the Rollercoaster of Diet Doom… at what, seven? Eight? Jeez.

    Doctor Naz, my current primary care provider, weighs me only to make sure that there’s been no sudden weight gain or loss that she should check into. The most she’s *ever* said that could be related to my weight is that I need more exercise, which is true. She’s supportive in every way. I would drive very far to keep seeing her – in fact, I drive to the next state over to do so. I wish I could clone her for all of you.

    I wish these doctors would all get a clue that their pushing and invasiveness and judgment doesn’t help us, it only hurts us – and sometimes makes us want to stop getting health care altogether.

  11. I’m glad I’m not the only one who calls them vampires. But then, I’ve had so many blood tests done over the years that I practically have track marks.

    You do “diet”: you eat! http://en.wikipedia.org/wiki/Diet_%28nutrition%29 And you practice intuitive eating, which is a specific focus of food. I think that’s kinda-sorta what I do, only less consciously. I may have to try to do it more consciously; I really like the idea.

    As I mentioned above, I have the issue that I’m underweight. A good non-pregnant weight for me is around 165, and at 14w pregnant I may have hit 161 (pure guess, we don’t own a scale, but my lowest recorded weight this pregnancy is ~157). My midwife’s suggestion? Eat a lot of ice cream. But that’s not an acceptable solution; I’m pretty sure I’m beginning to experience some insulin resistance, and eating a lot of sweets while pregnant won’t contribute to my health or my baby’s, anyway. Right now I’m eating what I’m craving: lots of cheese-stuffed pasta doused in butter and parmesan. But… that’s not entirely satisfactory either. :/ I guess I will continue to listen to my body and my intuition, and eat as much as I can of fresh, whole, as-local-as-possible foods, and supplement with whatever else as I have to.

    BTW, this post is so awesome that not only did it blow the top of my head off, but I had to send the link to my mom (who was the first woman in my life to inspire my awareness of size).

    • Katie B. — I say that I have a diet, because there is food that makes up my way of eating, but I do not diet-as-a-verb, meaning to watch or restrict what I eat in particularly with a goal of weight loss, which is a corruption of the original, neutral word.

      And thanks. :) Good luck with the pregnancy!

  12. I have to have thyroid surgery in a few weeks and yesterday met the surgeon for the first time, with great trepidation. When I saw he was a thin, middle-aged, white man, I was even more worried. Much to my surprise and delight, he was very size-positive, confident about surgery on fat patients, and answered my questions clearly and without being at all condescending. Good doctors are out there, and I wish you all the best in either finding or educating one!

  13. So the big question, will you actually send this to your health care provider?

    Doesn’t the concept of intuitive eating freak the hell out of people? I always take this as further proof that intuitive eating is the right thing to be doing.. if intuitive eating *still* seems so dangerous to people then that is all the more reason for me to believe that the world I live in has *issues with food* and listening to my body is the *only* way to go.

    • blue milk — That is the question, isn’t it? I’m not sure. I have another appointment with him in a few weeks, which is what prompted me to finally write this (the inspiring incident was a couple months ago), and I’m thinking over how I’m going to handle it (and being pissed off that a health care visit is something I have to handle). We did come to a sort-of accord last time, I think, wherein we agreed that weight is not the same as health, and I was there to work with him on my health — which is why I didn’t simply walk out that day, and why I have another appointment with him.

      I might send this, or I might take snippets of it with me. I don’t want to piss him off (because I’d like to work with him), but I do want him to understand where I’m coming from. So… I don’t know.

      Doesn’t the concept of intuitive eating freak the hell out of people? I always take this as further proof that intuitive eating is the right thing to be doing.. if intuitive eating *still* seems so dangerous to people then that is all the more reason for me to believe that the world I live in has *issues with food* and listening to my body is the *only* way to go.

      Oh so much this.

  14. I love my doctor. She talks a lot about diet but never about dieting. She talks about concepts that apply (she believes) to everyone in order to feel their best, not just fat people. Like for instance, she thinks most people in the NW need vitamin D supplements and that human bodies aren’t made to deal with so many grains (even whole.) She doesn’t believe in using the scale as a routine diagnostic tool. She herself is quite slim and athletic but doesn’t have a problem with the notion that there are different body types and many valid ways of being in the world. She’s smart and she listens. I can’t tell you how much I love her. Sadly, my insurance doesn’t cover her.

    Re: Michael Pollan, first a disclaimer, I really like him and have since The Botany of Desire. :) And he’s not overtly an anti-fat crusader like Jamie Oliver. But it is in the subtext. He does believe that if people eat ethically (as he defines it) they’ll look like him. And what is “not too much”, after all? Whatever doesn’t make you fat, obviously.

    • That’s a really good point about “not too much”. I had always taken that to be a response to Western-diet consumer culture, which dictates that more is always better (e.g. super big gulps, impossibly large portion sizes at most sit-down chain restaurants, all-you-can-eat buffets). I think our consumer culture nurtures a compulsion to get one’s money’s worth when it comes to food, that is, get the biggest amount of food for the smallest amount of money, and also to eat all the food we buy so as not to waste it, regardless of how much we would actually like to eat. And of course, at the same time, we are being constantly being told to “diet” and “watch our weight”.

      So I hadn’t interpreted “not too much” to mean “not so much that you’ll get fat”, but now I can see how you (or anyone else) would read it that way.

      • Linda and maria — My problem with “not too much” is that it still is putting the emphasis on a guide from outside our body. If we define “not too much” as “not more than our body is indicating”, then yea, I can agree with it — but we need to add “not too little” to that as well. And given our current diet culture, I think it’s irresponsible to use a phrase associated with food-restriction and external control of eating.

        We don’t need anyone else telling us how much to eat; we need more support for listening to our bodies and eating according to our own intuition, whether that’s leaving food on the plate or going back for seconds. Or sometimes doing one, and sometimes the other.

        • Arwen: Oh YES to the “not too little!” That’s been *such* a problem for me and many folks that I know – some, from being told continuously to “stop eating so much, fattie!” and others from forgetting to eat regularly.

          Food is not BAD. We need food to LIVE. That’s been the hardest lesson ever to learn, and now I revel in the budding relationship I’m building with my body – the relationship of listening to each other, brain and body.

          [thank you for this post, it's been a wealth of discussion fodder for me!]

  15. Arwyn, this rocks. Thank you.

    I’m British, and hubby and I both recently received letters inviting us to our GP’s surgery for a ‘health MOT’, a new thing that’s being pushed for anyone over 40 (we’re both pushing 42). It states that measurement of height, weight and waist size are involved, and neither of us will be going for precisely that reason. None of the three doctors I’ve seen since I signed up at the surgery over a decade ago have ever weighed me or commented on my weight, but it seems the NHS is now pushing them to do so. I half thought about writing to them to explain why focusing on weight is not only a useless health indicator but will actually put many people off going for checkups, and your excellent letter has inspired me…again, thanks.

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  17. I was pointed this way today by a friend who agrees with you 100%, Arwyn. And I do too!

    For most of my life I have been seriously underweight except when I was pregnant. Nothing I did put the weight on. Then I hit menopause and gained 35 pounds in one year, and actually started feeling healthy because of it.

    But now my GP has begun harping on me about my cholesterol level (which also skyrocketed as soon as my hormones shut down my ovaries) and my weight gain, insisting on my switching over to “diet food” and that I need to drop 15 pounds, etc.

    Well, for 6 months I tried to follow what that nutritionist she sent me to said and I am in worse shape now than I was before. So I have thrown that “low-fat diet” out the window. No more fake-butter made of chemicals that I can’t pronounce. No more angsting about how to meet that diet and still ensure that my children are getting enough fats and proteins in their diet to keep their brains developing and growing properly. No more building up insulin resistance because of the increase in carbs and reduction of proteins that came from cutting down having meat to only 3 times a week.

    Intuitive eating is working for me and my family is finding me a much easier person to live with because of it. I haven’t gained nor lost anymore weight, my clothes fit me just fine, and my kids say that it’s nicer to hug me now because I’m “cuddly” instead of boney. :)

    I just wish that I could go to a different doctor who is more accepting of my choices… but I don’t have that option at the clinic that I have to go to.

    Thanks again for your blog post. It absolutely ROCKS!

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