NYC Large Soda Ban: Right Law, Wrong Reasons

So New York City is banning the sale of sugary beverages over 16oz.  (http://www.cnn.com/2012/05/31/us/new-york-sugar-drinks/index.html) Bloomberg is touting this as his administration’s way to “do something” about the city’s obesity epidemic, and he claims that sugary drinks are the leading cause of obesity. 

One of my favorite bloggers, Regan at Dances With Fat, recently wrote a post about her opposition to the law (http://danceswithfat.wordpress.com/2012/06/01/sixteen-ounces-of-dumb/).

Regan and I usually agree – in fact, her blog was my primary introduction to Health At Every Size and Size Acceptance.  In this case, though, I strenuously disagree with her.

While I also disagree with everything about the phrase “obesity epidemic,” I do think this law is a good idea.

Now, don’t get me wrong, Bloomberg’s obesity-based justification for the law is problematic.   In fact, he should just stop talking.

Obesity is not a health problem, it’s a body size. When people talk about the “health consequences of obesity” what they really mean to address (I hope) are the health consequences of sedentary lifestyle and poor diet.  Conflating obesity with poor diet and lack of exercise is problematic for several reasons.  First, good diet and lots of exercise don’t necessarily make obese people thin.  Secondly, plenty of thin people have a bad diet and get no exercise – these people are not healthy by virtue of being thin, they’re just smaller.  Thirdly, you’ve muddied your discussion of an important public health issue with the rhetoric of anti-fat prejudice.

So let’s just leave obesity out of it.  Poor diet is still a public health problem.  It’s a public health problem that affects people of all sizes – the consumption of thousands of calories of sugar-water is not good for you, whether it leads to weight gain or not. 

A 2007 meta-analysis (Vartanian, et al. “Effects of Soft Drink Consumption on Nutrition and

Health: A Systematic Review and Meta-Analysis,” American Journal of Public Health) found that increased soda consumption led to increased caloric intake over and above the calories in the soda itself, suggesting that soda consumption stimulates the appetite or affects satiety.  Increased soda consumption was also associated with decreased milk and calcium consumption.

In terms of health outcomes, daily soda drinkers had double the risk of developing type 2 diabetes compared to infrequent soda drinkers.  This was true even when controlling for BMI.  Let me say that again - the behavior of drinking soda was associated with increased risk of developing type 2 diabetes, regardless of weight.  Skinny soda-drinkers – you are not safe!

So type 2 diabetes is no fun.  It is a legitimate public health issue.  In fact, I might even let Bloomberg call this one an epidemic.

So soda is not a benign substance – what is the best way to address that?  One ever-popular approach is to encourage individuals to “make good choices.” (Can’t you just hear Michelle Obama’s voice saying this?)

“Making good choices,” is appealing to Americans, because we tend to believe in this fantastical individualism myth – individuals can pull themselves up by their bootstraps, it’s the American dream, etc, etc.  (The more conservative you are, the more likely you are to subscribe to this worldview). 

Regan argues the other side of the individualism argument, asserting that people have the right to prioritize or not prioritize their health.  This comes up a lot in her blog, where she argues that while it is possible to be fit and fat, it is also not the responsibility of every fat person to be fit; that fat people have just as much right to have unhealthy habits as thin people.  And in general, I agree, that individuals have the right to prioritize health as they see fit for themselves; but as a public health scholar, I am interested in maximizing the health of populations.

And I take issue with the idea that freedom means being able to buy a Double Big Gulp.  New York banning large sodas is not the nanny state restricting individual freedom.  It’s a public health measure countering the enormous marketing pressure of the beverage industry.  Your choice to buy a Double Big Gulp isn’t a free choice, it cost Coca-Cola many billions of dollars in clever polar bears, dancing young people, and a cultivated Pavlovian response to their red logo. 

Individuals can’t realistically resist a mammoth like Coca-Cola using will-power alone.  Instead, systemic unhealthy influences are best countered by public policy.  And the large soda law is a great example of putting the pressure in the right place, not on the consumer, but on the seller. (I’d love to see the law targeting the beverage companies themselves, but at a city-wide level, targeting restaurants is probably as high up the food chain as they can go.)

Regan argues that using the obesity justification for this law will make thin people resent fat people for restricting their choices.  I agree the obesity justification for this law is terrible.  But the whole anti-obesity campaign is terrible.  Thin people already resent fat people.  Fat people are blamed for everything from health care costs to global warming. 

So yes, it is important to resist anti-obesity rhetoric.  But pitting Size Acceptance against public health is not the way to go.  A broader understanding of both Size Acceptance and public health reveals that Size Acceptance is public health – it’s a movement advocating for the improved social standing and mental health of 2/3 of American adults. 

Race and the "Default Experience"

Following the Trayvon Martin story has gotten me thinking about race. 

First, I just want to say that I am probably not properly qualified to speak on any of these topics.  These thoughts are not the well-crafted ideas of someone who has a deep and nuanced understanding of race issues.  These are the fledgling ideas of a privileged white woman who learned the word “privileged” within the past year.  So bear with me. 

As a white blogger, I feel it is important for me to share these thoughts, rather than just, say, continue to whine about the uncertainty of my maternity leave status.  Because the black community doesn’t have the option of not being affected by this story. 

I was listening to Elon James White’s podcast, “Blacking it Up,” where he describes just feeling hopeless and confused about what to do.  An older woman called in and said she was just “broken.”  How do you react to concrete evidence that your society simply doesn’t value the lives of people who look like you?

I have trouble wrapping my mind around that, I have trouble engaging with it.  It’s too big, too scary, too unjust.  And I think this is why a lot of people just walk away from this discussion – or justify why Zimmerman’s actions were legitimate.  It’s a lot easier to deal with one kid who really was up to no good than it is to acknowledge that the society you live in (in which you may be personally very comfortable) is fundamentally dehumanizing, wrong, and unfair.

I’m not ready to bite off a chunk that large.  So, I have tried to stay aware of race in other ways.  Here are just two of the things I noticed in the past few days:

1. I volunteer at a sliding scale clinic and wellness center in East Baltimore.  Most of our patients are black, most of our staff and volunteers are white.  Today I was helping with a session on stress management and we showed a movie about the physical effects of stress.  The doctor they interviewed was a black man, but all the actors that they had demonstrating the effects of stress were white.  Moreover, they were all white men in ties.  The language the narrator used was generic, he would say “stressful jobs,” but the actor would be a white guy in a tie massaging his temples as he sat before a computer screen in an office.  Clearly, he had a very stressful pie-chart presentation to give.  Bummer. 

This is not the kind of stress my patients are dealing with.  My patients are dealing with losing their jobs for taking too much sick time after their daughter was killed and they took over raising their autistic grandchild.  My patients are dealing with having a stroke at 45 and re-learning how to walk.  My patients are dealing with being laid off from the job that was already barely getting them by.  And sure, on some level stress is stress and we can all relate to that experience.  But it’s always non-whites who have to do the relating.  Because my experience as an upper middle class white person is always the default experience, even in places like Baltimore where it is not the majority experience, either in terms of race or in terms of class.

When I can expect that my experience as a white person is the default experience, that is privilege.  When you are in a position to craft how you represent the default experience, and you perpetuate that privilege – is that racist? It’s not racist the way not arresting Trayvon Martin’s killer is racist, no.  But I think it’s probably a more subtle angle of the same beast.

2. Later, I was working on my thesis, which is about obesity stigma.  I was doing some research into the Body Mass Index and found that one of the problems with it is that the cutoffs for overweight (>25kg/m^2) and obesity (>30kg/m^2) is that they were developed based on studies of mostly white people.  Theoretically, the normal weight range (BMI 20-25kg/m^2) was chosen because it represents the range associated with lowest all-cause mortality.  But it doesn’t apply to non-whites. 

For African-Americans, the lowest mortality rates are found at BMI values in the “overweight” range.  This means the NIH has duped thousands of (probably) well-meaning doctors into nagging black patients to lose weight when they are already in the healthiest range. I myself have done this, I am sure, trying to be the good little medical student supporting lifestyle change.

Here we see the consequences of white being the default experience.  Studies are done on whites and results inappropriately extrapolated to every other race.  Even when studies on other racial groups demonstrate that there are differences, the guidelines remain rigid.  The NIH claims that “there are no studies that would support the exclusion of any racial/ethnic group from the current definitions of obesity.” 

I think this example is particularly interesting because it exists at the intersection of two different kinds of prejudice – that based on race and that based on body size.  (Please note that I am not stating that one is worse than the other or that they are comparable, just that both are coming into play in this situation.)  It isn’t overt racism – no one is using the N word or shooting anyone.  Instead, it’s just this insidious and officially sanctioned suggestion that black people should internalize discomfort with their own bodies, that they should conform to medical standards designed for white people. 

I guess I am frustrated and anxious to move on to the next step.  I’ve noticed this, so now what do I do about it? Even the relatively smaller examples seem too large to wrap my mind around when I consider how to eliminate them. 

So, in conclusion, I am frustrated that racism still exists.  I was raised by hippies and would say I am oriented towards activism (not that I am particularly good at it).  But I have a feeling that on this one, I have a lot of internal work to do before I start grabbing petitions or taking to the streets.

Body Image, Pregnancy, and Obesity Stigma

I’m sixteen weeks pregnant and I have officially given up on all my non-maternity pants.  In a fit of nesting, I bought a bunch of clear plastic storage bins and stowed away all my too-tight pants under the bed.  The bin was nicely labeled, and I think that come October or so when I may fit into those pants again, I will remember where they are.  I would like a sticker, please.

Maternity pants are awesomely comfortable.  I had no idea pants could be this comfortable.  I especially like this one pair of jeans that have an elastic waistband rather than the huge elastic panel (though I know I am destined for panel-pants-land eventually).  The only problem with these pants is that I am constantly hiking them up.  Hence, long comfy maternity shirts.  Bingo!  As an added bonus, I got almost all my maternity clothes from a friend, who was clearly on the purge portion of the gather/nest/purge cycle.

I’m digging the new pants.  I am digging my “baby bump,” (though I agree with Lake Superior University that this phrase should be banned http://www.lssu.edu/banished/current.php). I’m enjoying constantly palpating my abdomen to locate the firm edge of my uterus.  (Do pregnant people who are not medical students do this? I don’t know.) 

Other than the debilitating heartburn, I am feeling pretty good about the whole situation.  Until I read an entry on one of my favorite blogs, The Underwear Drawer, whose author, doctor-mother-extraordinaire Michelle Au is sixteen weeks pregnant with her third child.  The blog post contained one of those ubiquitous belly-shots, which you can see here: http://theunderweardrawer.blogspot.com/2012/01/16-weeks.html.

Michelle is tiny, and in pregnancy seems to be remaining tiny.  Or maybe before she was pregnant she was actually translucent.  In any case, it made me feel like a giant pregnant whale.

Then my “What To Expect” week-by-week pregnancy guide tells me, “It’s hard to watch yourself gain weight during pregnancy, even when you know there’s a wonderful reason for it.”

Is it?  Should it be?  Why do I feel chastised by another woman’s belly shot? Why are we so concerned about gaining weight? 

We’re concerned about it because we have internalized the societal stigma against overweight people.  Studies on weight stigma have shown that people are more likely to judge the obese to be lazy, unintelligent, and incompetent.  

I suspect that the embarrassment of gaining weight during pregnancy comes from a desire not to be confused with “those people.”  You know, fat people.  Especially in early pregnancy, when you know people are debating whether you are “with child” or “with Chipotle.”  We want to represent ourselves accurately, “I’m not lazy and unintelligent, I’m just pregnant!”

Um, fat people aren’t actually those things either.  Fat people are no more likely to be lazy, unintelligent, or incompetent than thin people.  (See my master’s thesis on Obesity Stigma for full details, you know, as soon as I finish writing it.) 

Rather than carving out a social exception for ourselves (“I’m not fat, I’m pregnant,” we should be questioning why society judges fat people so harshly.  We should be questioning why it is socially acceptable to disparage people based on weight in ways that it is no longer to disparage groups of people based on race or sex.  (There are tons of examples of this, and I will get to them in a later post).

I am making it my goal during pregnancy and afterwards to eat well, exercise, and just not worry about what I weigh.  And I am also making it my goal to examine my attitudes towards others and challenging those attitudes when they are based on stereotypes and prejudice.

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