Naomi Arnold talks to those fighting the stigma of size in a thin-obsessed society.

Pretty much the first thing that fat studies scholar Dr Cat Pausé asks when I contact her to see if she'd like to contribute to our story on fat is, "Are you going to use any photos of headless fatties?"

If we are, she's not interested.

Awkwardly, we were going to, actually. For the cover, we had planned to use a photo of a headless fat person with the headline, "What's wrong with this picture?" and then earnestly point out how frequently the media uses images of headless fat people and how problematic they are.

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Even though it was meant to be sympathetic, meant to open discussion on the problems of being fat in a society obsessed with the thin, Pausé, a Massey University senior lecturer, said no. It's still a headless fatty. Even if you're trying to be clever with it. No interview.

"Why not use a photo of happy, smiling, laughing fat people with the same headline?" she said. "When do you ever see that?"

She has a point. Because we all know the photos she's talking about. They're the ones usually accompanying the headline "Obesity Crisis". We see those pictures on the news, in the papers all the time: fat people's bottoms walking along a street, fat people in the mall, and the Holy Grail: fat people eating and drinking. (Because, how dare they?) The photos are snapped sneakily, to avoid the need for permission, and to avoid embarrassment. (Because they should be embarrassed, right?)

The term "headless fatties" comes from a 2007 essay of the same name by London-based psychotherapist, author and fat activist Dr Charlotte Cooper, who began noticing it was "a staple of news journalism", with bigger people literally beheaded and turned into an object of shame, ridicule — and warning.

"We are presented as objects, as symbols, as a collective problem, as something to be talked about," she wrote. "Unless we play the game and parrot oppressive, self-hating, medicalised views about fat, fat people's own voices, feelings, thoughts and opinions about what it is to be fat are entirely absent from the discourse."

It has become such a recurrent trope that Pausé has simply said, "No." No heads on the fat people, no interview. We did want to talk to the main Fat Studies scholar in New Zealand for a story on the stigma of being fat. So, heads it was.

It's really come to this. Fat people are so dehumanised in our society that those who are protective of their mental health actually have to demand of our mainstream media that real human beings deserve the respect of their head — along with their brain, feelings, mouth, and voice.

If you're in a bigger body, what effect is this mindless discrimination having on your health? And how much of the poor health outcomes of bigger people are due to the fat your body carries, and how much is due to society's discrimination against it? That depends on who you talk to, Pausé says.

"A growing number of scholars, myself included, would argue all of the disparities that exist health-wise between fat people and non-fat people can be explained by the structural discrimination and stigma fat people experience. Just as many, and probably more scholars would disagree with that and say fatness is a risk factor for X, Y and Z."

This is the point where we would normally bring in a medical professional to share their thoughts; the most common argument people make when confronted with the depth of discrimination against fat people is "But being fat is unhealthy." Pausé counters by saying you can't hate people healthy.

"More importantly though, when we're talking about fatness as a civil rights issue, I would suggest that it's incredibly dangerous to suggest that someone's civil rights should be based on their health status," she says.

"That's not a road we go down with any other group; we don't say, 'Oh, but the health costs associated with being X means we should allow them to be discriminated against.' I don't think that most people would be comfortable suggesting that someone's health status is how we should determine whether or not they have the same rights as others."

So, we're not going to talk to medical professionals for "balance". There are lots of those stories published every day. This is a story focusing on being fat, and how the stigma of that endangers your health all by itself.

Many of us are likely to have inbuilt negative attitudes towards bigger people, deeply if unconsciously believing they are lazy, greedy, or lacking willpower. In one experiment, subjects who were tricked into thinking they should smell something in differently coloured odourless creams reported they smelled less pleasant odours when they viewed pictures of the bigger people in the study.

It has been well-documented internationally that experiencing prejudice — both overt and unconscious — can result in worse health. After the Christchurch mosque murders, the Mental Health Foundation drew a direct line between discrimination and poor mental health. "Being on the receiving end of racism, discrimination, exclusion and bullying are all risk factors for mental distress," it said. "They all contribute to suicide."

But it's not just mental health. United States research into the health effects of racism, for example, demonstrates that those who report regularly experiencing even small, day-to-day occurrences of disrespect develop coronary heart disease more rapidly than those who don't. Pregnant women who report high levels of discrimination give birth to babies who are lower in birth weight. And being black or of another minority means you receive poorer-quality medical care across nearly every single medical intervention, irrespective of education level, job status, the severity of the disease, and health insurance.

It's a similar story with people who are fat. Fat stigma has a powerful effect on your mental and physical health; research shows that just like experiencing racism, living in a larger body in this thin-obsessed society can make you sick. Furthermore, discrimination against fat people actually increases the likelihood of weight gain.

It is difficult to measure the extent of fat stigma and discrimination in New Zealand, because there hasn't been specific research into it. Pausé hasn't yet been able to get any funding to collect data around the perceived and actual experiences of discrimination of fat people here.

"I think there would be a lot of money if I was proposing a way to 'cure obesity', but that's absolutely not what I am doing," she says. "I still think the type of work I want to do is difficult for a lot of people to wrap their head around, because they can't understand fatness through any lens other than 'the obesity epidemic'. So why would you study anything about it except how to how to fix it or make it go away?"

It has been studied internationally, however. In 2017, a review of 33 published studies into the link between fat stigma and physiological and psychological health, published in the Journal of Advanced Nursing, found weight stigma resulted in worse health outcomes. It was positively associated with obesity, diabetes risk, cortisol level, oxidative stress level, C-reactive protein level (a blood marker for acute inflammation and infection), eating disturbances, depression, anxiety, body image dissatisfaction, and negatively associated with self-esteem among overweight and obese adults. The researchers said there was a need to increase awareness about the effect of weight stigma and develop strategies to prevent it.

Fat people face discrimination at work, in terms of lower salaries, being passed over for promotion, or getting jobs at all. There is, in fact, research to support the idea of a fat gap; a British Medical Journal study found a high BMI was a factor in worse income and deprivation for women, and shorter men had worse education, income, and job class. Pausé is currently working towards seeing physical size added to the Human Rights Act in order to ensure fat people have the same rights and legal recourse when they are discriminated against.

"At the moment, that option isn't there for fat people, and so, even though we know that they're less likely to be hired and promoted and earn the same wage as their non-fat colleagues, they're less likely to be supported to go to university, less likely to get evidence-based health care — I could go on and on," she says.

"There is no legal recourse for them in New Zealand or most of the world at the moment."
Medical professionals are not exempt from perpetrating this. Fat people delay both urgent and routine healthcare checks because their GP fat-shames them. Research shows that not only do doctors spend less time with fat patients, but, as a study in Obesity Review found, many healthcare providers hold strong negative attitudes and stereotypes about them.

"There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behaviour and decision-making. These attitudes may impact on the care they provide," the study's authors said.

Sometimes, doctors miss health problems because they attribute all issues to weight. Auckland fashion blogger Meagan Kerr hears many of these stories from her audience, which includes 27,000 followers on Instagram.

"They don't go to the doctor for wellness checks, for things like smears and breast checks or to get things they're concerned about seen to," she says. "So they are reporting it later, when it is a bigger issue and harder to do something about. People are routinely denied medical care because many doctors don't examine them, they don't listen to what their symptoms are and they prescribe weight loss instead of whatever will fix the problem."

She experienced this herself, visiting a specialist to try to find out why she was regularly dislocating her knee.

"The specialist said it was because I was fat and suggested bariatric surgery. It turned out to be a tumour in my knee, so bariatric surgery would not have fixed that. That would have been missed if I hadn't been confident enough to press it further and lay a complaint about the fact that she was misdiagnosing me."

If doctors don't suggest bariatric surgery, they often suggest controlling eating. But we have known for years that diets don't work; the overwhelming majority of diets fail, and the biggest predictor for weight gain is, in fact, dieting to try to lose it. In fact, your first diet is where many eating disorders begin.

The American Journal of Public Heath published a study which found long-term weight loss is all but impossible for most people. In fact, researchers from Kings College Cambridge have quantified this; they looked at 10 years' worth of data from 278,982 people in the UK health records and found women in the "obese" BMI category have a one-in-124 chance of reducing their BMI to the "healthy" BMI range, or a one-in-677 chance if they are "severely obese". It's worse for men. A man with an "obese" BMI has a one-in-210 chance of achieving a BMI in the "healthy" range. This becomes a one-in-1290 chance if he's "severely obese".

"Overall, the evidence seems clear," New Zealand endocrinologist Dr Robyn Toomath said in her 2016 book Fat Science. "For the great majority, dieting as a means of achieving lasting weight reduction just doesn't work."

What the dieting process does achieve is shame, disordered eating, and a lack of trust in your body, its needs, and its cues.

Emma Thomas, a psychotherapist at the New Zealand Eating Disorder Clinic, never uses the words "obese" or "overweight" with her clients; the phrases can be hugely triggering. So much so, that she uses the phrase "the O-word", along with ironic quotation marks. (Pausé points out that "overweight" implies there's a weight we should be — "Over what weight?" — while "obesity" pathologises a body based on its size, inferring it's diseased. Pausé prefers "fat", and so does Meagan Kerr, so we have used it throughout this story, too.)

Thomas uses a mixture of CBT-E (cognitive behaviour therapy for eating disorders) and the Health at Every Size paradigm to help her clients recover from poor body image and a crippling relationship with food.

"The latter doesn't come without the former," she says. Her typical client swings between restricted eating and the resultant, inevitable overindulgence, a pattern that may have lasted years by the time she sees them.

"Disordered eating is a spectrum and unfortunately my belief is that most women are on that spectrum," she says. Many of her clients come to her saying, "I'm too fat to have an eating disorder." But she says any kind of dieting to lose weight is unhelpful.

"We don't have to love our bodies to be okay but if we are spending an unusual amount of time and energy on hating our bodies and trying to do something about it, that's where the problem comes in," she says. That includes avoiding life: Relationships, trips to the beach, travelling in aeroplanes, and clothing that shows off parts of your body you hate.

"That impacts our self-worth and happiness," Thomas says. "From a neurobiological point of view the more effort we put in to trying to change our bodies the worse our body image will become."

It's nobody's fault, she says. "This is diet culture. That is what we are taught as women; that this is what we should be focusing all our energy on." As Naomi Wolf says in The Beauty Myth: "Dieting is the most potent political sedative in women's history; a quietly mad population is a tractable one."

Thomas tries to get her clients to the point where they may still want to lose weight, but the urgency of that desire has lessened.

"You will probably be left with the thought 'I wish my body was smaller' but in the same way someone wishes their nose was smaller, or everyone wishes they had more money," she says. "It doesn't become an obsession and there's a level of acceptance there."

As for how we can individually address fat stigma, Kerr suggests simply not talking about yours or other people's bodies. Ever. Particularly to children.

"If you are catching yourself saying or thinking things about your body or about other people's bodies, take time to examine why you're doing that and what you can do differently," she says.

Thomas echoes this. "The idea that big bodies are bad can be extremely triggering for others with their own body insecurities, and we may be inadvertently reaffirming their own eating disorder behaviour. Eating disorders come in all shapes and sizes.

"And what I would say to people living in larger bodies and feeling shame about that is: Your body is not your fault. Your body is not a problem to be fixed."

Your relationship with food and your body image might need help, she adds — but your body is simply doing what it does best. Surviving.

INTUITIVE EATING

Developed by US eating disorder specialist Elyse Resch and dietitian Evelyn Tribole, Intuitive Eating is a clinically-proven programme, often undertaken in eating disorder recovery, that teaches you to reject diets and eat whatever you want, whenever you want, while respecting your internal cues of hunger and satisfaction; honouring your health and taste buds; and moving your body for enjoyment.

It is based on the idea that restricting certain foods is what makes you overeat. When the emotional side of food is addressed, eating normalises, in a process that may take years.

You may then slowly return to whatever weight your body is meant to be. But that weight may be higher than what you started with, Resch and Tribole caution; they say undertaking Intuitive Eating can initially involve a traumatic process of letting go of the dream body that our thin-obsessed society has told you you're meant to want, and accepting your genetic blueprint. But in return, Intuitive Eaters report that a new sense of freedom and peace returns to eating, something they may not have experienced since early childhood.

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