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FAQ and some Infrequent Answers

Fri, 18 Jul 2008 01:38:52 GMT

These are questions I frequently hear rattling around in my monkey mind. The ones I ask myself.
Especially when I'm sleep deprived.

Q: Will I ever be beautiful?

A: (Deep breath, summoning up patience) You are really tired, aren't you?
Okay, so, the short answer is no. Not by the concept of beauty that the question is rooted in. You will never, ever be that kind of beautiful, the beauty-contestant-of-the-mid-70s beautiful.
And here's the good news: You don't have to be.
That question, it comes from a child who thought that beauty would provide safety and love. You have safety (as much as there is in the world) and love (again, pretty much as much as anyone can get).
And, as a bonus, your idea of beauty, what it is, has changed. So, let's say that the beauty you are imagining is like a firm, unopened rose bud. Perfect, closed, and pretty, but rather boring. The beauty you can now see is riotous blooms -- some tiny, some dinner-plate-dalia huge, everything in-between. Bursting with color, with wrinkles, with giant blissed-out bees buzzing around them. With heavy, wonderful odors, and fuzzy petals and clouds of pollen that float off in the summer air. Each blossom different yet totally beautiful -- beautiful upon opening, while in full bloom, and while fading, drooping. You've never really been a rosebud, but a gorgeous, appreciated, wild thing that keeps coming back year after year. Now, that kind of beauty, which you can now appreciate, you have that. So in that sense, yes, you will be, are, have been beautiful.

Q: What is wrong with me?

A: You're human. As it turns out, you need sleep, food, and to engage in all of the glorious, mundane and hideous things about being alive. Your hunger sometimes leads you to strange and uncomfortable places, but that's part of being a living thing. So, either nothing is wrong with you, or what's wrong with you is the same thing that's wrong with everyone else.

Q: Really, I want to know, do I ever get to be beautiful?

A: Oh, sweetheart, I know you must be tired. That's when you ask this question a million times. When you whine "pleeeeeeeeeeeese can I be beautiful now?" I'm going to try to translate that question into, "I'm really tired, when do I get to rest?" And the answer to that question is, once little one goes to sleep for the night. Which happens to be right now.

A brief return to blogging with two questions

Fri, 27 Jun 2008 15:11:46 GMT

I'm in the midst of many transitions. It's a gorgeous June day (which does not go without saying in the Pacific NW) but I'm inside at the computer, finally caught up on skimming the fatosphere feed after nearly a week away from my computer.
I've missed you, fatosphere, and my self-esteem has suffered a bit.
I am transitioning between two jobs with a short, far too short, break in-between.
I've spent this free day (I have the house to myself, the computer to myself and a million things to do) about a million times over in my head.

Speaking of my head, I need to get two questions I have out and into inter-space.

Question 1: If there are more fat people than thin people in the U.S., why is there so much virulent fat hatered in the comments that appear on press web sites?

Is that the class/weight divide showing up? Internalized fat hatered? I know, I know, this is how these things (namely, rampant baseless hatered) work. But still, it's disturbing. If I had more Sanity Watchers Points, I would try to collect the worst offenders and store them up as evidence.

I really, really need a nap. But first, this question.

Question 2: Do you need to know if you have diabetes? Or would you rather go for years with undetected high blood sugar?

The U.S. Preventive Services Task Force issued a revised recommendation in June: People who do not have obvious symptoms, and also do not have blood pressure above 135/80, do not need to be screened for diabetes.

In other words, you could have abnormal glucose levels for years, and as long as your blood pressure isn't creeping up, the U.S.P.S.T.F. thinks you don't need to know you have it.

Junkfood Science recently reviewed changes to the U.S. Preventive Services Task Force and how this group whose recommendations were previously seen as unbiased reviews of the scientific evidence are now subject to greater influence by non-scientific entities.

In the Reuters article linked above, one of the members of the Task Force that issued these particular guildlines, Dr. Susan L. Norris, stated:

Aggressive lifestyle changes can dramatically reduce the incidence of diabetes, but it is not clear whether the diagnosis of pre-diabetes confers any particular health benefit over and above what one might expect if all obese patients were counseled to pursue these lifestyle changes.

In other words, all fat people, regardless of their actual health status, need to be counseled to pursue "agressive lifestyle changes." Because, we have evidence that it works, right?

If I had to hazard a guess, I would say that this is an attempt to stop providing preventive services to people with type 2 diabetes until they are much, much sicker, at which time they can be blamed for not having adopted the "agressive lifestyle changes" that all fat people should adopt. Maybe their care won't be covered, or they will be triaged so low that they go untreated.

If you can, try to be one of the lucky fat people without undetected, uncontrolled diabetes. Or one of the lucky thin people without undetected, uncontrolled diabetes. Or, if you do want to have your glucose level tested, you know, just to be on the safe side, try to sustain a blood pressure of more than 135/80 so your insurance company will cover the cost of provider adherance to the "evidence based" guideline.

I think (hope?) most providers will continue to order fasting blood glucose tests of patients that they suspect might have diabetes, based on the American Diabetes Association's guidelines. But what use are the U.S.P.S.T.F. guidelines if they don't lead to better health? Are they now more about the bottom line for health insurers and payors, state and federal governments included?

What do you think? Will you use this as fodder if a health professional wants you to have a fasting blood glucose test, and say, no thanks? Would you prefer to wait until you had symptoms, such as frequent urination, excessive thirst, extreme hunger, unusual weight loss, increased fatigue, irritability or blurry vision? How many of those symptoms might you dismiss (increased fatigue, for example)?

Quotes from one of my heroes, part 2

Sat, 07 Jun 2008 22:12:03 GMT

In my previous post, I quoted Dr. Camara P. Jones, MD, MPH, PhD, who is described on the Unnatural Causes Web site in this way:

Camara Phyllis Jones, M.D., is research director, Social Determinants of Health and Equity, at the Centers for Disease Control and Prevention, and a professor of medicine and public health in Atlanta. She is also a family physician and social epidemiologist whose research focuses on the effects of racism and the structural causes of "racial” health inequities. Though her work, she hopes to initiate a national campaign against racism.

She participated in a forum to answer questions posed by site visitors, and when asked to do this:

"Name three things that every person can do to work towards health equity."

She said this:

"1) get active politically; (2) name racism and other systems of power which create uneven playing fields – in other words, don't be in denial; and (3) understand and act on our interconnectedness – know that we are all in this together, and act upon that knowledge."

I aspire to all three of those, in particular the third, and second, and the first, well, all three.

I think that's why I'm blogging. I'm sure there is more I can do (and there is more that I do). I'm stumbling through. I'm a terrible speller and grammar is far from my forte. I say the wrong things and I'm unable to post comments on several blogs for reasons unknown to me. But I don't think there's any other way to understand interconnectedness than to talk about it, stumble around trying to guess at the shape and size of it, and say, okay, I'm going to be on this side of the fence, even if it doesn't feel entirely safe or perfect, because not taking a side would feel much worse.

Risk Markers and Risk Factors

Fri, 06 Jun 2008 01:07:57 GMT

One of the people I most respect in my field is Camara Jones, MD, MPH, PhD, research director, Social Determinants of Health and Equity, at the Centers for Disease Control and Prevention. I really need to write a whole post just about her, but for now, I want to share some excerpts from a Q and A session that has been posted on the Unnatural Causes Web site.

As part of a response to this question:

Health outcomes are based on so many factors that it seems irresponsible to pin it all on racism, especially if one can "perceive" racism that isn't necessarily there? Isn't the program doing a disservice by lulling people into thinking the problem is "out there" rather than focusing on the way we react to situations?

Dr. Jones responded:

"I’d also like to say that racism is not some miasma, some cloud, and “Oh my god, it’s racism! What can I do? Let’s hunker down and maybe I’ll eat five to nine fruits or vegetables a day, or go out and walk,” something like that. Racism is an actual system of power. It’s made up of structures, policies, practices, norms, and values – the who, what, when, where, and how of decision-making. The mechanisms of racism are knowable, they’re identifiable, and they’re addressable. So when you start naming racism, then you can ask, “How is racism operating here?” When you ask that question, then you start to identify some of the mechanisms and then you have targets for action."

Wow. That's worth chewing on and digesting.

An in response to this excellent question: Should doctors take race into account when treating patients?
Dr. Jones has much to say, including:

...physicians should not include so-called race as part of the Chief Complaint, but should include it as part of the Social History. In fact, a lot of my work started when I was a physician in training and I was noticing the routine use of race in the Chief Complaint, so I would challenge my colleagues, "Why are you including race in the Chief Complaint?"

The Chief Complaint is the little telegraphic message that one physician communicates to another with the most salient aspects of a case. So if I have just seen somebody in the emergency room, and I want to tell another physician to get their advice or whatever, then I might say something like, "Mrs. Jones is a 26-year-old Black female who presents with a two day history of cramping abdominal pain." And I would ask, why is it so important to include race along with age and gender in the Chief Complaint? The long and the short of it is, that's how people were trained. They never thought about it before.

But then some also admit that they think race might be a biological predictor, and that's because of the way that the epidemiology is presented to physicians. I mean, some doctors still think about race as a biologic risk factor because of how the studies are done. The studies document race-associated differences and then adjust for race, but they don't ask, "Well, why would we see these differences?" So, many of us on the research side are trying to investigate exposure to racism and other socioeconomic and cultural components to provide more details to physicians.

My last point is that race IS a very potent social marker. But it's a risk MARKER, not a risk FACTOR. It doesn't cause diseases but it marks all of the other things around it that can contribute to disease. It's important to know about those things, so the Social History part of the medical record, where you talk about where that person is coming from and their experiences, including racial-, ethnic- and class- based experiences, is an appropriate place to mention race.

Ah, now, if only some of this thinking could be extended to the obesity paradigm. I know it's not the same, and yet, the overlap is unmistakable, especially when I consider some of the posts at First, Do No Harm.

I'm going to let the idea of fatness as a risk marker roll around in my head for a few days and see what comes out. I think differentiating between a marker for risk and a cause of disease is a detail that is too subtle for some people, including doctors, to grasp.

More to follow.

A Presumptive Nominee: Relief and unease in equal measures

Wed, 04 Jun 2008 07:46:58 GMT

Maybe it's that I'm nearly 40 years old -- no longer young enough to be strictly optimistic, not cynical enough to resort to "snarkiness," not so old that I've seen it all before, but old enough to have been disappointed more than a few times at what U.S. voters on the whole will do (or U.S. voters in a corrupt system).

Maybe it's all that and more that makes me wary.

There are many things about Barak Obama that I like. He's energizing. I love how many people he's gotten engaged in the democratic process for the first time. He says most of the things I want to hear, such as this:

"Change is building an economy that rewards not just wealth, but the work and workers who created it. It's understanding that the struggles facing working families can't be solved by spending billions of dollars on more tax breaks for big corporations and wealthy CEOs, but by giving a the middle-class a tax break, and investing in our crumbling infrastructure, and transforming how we use energy, and improving our schools, and renewing our commitment to science and innovation."

Where unease seeps in is in how close this race was, and how divisive it has been.

When I caucused in my state (my first time caucusing) I was undecided, and remained so. The candidate whose platform best matched mine was John Edwards. I was ready to back HRC if she were the nominee, even though my unease with her was even greater. But I watched those energized by Obama and got a bit inspired.

I am someone who believes that (non-violent) conflict isn't always a bad thing. Conflict can lead to hearing those whose voices were not previously considered, and to help us define what we truly value. However, I was uncomfortable with the calls for HRC to leave the race before the primaries were finished. I thought that the way that the states who moved their primaries up was handled meant that there was this uncomfortable lack of clarity about who "really won" the popular vote -- and that isn't the system we currently have, anyhow, for choosing a nominee. (Anyone up for reforming this?)

I am excited about Barak Obama. I don't doubt that he can win the general election, depending on how things play out. I'll be waiting to see how he courts the hard-core HRC supporters, and, just as importantly, how far he will go to court the independents and on-the-fence Republicans.

The top issues I want to hear addressed in the general election, in no particular order, are:

Poverty and hunger (inside the U.S. and internationally)
The rich paying their fair share of taxes (and if my taxes go up a bit, too, I can live with that)
"Investing in our crumbling infrastructure"
Improving the quality of our schools and other public institutions
Improving access to those things that contribute to good health -- health care being one of them -- without scapegoating people who are "driving up costs" by actually needing health care. The other things that contribute to health being, as I see it:

education (starting with early childhood education all the way through graduate degrees for all those who want it)
affordable and quality childcare for families that need it, including enriching after-school care
jobs with living wages and livable working conditions for everyone, regardless of legal status
safe housing and neighborhoods
clean air and water
food of excellent nutritional value to all who need it, not just those who can afford it
ending as much discrimination as we possibly can in every sector that we can

How does this connect to fat acceptance?
I think it's interconnectedness with people struggling for acceptance, for respect, for equal rights, the right to love ourselves and each other and be able to do so openly without fear of attack, for the right to be ourselves and obtain unbiased assistance when we need it, whether from medical professionals or police or social service agents or simply our fellow human beings.

I've been thinking about how to convey to the Obama campaign my desire to never again hear the words "obesity epidemic" come from Barak Obama's mouth, and that what makes much more sense is to talk about helping everyone in the U.S. to achieve the best quality of life, and to address the social determinants of health, is what will result in the outcome we're looking for. How when we focus on reducing health disparities, individual choices are a small, if important, piece of the puzzle, and usually the last one to fall into place. How scapegoating fat people will do no good, unless he's willing to write off the majority of the population. How the focus on childhood obesity (rather than child welfare) will make health worse for not only fat children, but children and teens who are afraid of becoming fat.

Well, that's a start of what I want to say.

This is my first political post ever. Comments appreciated.

The Ethics of Public Health Education

Wed, 28 May 2008 01:19:08 GMT

The title caught my eye from the Fatosphere: Public Health -- A different concept of medical ethics, posted on Junkfood Science. While the post makes important points, I feel the need to clarify something -- those are not the ethics I was trained were "true" public health ethics. I find it horrifying that there would be an entire journal that hijacks the ethics that I was trained in.
It's far from true that all medical practitioners share the same view of medical ethics, but there are bodies that can hold practitioners to ethical standards and when these standards are violated, there can be consequences. The main body that holds public health practitioners to ethical standards are public bodies. Public health is political, more often than not the decisionmakers are appointed by elected officials, and they are accountable to their constituencies. While there are most certainly private forces that influence and impact public bodies, as Sandy Szwarc often reports on, public opinion also matters, and we all have ways in which we can express our opinions.
From the Ethics of Public Health Education, as I was taught them, from the Society of Public Health Educators (or SOHPE), here is the main principle that I operate under:

Responsibility to the Public

A Health Educator's ultimate responsibility is to educate people for the purpose of promoting, maintaining, and improving individual, family, and community health. When a conflict of issues arises among individuals, groups, organizations, agencies, or institutions, health educators must consider all issues and give priority to those that promote wellness and quality of living through principles of self-determination and freedom of choice for the individual.

(Emphasis mine)

This is in sharp contrast to the paternalism advocated by the professor cited in the post at Junkfood Science. The ethics described on the SOPHE site aren't the only ones that public health professionals adhere to, and medical ethics and standards of practice of the organizations that we operate in are also guiding our behavior. I spend a good amount of time contemplating nonmaleficence and beneficence when deciding on a course of action in my work. I know I'm not alone. Many people don't like it when you raise ethical questions, though, and can be defensive in their responses.

I know I've said this before, but if you don't like something that a public health entity is doing, it is your right to speak up, weigh in, and advocate for your perspective.

Which serves as another argument for those of us whose perspective on fatness differs from that of the powers that be to "get organized."

Accepting fat and addressing diabetes

Sat, 24 May 2008 16:01:56 GMT

Rachel at TheF-Word.Org has a thought-provoking post about diabetes. She says:

Type 2 diabetes is the prime weapon of choice in the arsenal of the anti-obesity establishment, who fear-monger the disease to promote their own weight-based agendas.

And asks:

Is the emphasis today constructive or potentially harmful?

I think the answer to that question is: Yes. Both.

In response, I (humbly) submit this preliminary list of things that people who support fat acceptance can do about diabetes:

1. Know more about it.
The National Diabetes Education Program is a good place to start. For the most part, you don't need to check your fat acceptance at the door here. The more you know, the fewer inaccurate myths you harbor, the more you will be able to help your friends and family, or strangers online, who may be impacted by diabetes.

2. If you have diabetes, it's better to know it than to not know it.
Find a health professional you can work with, and see her/him regularly.
Here are the recommendations about type 2 diabetes screening from the American Diabetes Association:

1.     Testing should be considered in all adults who are overweight (BMI ≥25) and have additional risk factors:
    * physical inactivity
    * first-degree relative with diabetes
    * members of a high-risk ethnic population (e.g., African American, Latino, Native American, Asian American, and Pacific Islander)
    * women who delivered a baby weighing >9 lb or were diagnosed with GDM [Gestational Diabetes]
    * hypertension (≥140/90 mmHg or on therapy for hypertension)
    * HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l)
    * women with polycystic ovarian syndrome (PCOS)
    * IGT [Impaired Glucose Tolerance] or IFG [Impaired Fasting Glucose] on previous testing
    * other clinical conditions associated with insulin resistance (e.g., severe obesity and acanthosis nigricans)
    * history of CVD
2.     In the absence of the above criteria, testing for pre-diabetes and diabetes should begin at age 45 years
3.     If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.

If you are wondering about the "overweight/BMI≥25" as the criteria, screening is about trying to find people with a condition, not about identifying what causes the condition. This casts a wide net in order to try to find people who have diabetes. This is done because people who go for years without knowing they have diabetes can have serious damage to their small and large blood vessels, which can cause serious harm to organs (eyes, kidneys, heart, brain) and body parts. Sometimes, it's only when people are in the hospital or emergency department for something else that they find out they have diabetes. It's estimated that for every two people with diabetes, there's another person walking around with diabetes who doesn't know it.

3. Try not to distance yourself from people with diabetes.
People with diabetes aren't bad. They didn't bring it on themselves. People can do "everything right" and still have diabetes. People with diabetes can do "everything right" and still end up with complications. There is so much still unknown about diabetes.

4. Try to find a source of physical activity you enjoy.
Whether you have diabetes or not, being physically active is a good thing, if you can do it. Work to figure out how to do something you love, like or can at least tolerate. If you connect being physically active with losing weight, and are avoiding it for that reason, work on it as you can. [I'm working back up to more activity as I've been sidelined by a series of bad colds. I feel like I'm right back at the beginning on this one, but I know it's essential for my mental health as well as better diabetes control.]

5. Try not to judge what other people are eating.
People with diabetes (and those who may be trying to avoid it) have a very good reason to figure out how they can eat that will lead to the best outcomes for them. This might mean choosing artificial sweeteners over sugar, (or not), or sometimes allowing themselves to eat something that will make their blood sugar go higher than is recommended because they are human. Each person with diabetes has a right to experiment to find what works for them. What a person with diabetes eats is their own resposibility, and not open to comment from others just because they have diabetes. People with diabetes can be under tremendous pressure to lose weight or not gain weight, and this can have an impact on their food choices. So some compassion and consideration are definitely in order.

6. If you are thinking about quitting smoking, get all the support you need.
What is this doing here? I thought we were talking about diabetes? Smoking makes diabetes more dangerous if you have it, and there is mounting evidence that smoking may contribute to the development of type 2 diabetes. I don't say these things to try to scare anyone into quitting. Quitting is hard. Support, in the form of medications, coaching and other stuff, is out there, often for free. Here's a link to some resources.

This list is a start... is there anything you would add?
Do you have questions about diabetes that you want answered?
Maybe I can provide you with an online resource that could help.

Looking at "accumulated advantage"

Thu, 22 May 2008 01:17:09 GMT

Just a quick post to say that I ran across something interesting today at work, namely, an "interactivity" called "Accumulating Advantage." It briefly sums up how advantages pertaining to race and class get accumulated, and how this can have an impact on health. Personally, I think it would have been great to add in some of the concepts from the research done on adverse childhood experiences, but as it is, I thought it was great.
So, take a look and let me know what you think:
Accumulating Advantage

Sick and tired, and this is what I do

Fri, 16 May 2008 11:54:11 GMT

It's been two weeks that I've been battling a nasty bug that causes me to be extremely tired, congested and overall, yucky. I will admit that I've been feeling sorry for myself. And also annoyed with myself because I'm aware that this is just a cold, I will get better, and there are people facing far, far worse things right now.

So, I did something I almost never do, I wrote to my senators and congressperson.
It's not the most eloquent piece of email they've ever received, but it captures how I've been feeling at the moment:

I am writing to you today out of my concern over international crises faced by natural disasters and food shortages. I am in favor of increasing aid to provide food to those who face shortages, aid to those affected by the cyclone in Myanmar and the earthquake in Sichuan, China. Even if this means a tax increase for my family, I want to see financial and food aid increased, in addition to policy changes to ensure that the resources of the U.S. are utilized to feed the hungry and attend to those in need in wake of natural disaster.
Please do all that you can to increase aid to those in need, make changes to the policies of the U.S. government so that food shortages are not exacerbated, and that poor people throughout the world are protected from rising food costs.

Mother's Day 2008

Sun, 11 May 2008 23:20:49 GMT

This is my third mother's day (as a mom).
I spent the day with my little family and some friends, doing typical Sunday things, now that I'm back at home from a brief trip away.

It seems I missed some controversy that I've been catching up on today. I'm still recovering from a very nasty cold so I'm going to sleep very soon, but here are some things I'm thankful for this Mother's Day:

My mom
My little one's laugh -- I would do almost anything to hear it
After trying for a long time, and worrying about having type 2 diabetes (and the dreaded fatness) prior to pregnancy, that I lucked-out and had a healthy baby
I nursed said baby for almost two years (and I still feel guilty about weaning?!)
Sometimes, a stern look or tough-sounding voice is enough to trigger my little one's budding conscience
I'm not the worst mother ever
I'm not a very sound sleeper
I'm okay with not getting any gifts for Mother's Day (really. No, really.)
I earned my "mommy wings" by surviving two seven-hour cross-country flights on my own with a 3-year-old and didn't resort to hitting, screaming, yanking or consuming any in-flight alcoholic beverages. (Edit to clarify, my 3-year-old hasn't ever been hit, spanked or yanked and when it comes to witnessing me consuming alcoholic beverages, except for one drink on my birthday, that's pretty rare. As far as the screaming, well, it doesn't happen all that often and I'm working on it).
I get to be a mom and also be "in the world" in a real way, and this blog is part of that, so to anyone reading, I'm thankful for you, too.