Fat, Fillyjonk, Medicine

The nocebo effect

We talk a lot here about how mental health is just as important as physical health. This is often in the service of pointing out that even if losing weight were in and of itself a healthy goal — and there’s plenty of evidence that things aren’t that simple, and that in fact the pursuit of weight loss can be physically harmful — you would also have to take into account the violence that dieting can perpetrate on your emotional well-being.

What we don’t often discuss is how deeply intertwined mental and physical health can be. This week there’s a fascinating article in New Scientist that delves pretty deeply into that connection. We all know about the placebo effect — that you can see benefits from a treatment you’re not really getting, as long as you think you are. And if you’ve ever looked at the results of clinical drug trials and seen how many control subjects experience side effects from a medication they’re not taking, you know something about its shadow partner the “nocebo effect,” where the same nonexistent treatments cause harm. But the power of somatization is even stronger than that. Apparently it’s so strong, at least in some people, that just being convinced that you’re about to die can actually kill you.

Fat people are unceasingly told that the size of their bodies will kill them — if not personally by their doctors, families, and acquaintances, then collectively by the media or by strangers. Trolls like to tick off all the diseases your fat ass is going to get; one commenter at Powell’s actually implied that people would get heart disease just from reading the book. There’s a constant cultural susurrus about diabetes, heart attacks, health care costs, living to see one’s children grow up. Even leaving aside the fact that this inescapable refrain can make people fear exercise or stop getting medical care, it tells us we’re already doomed. And look what that can do.

Think about it. Being convinced you’re sick can kill. Being convinced you’re well can cure. If indeed fat folks are iller, can we really be surprised?

78 thoughts on “The nocebo effect”

  1. What’s more, people who believe they have a high risk of certain diseases are more likely to get them than people with the same risk factors who believe they have a low risk. It seems modern witch doctors wear white coats and carry stethoscopes.

    Wow. This is really fascinating.

  2. Mind over matter works in many many ways…even to harm ourselves.

    Hey kids! Let’s start a movement, one where we don’t accept this kind of BS!

    Oh, wait…we already did :)

  3. This has already been shown in the context of weight.

    I am a new reader, so I don’t know if you discussed this article when it came out, but there was an article published in the American Journal of Public Health about a year ago. The analysis suggested that people’s perceptions about their weight were more influential on their health than their actual weight.


  4. P.S. For those who don’t click the link, the abstract’s conclusion:

    Conclusions. Our results raise the possibility that some of the health effects of the obesity epidemic are related to the way we see our bodies.

  5. Holly, we did discuss that briefly when it came out; worth nothing that while they’re on the right track, what they examined is the effect of negative body image on people’s self-reported “healthy-feeling” days. It’s very important to point out that negative body image makes it hard to recognize your own level of health, or makes you put a negative spin on what your body can and can’t do. But what I’m saying here is slightly different, to wit: being told that you are unhealthy because you’re fat will actually make you sick, i.e. that the “obesity epidemic” is a self-fulfilling prophecy (at least when it comes to health effects). Sort of takes it a step further.

  6. As someone in the mental health field, I am not surprised. As someone who has worked with families, I would add that parents’ beliefs that a fattie child will die compounds the effect. As someone whose family has communicated that she will die an early death or at least live a miserable, pain-filled life because of teh fat, I want to sob.

  7. Jinx, Holly. I just this week read another paper by the same guy (Muennig, from the Mailman School of Public Health @ Columbia) here: http://www.biomedcentral.com/1471-2458/8/128


    “Obese persons experience a high degree of stress, and this stress plausibly explains a portion of the BMI-health association. Thus, the obesity epidemic may, in part, be driven by social constructs surrounding body image norms.”

    “If shifts in depictions of beauty in the media are partially to blame for the health effects of obesity, public health officials may have unwittingly exacerbated the problem by promoting thinness. This paper’s hypothesis thus speaks to larger examinations of public health policy, and health communications campaigns. If the obesity epidemic is partially attributable to social constructs surrounding ideal body types, there is a need for new research and policy paradigms that emphasize fitness and healthy eating habits[73] alongside social acceptance of heavier members of society.”

    Lotsa footnotes, too.

    I don’t think he completely discounts teh death fatz, and I’m not qualified to judge the science.

    But it seems like a definite step in the right direction.

    Interestingly, I found this accidentally by searching for hard numbers on a short reference I read in Self magazine (that well-known bastion of size acceptance; not) to a study that found that people who desired to lose weight (regardless of current BMI) reported more “unhealthy days”.

    Now, mind you, that study was also Muennig-related. Which does kinda make you go “hmmmmmm”. We’ll just hope he became fascinated by the anomalous-according-to-accepted-wisdom data and kept following it.

  8. …. and if I would have read more carefully, I would have seen that is the same study you linked to; blush.

  9. @Vixen: Do I miss something here? As far as I can see, you and Holly linked to two different studies. And the one you linked to is in some ways more interesting because the researchers actually measured biomarkers of stress in the blood of people – and found that they were elevated in fat people. Which is a strong indication that fat people are actually more stressed.

  10. i haven’t read the studies, and as it’s nearly 5 am (i haven’t slept yet) i won’t try to read them right now. *^_^*

    but i can say from personal experience, when i’m told that i will die because of x in my food, x in my body, or x anywhere, i start feeling bad about myself. one thing that i’m trying to accept is that if i *do* have heart problems in the future, it’s not my fault. at this moment i can say “fat people AND skinny people get heart disease” and completely believe it. but there is a softer voice that tells me if I get it, it’s All My Fault because i’m fat.

    that is some nasty shit to wrestle with. but then, i suppose all shit is nasty if you wrestle with it. it is shit, after all.

  11. i just had an odd-yet-interesting analogy pop into my mind.

    i was thinking about one of my sisters who is getting fairly serious about supplements and raw foods. she feels healthier for doing this, and she really wants our other sister to start doing it because she’s been sick a lot lately.

    while i was thinking about this, i suddenly thought of shoes. i imagined going to sister 1 and saying, “you should really wear my shoes! they’re fabulous!” and then her pointing out that they aren’t her size and wouldn’t fit. in my dream convo we go back and forth with this debate for a while. ^_^ but the conclusion of it is that just because something is fabulously comfy on my feet doesn’t mean that they will be fabulous for anyone else. feet are different! people are different!

    yeah, i know this is obvious to everyone else, but it was a neat little story in my head and i wanted to share. ^_^

  12. I touched on this briefly in The Rotund’s latest thread, where a doctor bascially said more fat people suffer depression and suicidal thoughts. First of all, that’s a dangerous blanket assumption to make, as not all fat people are depressed and unhappy about their weight. Second, mental illness does not discriminate when it comes to size. Third, the doctor doesn’t want to realize that maybe it’s not the weight itself that is causing people to feel mentally unwell, but the hostility from media, the medical community, and strangers over fat.

    This same doctor did advocate weight loss to help treat mental illness….I just don’t understand the logical disconnect so many so-called experts seem to have. Weight loss doesn’t make everyone happy, especially if you’re starving!

  13. Y’know, reading today has just caused me to experience a tiny epiphany. I am Officially Old having had my 75th birthday yesterday. For some considerable time, I have been observing that many people of my age talk about nothing except their bad-health problems which they seem to have ad infinitum. And then they say some form of “Oh, you are SO lucky! You are NEVER ill.” Yesterday I stopped smiling through gritted teeth and actually mentioned my two separate bouts with two different cancers, my hip replacement, and the fall a week ago that chipped a bone in my right wrist.

    But the thing is, and here comes the teeny tiny epiphany I just had, I actually DON’T expect to be ill. If I am, I deal with it, of course, but I am not hanging around dodderingly waving my cane and waiting for ill health to descend on me. I do not live in a climate of “Well, at your age, you must accept that…blah blah blah..” And so, basically, I am NOT ill!

  14. FTA: most of us would laugh if a strangely attired man leapt about waving a bone and told us we were going to die. But imagine how you would feel if you were told the same thing by a smartly dressed doctor with a wallful of medical degrees and a computerful of your scans and test results.

    Interesting discussion. How does repeatedly hearing things like “the fat is gonna kill ya” affect us? Is it the repeated suggestions that somehow lead to neuro-chemical-biological changes, thus causing illness; or might it be fear that one is already ill (because of the repeated suggestions) that lead a person to postpone care? I imagine it would be really difficult to study this phenomenon. How do you measure belief? How do you measure the influence of years of repeated insults, death threats, and derision from health care “professionals” and the media?

    One thing I’ve always tried to do in my own work as an RN is to tell people that statistics about illnesses, life expectancy, etc. just give us a big picture; they can not predict what is going to happen to any individual person. I don’t know if that has any effect or not, but I hate this idea that health care professionals are being “honest” about a patient’s illness when they dole out these figures.

  15. I wouldn’t be surprised if stress was a huge factor here. We know that stress has a big impact on things like blood pressure and blood sugar. If you really believe that you are not going to live to see your children grow up, because over and over you hear that if you have a BMI over 30 you are just a heart attack waiting to happen, that has to be a constant stressor that is always in the back of your mind, even when you aren’t consciously thinking about it. There are so many messages coming at us daily about how being fat is wrong and bad and ugly that I bet we don’t even process all of them consciously, but they’ll still affect us. It wouldn’t surprise me at all if they create this kind of stressful background noise in our lives that has harmful effects on us even if we aren’t really thinking about it.

  16. I have personally often wondered how much of a negative effect on health does constantly being told that your body is unacceptable/you’re unhealthy/ you’re going to die have on your actual body.

    I wonder how health statistics of fat people look like in societies where fatness is seen as a normal or even desirable physical state?

  17. I sort of just realized that I’ve been waiting 10 years to miraculously lose weight so I would feel better about myself (I’m a size 12, or thereabouts). I looked at photos of myself and noticed that I’ve looked like this for my entire marriage (since my pregnancy), and my naturally slim husband still loves me, whoa. Last year I had a bit of a mental health crisis (and lost a few pounds without trying), but managed to pull out of it. Feeling much better, I saw the clinic shrink (for meds), and happily told her how I was doing much better, although I was pretty sure I’d gained back a few pounds. “Well,” she immediately said, “What are we going to do about that?” I just stared at her. Until that moment it hadn’t occurred to me to do anything at all about it, except maybe try to walk more. I left her office feeling like shit – like I’d been slapped by the Fat Police.

    I discovered that I feel as stressed out and depressed over my body at a size 12 as other women do about being a size 22. This is ridiculous! I haven’t allowed myself to buy nice, fitted, structured clothing because I’m not thin enough yet to “deserve” it, or something. I realized that – whoa – this might just be what my body looks like now, period. I’m 39 and have been sooo depressed that I don’t have the lithe skinny body I did when I was in high school. How unrealistic can you get?! I’ve been so ashamed, and yes paranoid of what others think of me.

    I’m looking forward to shedding this toxic mind set. I want some new fabulous clothes! Oh – and I never went back to that shrink. She’s toxic, too.

  18. Glad to see this. I have been saying this forever and bringing it up in class when I teach research. My students are open minded, but most MSM fed sheeple just give me a blank stare. I hope the world starts to give this more serious consideration.

  19. What I’ve wondered about … from what I’ve observed, it also seems to me that between the obsessions for ‘wellness,’ the obesity panic and our disconnection with our own bodies, there’s a tendency to believe that if we’re not … slim and supernaturally well, then something must be wrong.

    Somewhere on this blog, there’s a discussion of huffing and puffing on the stairs, and how some folks took that as a sign of ill-health rather than an ordinary physiological response to a bit of a workout. That’s the sort of thing I mean.

  20. I hate it when I try to clarify only to obfuscate.

    The study I linked to is different than Holly’s. Same guy, though.

    I don’t know if it’s possible to tease apart all the possible causes …. how do you determine between “Your fat is visually hideous (according to cultural beliefs)” and “Your fat is making you sick (according to cultural beliefs)”? It’s sure another board in the coffin, though…..

    I’m a bit dubious about “reported unhealthy days” as a unit of measure …. but it was interesting that apparently there is data to indicate that men who wish they weighed MORE also experience the same dynamic (more unhealthy days reported) as women who wish they weighed LESS.

  21. This is fascinating stuff. I saw this article the other day
    titled “One In Five Obese Women Select Overweight Or Obese Silhouettes As Their Ideal Body Image” and I took this as a great sign of fat acceptance. However, the authors conclude that it is important to convince these women to try and lose weight. So disappointing and negative!!!

  22. Happy birthday Patrisha!! You have the same birthday as my older son! :)

    That story is really interesting… I’m mulling over, and appreciating, how it provides a way of thinking about the connection between psychology and physical health — *without* blaming sick people for being sick because (the thinking goes) they didn’t “trust their bodies” or “think positive.”

    Huh. *mulls some more*

  23. Has anyone seen the movie What the Bleep Do We Know? It deals with the effects negative thoughts can have, among other things. There are pictures of water labeled with words like “I hate you” and “love.” The vials of water with negative labels have chemical changes, presumably from others looking at them and emitting negative energy toward them. If there can be chemical changes to water from unconnected people thinking negative thoughts in its proximity, what do we do to our own bodies (which are largely water) with constant negative thoughts? Or positive thoughts?

  24. A Sarah, I had similar thoughts. While I believe positive thinking (or the opposite) can be a factor in one’s wellness, it’s a short step to a place where people start saying illness (or weight) is caused by incorrect thinking and any problems can be solved with correct thinking. That makes me nervous.

    I mentioned on here another day about a “friend” who told me Jesus said heal thyself about my weight. She also went on a tear about my weight being the result of not “attracting” wellness because I don’t really love myself and don’t believe in the power of God’s miracles. She has adapted The Secret as her personal mantra and thinks thoughts create everything that happens to us, no exception. If I only “really” believed, I’d be thin and well right now. She even told me that the Jews “attracted” the holocaust because they have a persecution complex! As I mentioned, we’re no longer friends.

    @one jewish dyke: I really liked many of the ideas in that movie, but the water thing was a little much. The truth is there is a great variety in how water molecules look from moment to moment with or without words taped to the container. Emoto is more of an artist, in my mind. What he does is take multiple pictures of ice crystals then picks the ones that support his theory. His experiments are not double blinded and have not been replicated by other scientists. Also, he sells blessed water ($35 for 8 oz) and stickers that say things like “god of wealth” to put on your wallet and change it’s vibrational energy. Not exactly scientific in my mind.

    Happy Birthday Patrisha!

  25. Actually, I read many years ago about studies of cultures where fat is accepted &/or celebrated, most especially Pacific Islander cultures, where many people are very large & normally become moreso with age. People in these cultures were comfortable with their size & in their bodies, so carried virtually none of that stress, & they had very a very low incidence of heart disease, hypertension, etc. A couple of years ago, the King of Tonga died; he had weighed between 380 & 475 pounds all his adult life. He was also 88 years old when he died.

    The early pioneers of fat acceptance, particularly the Fat Underground, believed very much in this…that, first, all their attempts to be thin had made them fatter than they would have been had they never tried to ‘control’ their weight, & 2) that the hatred, discrimination, abuse, & lack of access suffered by fat people accounted for almost ALL of any difference in ‘health’ between fat & thin people, with the rest being accounted for by the damage done by dieting. not to mention the deadly effects of WLS. So much research seems to indicate that, all other things being equal, fat people are every bit as healthy at thin people, if not often moreso. We are fine as we are; ‘obesity’ is an artificial construct created by pharmaceutical & insurance companies, medical researchers wanting more grants, diet companies, & anyone else who stands to profit from convincing us that we are killing ourselves…& don’t forget THE CHILDREN…with fat.

  26. Sticky said, “While I believe positive thinking (or the opposite) can be a factor in one’s wellness, it’s a short step to a place where people start saying illness (or weight) is caused by incorrect thinking and any problems can be solved with correct thinking. That makes me nervous. ”

    Ditto times a thousand.

    I think the *really* helpful thing is to gain awareness about the massive negativity load bestowed by merely absorbing, unquestioned, the moral and aesthetic tenants of the dominant culture.

    Forewarned is forearmed.

    That’s why I so appreciate this space and others like it.

  27. I wrote about something similar in a blog of mine in early April. As I have reviewed my life I see a clear correlation between mental/emotional well-being and physical well-being, and any time I am focused on my size my health suffers.

    I have a CNM who I see for well-woman care that I love dearly (she was the first medical care provider to realize that I am hypothyroid and helped see me through a very weird and hard-to-diagnose cancer) but she is obsessed with my weight. Every chart I have in that office has that lovely clinical diagnosis of “obese.” What amazes me is that she thinks my size is unhealthy when she is well aware that I have low blood pressure (even after a hysterectomy and the loss of protective, pre-menopausal estrogen levels), good blood sugar, good cholesterol, etc. This last visit she was trying to encourage me to get under 200 and I tried, unfruitfully, to help her understand that if I focus on losing weight I lose my mental health, and when I lose my mental health I suffer physically (and gain weight to boot) . Not to mention that my weight is pretty irrelevant in light of my overall physical well-being. One of these days I am going to take her a copy of The Obesity Myth and Rethinking Thin. I have already printed out at least one of the articles listed above to mail to her.

    When my CNM sent my records to an endocrinologist (for the hypothyroid) they were coded in such a way that the endo thought I was there for help with weight loss! I quickly set the endo to rights and, to my eternal gratitude, she was relieved – she is firmly against any sort of dieting. The endo is totally my kind of woman – she clearly believes in health at every size and focuses on me staying physically active and mentally/emotionally fit.

    I find when I get my mind in the right place, my body follows. Here is a great article from my favorite tarot reader and metaphysicist, Margaret Ruth, about just that idea:


    Hope this is not too long for a first ever comment!

  28. I had too many thoughts about this to post a comment, so I wrote an epic post about it on my blog (which anyone interested can get to by clicking on my name).

    But what I took away from the New Scientist article was about the gap between what’s happening biologically (say, in the case of cancer) and our own body’s response to thoughts of being in poor health, such as stress and immune responses.

    I think that there’s what’s happening (like a heart attack) and how we respond to it with thoughts — and that in that space between the best possible and worst possible outcome with a particular condition might be mediated to a degree by what we are told about it and how we think about it (not entirely in our control, as we didn’t build our own brains or put only what we wanted in them). The space between the best possible and worst possible outcome might be very small or somewhat large. And I wouldn’t blame anyone for not being able to “think positive” — I think we all struggle with mental hygiene to some degree or another, and some people are born at a chemical disadvantage, while others had devastating things done to their circuitry at an early age (or at some point).

    I think about this effect when I realize what a hard time my husband has taking medication he needs in order to function (or at least function well enough to be a partner I can continue to be married to). When he takes his meds, it reminds him he’s sick, and so he feels sicker. Does he still need the meds? Yes. Does the impact of the med outweigh the nocebo effect? In my estimation, it does, but not necessarily in his. If I could find someone who was his version of a witch doctor to bless the pills, it might make it easier for both of us.

  29. I would hug you so tight if I could. Thank you for writing this… this is exactly the idea I was trying, in my feeble way, to get across to someone who was fat-hating-in-the-guise-of-health on another forum, and you have just said it so succinctly and beautifully.

  30. Does anyone else remember that X-Files episode where some guy can control people’s minds and makes a fat guy have a heart attack?? I have to think of that whenever I read about the nocebo effect.

  31. I mentioned on here another day about a “friend” who told me Jesus said heal thyself about my weight. She also went on a tear about my weight being the result of not “attracting” wellness because I don’t really love myself and don’t believe in the power of God’s miracles. She has adapted The Secret as her personal mantra and thinks thoughts create everything that happens to us, no exception. If I only “really” believed, I’d be thin and well right now. She even told me that the Jews “attracted” the holocaust because they have a persecution complex! As I mentioned, we’re no longer friends.

    People like that shouldn’t have ANY friends.

    I think there’s a big difference between believing you’re sicker than you actually are by objective measures and having that affect your health outcomes, and not acknowledging how sick you actually ARE. I mean, night and day difference. Lots of people who really are terminal deny it, but it doesn’t change anything.

    Also a big difference between hearing about a certain illness and then developing symptoms as a result of obsessing about it, and developing symptoms and THEN finding out what you actually have.

  32. I think there’s a big difference between believing you’re sicker than you actually are by objective measures and having that affect your health outcomes, and not acknowledging how sick you actually ARE.

    Yes! Thank you for explaining that thought so eloquently.

  33. yeah… well that whole “the Secret” lifestyle of thinking lost my goodwill the moment I heard someone use it to explain that anyone who gets raped was thinking too many negative thoughts and that if you followed the principles in the book/system whatever then you would not get raped.

  34. Sticky said:
    “I mentioned on here another day about a “friend” who told me Jesus said heal thyself about my weight. She also went on a tear about my weight being the result of not “attracting” wellness because I don’t really love myself and don’t believe in the power of God’s miracles.”

    The verse she’s talking about is Luke 4:23, and it’s not as simple as, “if you’ve got a problem, make yourself better by believing in Jesus!” She was taking the verse out of context.

    Certainly, Luke 4:14-32 is about the lack of genuine faith Jesus encountered in Jerusalem. The people he’s addressing when he’s there expect him to cure their ills without faith. The hypocrisy of expecting that one can trade faith for “miracles” like weight loss or wealth is exactly what Jesus was talking about in that sermon.

    Even though I’m not a Christian anymore (even though I’m an atheist now), that kind of thinking makes me see red. It’s as if one’s human failings are hard evidence that one isn’t believing in God the right way.

    If anyone else gets this crap from people they know and wants to show them a contrary example from their own Good Book, please feel free to cite John 9, one of Jesus’s healings, from which one can generalize that people are the way they are so that the works of God can be manifest through them, not because of their supposed sins. Or maybe James 5:9, the famous “judge not, lest ye be judged” verse, where Christians are instructed to show kindness to their fellow people.

    Or, you know, you can just tell them that there’s nothing wrong with being the size you are, and to please go suck eggs.

  35. Yeah, ever since a Secret-fan I was developing a really good friendship with told me he couldn’t be my friend because I was too negative and it wasn’t good for him, I have NOT been in favor of the whole idea. (I mean, FFS, I had just had my heart broken and had both a nasty cold and penicillin-resistant strep at the same time!)

  36. While in part I think a little bit of the secret is spot on and actually has a lot to do with what (I think) FJ is saying (thinking you’re going to be/already are fatally ill can actually create enough stress on your body to make you seriously ill) I have to agree that the part of the book talking about how people draw negative things towards them via thinking negative thoughts pretty much made me see red. There is a lot of shit that goes on in a really shitty ass world and wrongs are the fault of the wrongdoers, not the fault of the victims (often) just simply being in the wrong place at the wrong time. I had a really hard time with the concept after the author insinuated rape victims bring rape to them with their own negative thoughts because it sounded to me highly reminiscent of the whole “she brought it on herself dressing like such a slut” argument. As though a woman’s clothing is clearly enough to warrant rape.

    What’s sad is I think the book was really getting close to hitting on something good but only scraped the sun-shiney tippy top of the iceberg thereby failing and coming to be somewhat offensive and winding up for all its supposed “differentness” being highly reminiscent of the “if something’s wrong it’s obviously your own damn fault” ideology so prevalent in our culture today. Only instead of being told you’re too lazy or stupid to be rich (or thin) now it’s your thoughts that are wrong. As if it wasn’t bad enough having the fat police, we obviously need thought police too.

  37. The thing about the “power of positive thinking” stuff is that a lot of it is misunderstood and misinterpreted. Like, for instance, there have been studies done that people who are optimistic are A) interpreting reality less realistically than pessimists, who aren’t imagining the negative things they experience/believe in/fear, but B) also are better able to handle the negative things that happen in their lives, because they interpret them as having a silver lining, not being their fault, not being permanent, etc., and then sort of erase the thing from their memory for all practical purposes; basically, pretending the world is nicer and happier than it actually is, while actually a mild form of self-delusion, has mental health benefits.

    People who are pessimists believe that negative things that happen to them are their own fault, and that positive things that happen to them are a result of luck. They get depressed (not necessarily clinically) because they don’t feel like they have any way to make sure good things happen to them, and they beat themselves up for anything bad that happens.

    People who are optimists believe that negative things are a result of luck and positive things have come from their own merit and/or hard work. They’re happy because they feel like they have accomplished and deserve all the good things in their lives, and that the bad things are just temporary bad luck that will eventually pass.

    So yes, positive thinking is good for you; it’s good for your self-esteem. But giving someone a lecture about how if you don’t think positive (or any other task they’re supposed to perform to ensure health/wealth/happiness), bad things will happen, actually reinforces whatever pessimism they already feel and causes them to blame themselves, which is the problem in the first place.

  38. The placebo and nocebo effect are one and the same process. One postive, one negative.

    A Sarah,

    *without* blaming sick people for being sick because (the thinking goes) they didn’t “trust their bodies” or “think positive.”

    A lot of the people who object most to positive thinking have fully embraced it in obesity, and more.

    They are just as bad as Sticky’s ex-friend and a lot of them purport to be atheistic science advocates.

    They never cease telling us that we have choosen to be diseased (obese) and are also choosing more disease ( obesity related illnesses) and ultimately death as a result of that.


    I think there’s a big difference between believing you’re sicker than you actually are by objective measures and having that affect your health outcomes, and not acknowledging how sick you actually ARE.

    That’s the point about the placebo/ nocebo effect, if there is, we don’t know where that difference occurs if at all.

    We can create positive symptoms, we can create negative ones equally, the question is when, why and how.

  39. @juliah: Thanks for the Bible ammunition. I wish I knew all this when she said that to me, but at least now I’m forearmed for the future!

  40. Sticky said, “While I believe positive thinking (or the opposite) can be a factor in one’s wellness, it’s a short step to a place where people start saying illness (or weight) is caused by incorrect thinking and any problems can be solved with correct thinking. That makes me nervous. ”

    This has already been dittoed x a thousand, but let me do that again.

    To me, this is just one more problem with A) the general cultural desire for black and white answers to complicated questions, and B) the general cultural belief that we have WAY more control over our bodies/destinies/luck than we actually do.

    On the one hand, I get pissed off at people who dismiss the placebo effect or psychosomatic illnesses as unreal, as though the “effect” and “somatic” parts just don’t count. The way I see it, if a sugar pill or woo-woo therapy in can make me feel better just because I believe it can, AWESOME. The important thing is feeling better, not how you got there. And conversely, even if a physical illness has its origins entirely in my head, that still doesn’t mean it’s “all in my head,” because hello, physical illness. Remember that part?

    But on the other hand, bullshit like The Secret infuriates me, and I think the kind of people who sell cures and therapies with absolutely no science behind them are scum. There is a BIG difference between a little bit of helpful self-delusion, as Slythwolf noted, and flat-out magical thinking. Which is the whole reason I’m just as anti-dieting as I am anti-quackery. Because the belief that YOU will be in the tiny percentage of people who keep it off — because YOU have made a deeper commitment than all those weak suckers who gain it back — is about as magical as it gets. And that’s what the diet peddlers prey upon.

    I think it’s entirely possible — even probable — that optimism and self-respect can bolster your immune system, and pessimism and self-loathing can weaken it. But I also don’t think that a positive attitude can necessarily ward off cancer, or a negative attitude can necessarily cause a heart attack, any more than thinking happy thoughts can necessarily make you a millionaire. It doesn’t have to be either/or. We can say that trying to adopt a more positive way of thinking is a good idea, with potential health benefits, without saying it will cure every illness and bring you everything you ever wanted, so if your health or life fall short of your ideals, it’s all your fault for being a negative Nelly.

    Which is not unlike, oh, saying that eating a balanced diet and getting regular exercise are good ideas, without saying they will definitely cause a permanent, radical change to your body shape and keep you perfectly healthy until the day you die peacefully of old age — so if you get sick or remain fat or gain back weight you lost, it’s all your fault for doing it wrong.

    Unfortunately, being realistic about your limitations (without being so pessimistic you further limit yourself) isn’t nearly as exciting as imagining that all sorts of ideal outcomes are within your grasp if you just apply yourself. Sigh.

  41. Kate – you are right on with your reply.

    Also, might I just add that positive and negative thinking don’t only have to do with your personality and you willingness to think positive or negative but also with your environment? I think that’s actually the main point about the Muennig research – in an environment that stigmatizes group X it is very hard for members of group X to think positively. Now, if you still manage to think positively in an environment that stigmatizes you will no doubt have something to do with your personality. Nontheless, a person that thinks negatively about him or herself and gets stressed when stigmatized might be completely fine and healthy if the stigma was reduced.

  42. I think that’s actually the main point about the Muennig research – in an environment that stigmatizes group X it is very hard for members of group X to think positively.

    Totally. People keep asking me what I’d like people to take away from the book, and I keep saying, “I’d like them to see that not hating yourself is a viable option. That even if you can’t imagine not hating yourself right this minute, you understand that it is at least theoretically possible not to.”

    Because that’s the fucking problem with fat-hating being so pervasive in this culture. The stigma is so strong, most fat people don’t even recognize the concept of having a positive body image without weight loss as a real possibility. I mean, if you’d asked me before my first diet if I’d rather go through the hell of dieting to lose weight or just wave a magic wand and be happy with my body the way it was, I would have gone with the magic wand, no question — even knowing that many people would still hate my fat body for me. But since there is no magic wand, and fat hate is so omnipresent, I could not even conceive of following a different — equally tough, but far more rewarding — path to liking myself as I was. I thought the options were A) lose weight or B) hate my body (and self) forever. Period.

    If the stigma were reduced, imagine how many more people would recognize that there’s nothing fundamentally wrong with them and respond by treating themselves better, feeling more optimistic, inhabiting their bodies more comfortably, and engaging with their own lives more fully. None of that shit is guaranteed to prevent a health crisis, obviously, but boy, I expect we’d see some numbers change.

  43. Bravo, Kate! As usual, you’ve nailed exactly why I was so torn on this subject.

    One other piece I’d add: to me, there’s a difference between “positive thinking” and “you must be happy every minute.” To me, a healthy self-image includes the idea that it’s okay to have emotions, and to express them. A good cry or a righteous rant can be part of a healthy approach to a situation. I don’t know if anyone else experienced this, but I took me awhile to separate “hey, it’s ok to like yourself and enjoy life” from “anger sadness and frustration are unattractive, unfeminine emotions you’re not supposed to have.”

  44. There’s also a huge difference between saying “being told you’re sick or imminently dying can make you sick” and saying “if you get sick it’s because you had negative thoughts.” That’s actually a logical fallacy (affirming the consequent). The fact that (a particular kind of) “negative” thoughts can have a negative effect on your health does not mean that ill health comes from bad thinking.

  45. FJ: thank you for mentioning that specifically. That kind of borked logic drives me batty. Just because A can cause B doesn’t mean all B is caused by A.

    I mean we all know that it’s possible to wind up with a broken leg because you did something stupid, say, got drunk and jumped off a roof, but that doesn’t mean we go around asking every person with a broken leg what stupid preventable thing they did to end up there.
    I mean, you would think that anyone past a small child’s level of understanding of the world could grasp the concept that most things that can happen to people have multiple possible causes. and yet.

  46. That’s actually a logical fallacy (affirming the consequent). The fact that (a particular kind of) “negative” thoughts can have a negative effect on your health does not mean that ill health comes from bad thinking.

    Absolutely — and for the record, I hope it didn’t sound like I was taking issue with your post. I completely agree with you on the whole thing; was just jumping into the Victim Blaming Slippery Slope convo, which I saw as a separate thing. (Um, not that your comment was even directed at me, FJ. But I’m getting a lot of love here for saying things I’m pretty sure you agree with, and which I feel are a complement to the post, not even a partial refutation of it.)

  47. I have to say that Kate’s discussion about personal power and our ability to control disease and body size is so rightly on target. People love the easy answer.
    I was told once that all my problems were the result of
    “not being spiritual enough.” Now I’m more mature, but then I reeled in anguish. I see that spirituality is about being compassionate-especially to myself.

  48. Apparently there was some paticularly nasty torture experiments done in WW2 which proved the nocebo effect true. They told the torturee that they were going to kill them, then simulated the effect and the people actually died.

  49. The way I look at it is, whether positive/negative thinking has any demonstrable physical results or not, I know from my own experience that negative thinking is no fun. It sucks; it’s painful and it’s almost impossible to dig out of, especially on your own, especially if you have the entire culture in general and most of the people you know in particular telling you it’s your own damn fault and you should just stop thinking so negatively all the time.

    This is true about weight, feminism (the part where people claim feminists “look for” things to get mad about), all the other forms of oppression that people fight, as well as being depressed. It’s your fault, why can’t you just be happy! Well, because everybody keeps telling you all your problems are your fault. That’s not really a recipe for joy.

    And YES to the idea that it is possible to be happy without simultaneously working one’s ass off (in some cases literally) to fit some cultural standard for the minimum decorativeness of women’s bodies. And also yes that it seems genuinely impossible, to most of us.

    I will keep shouting this at every opportunity, I think, until I die: Your purpose in life is not to stand around and be decorative for other people to look at! You have better, more important, more fun things to do than to exist for the male gaze to objectify! Go do something fun and/or otherwise rewarding; you not only deserve it, you need it to survive!

  50. I’m surprised no one has mentioned _The_Matrix_ yet — like, how you could actually die from getting killed in the simulation.

    Another analogy: people sometimes voice hesitation about interracial families, or homosexual families, in terms of the difficulties such families are likely to face. But the difficulty only comes from the bigotry, the “social constructs” as Muennig says. I think it’s comparable:

    them: “careful, you’d be better off if you weren’t X.”
    us: “right, because people like you keep giving Xes shit.”

  51. I have an anxiety disorder, and before I got treatment, I spent about six months convinced that I was just about to die from one damn thing or another. I can say from experience that that kind of stress does some crazy-ass things to your body. It wouldn’t surprise me at all if the stress from doctors’ and society’s criticism and fearmongering could wreak havoc on some fat people’s health.

  52. “We all know about the placebo effect — that you can see benefits from a treatment you’re not really getting, as long as you think you are.”

    You’re awesome, so I feel bad nitpicking, but this isn’t actually what the placebo effect is. The placebo effect doesn’t, for example, actually shrink a brain tumor because you *think* you’re getting tumor-shrinking medication.

    As I understand it, what it involves instead is the effect placebos have on subjectively reported experiences, as in if people think they’re getting a medication for their problem, they are more likely to report that they feel better or experience less severe symptoms. So you might report that your headaches are less severe, even though your brain tumor is unchanged.

  53. kristin, while this might be true for some conditions, for many other conditions it is more complicated than that. For example, cardiovascular disease is strongly influenced by your psychological wellbeing, and placebos can influence that.

    The same goes for some infections – there is a study that shows people who have a more diverse social network are less likely to get a cold. Those effects seem to be mediated by the immune system and by stress hormones. There is actually a whole field of research that investigates these effects – psychneuroimmunology.

  54. I also think, regarding the victim-blaming issue, that there is a world of difference between acknowledging that people in positions of authority giving people dire predictions about their health can cause worse outcomes, and believing a la The Secret that genocides are caused by the victims just not thinking positively enough.

    I just can’t believe that the numerous size 16 women I know who seem to honestly believe that they will not live to see their grandchildren if they don’t lose weight somehow came to that conclusion on their own. These are healthy, active women who have no serious medical conditions and in most cases have a family history of longevity. And yet they appear to be completely convinced that unless they lose 30 or 40 pounds they won’t make it to 60. I’d have to think that believing that unless you do something you have been unable to do despite repeated attempts (losing a significant amount of weight) you will die before you see your freaking grandchildren get born would be massively stressful, and have a negative impact on health.

    But it’s still not like, in most cases, the blame for that belief can be placed on any individual. No matter how fat-hating doctors can be, I honestly can’t believe that doctors are routinely telling women with BMIs of 30-32 that they will be dropping dead before their children are grown unless they lose weight. I’ve been to numerous doctors while in that BMI range, and I’ve never had a doctor say anything even close to that. So I don’t think it’s even the fault of individual doctors scaring people (although they are out there, and no doubt as people get larger the scare tactics become more direct and personal), but the fault of a general culture attitude that fat=death, that people have internalized in all sorts of ways that, by any objective standard, are completely and totally insane, but have come to be seen as normal. (Case in point: somebody’s blog had a link to a story about Kelly Clarkson’s weight gain on an entertainment site, where numerous commentators expressed their concern for Clarkson’s obviously dire health. It’s delusional, in reality, but we see it as sane and rational.)

    Plus, we’ve turned something that should be pleasurable and affirming–eating–into a stressful and guilt-laden activity, and yet we still have to do it every day, often three or more times. I can remember my grandmother saying “White bread, you’re dead” as a mantra for years. I mean, the woman believed that white bread would KILL her. Not keep her alive, as food in fact does, but render her dead. Again, it’s insanity, that we believe that an activity designed to keep us alive–eating–will kill us (unless done in a very specific, perfect way), just like it’s insane that we believe that something that our body needs to keep us alive–fat–will kill us. But we do believe this, and as long as women keep reading comments about how terrible it is that somebody who used to be as thin and healthy as Kelly Clarkson let herself go to the point where she’s obviously at death’s door due to her extreme obesity (she’ll be lucky if she makes it to 40, that one), I don’t think it should be any surprise that the stress will cause ill health effects, and I don’t think it’s victim blaming, but culture blaming, to acknowledge it.

  55. kristin, while this might be true for some conditions, for many other conditions it is more complicated than that. For example, cardiovascular disease is strongly influenced by your psychological wellbeing, and placebos can influence that.

    Also, we know that stress plays a significant role in blood pressure and that hormones released during stress can affect blood sugar. Since high blood pressure and diabetes are the two most common health problems associated with obesity, I think the role stress may play in the health of fat people is especially important to note.

  56. I see what you’re saying, kristin, and it’s a really important point – but lessening of symptoms is a “benefit,” too. So FJ isn’t wrong (but I found your clarification is helpful!).

  57. As for the “psychosomatic” issue. . .I offhandedly told a yoga teacher that I wasn’t sure if I was “really sick” or if it was “all in my head.”

    She gently pointed out, “Well. .. you’ve probably already noticed, but your head IS attached to the rest of your body.”

    It’s perhaps a gross oversimplification, but that way of thinking about it has made me pause over the years to remind myself that “psychosomatic” is not synonymous with “not real.”

  58. On my drive to work on Friday, I heard an ad that began “There is a dark cloud hanging over our children’s future. Obesity rates for children have tripled …” It was the Canadian Heart and Stroke Foundation touting their new “Sparks” program to promote exercise and healthy eating for kids. I was appalled and wrote to tell them so. I sent them the link to the article blogged on Junk Food Science about the eating disorders caused among young people in Australia as a result of a similar push there, but i wish I’d heard about and sent this one too. The idea of instilling fear of death in children and parents revolted me. Now I see evidence of it being harmful beyond just the stress and self-loathing it’s bound to instill. Great job CHSF.

  59. She gently pointed out, “Well. .. you’ve probably already noticed, but your head IS attached to the rest of your body.”

    My response to this, obviously, would have to be “SPEAK FOR YOURSELF.”

  60. I haven’t read through the whole comments extensively, so forgive any overlap in mine. There are good studies that show the effects of stigma on health and mental health, so I can easily see how this study could be true.

    I just went to a seminar about mindfulness and compassion on Friday where I heard John Kabat-Zinn tell the audience that we all need to befriend our bodies, just as they are. I thought a choir of angels might just begin singing, I was so excited.

  61. Yeah, as I was typing my comment I knew it was really flawed because I was leaving out the measurable effects stress has on health. So, true, definitely.

    But still, “placebo” is not another word for “magic healing through the power of the mind” as it’s sometimes presented as shorthand for. More like “the effect of thinking we *should* be getting better so we describe ourselves as getting better even though we’re not.”

  62. People who are pessimists believe that negative things that happen to them are their own fault, and that positive things that happen to them are a result of luck.

    Actually, I don’t agree with this. I’m a fairly pessimistic sort, but I tend to think the other way round – if something goes right it’s because I’ve worked to make that happen and if something goes wrong it’s in spite of my efforts to avoid it…

    Ack @ the Secret. My DD’s dad’s mother gave me a book once called “excuse me, your life is waiting” and it was full of the same kind of crap, apparently little old ladies who get attacked while their homes are being burgled are also bringing it upon themselves by expecting such things to happen (and yeah, I think the Holocaust was mentioned…) Unfortunately the book was “from her and DD” so I had to pretend to like it for a bit until DD forgot about it and I could safely throw the damn thing in the bin.

  63. I just want to add a personal anecdote about how all of the anti-fat stuff we hear constantly affects us, even if we rationally know better.

    I’m off for the summer, and with only one child and a very small home, I have a LOT of free time, and last week I thought it would be fun to challenge myself exercise-wise. I normally walk about 3 miles every day, either all at once or 2 in the morning and 1 at night, which I enjoy a lot and which does wonders for my emotional stability. Last week I decided to push myself and so I did a 4 mile walk/run every morning. Then, on Friday, my fifth 4-mile day, I barely stretched because my son needed something just as I was finishing up, and then sat down at my computer to play The Sims, where I remained in the same position for about 3 hours.

    When I got up from the computer, a muscle in my lower back was so cramped up that I was literally hobbling around the house and in really bad pain. And, my first thought? Not, “Hmm, maybe I should have stretched more” or “Maybe walking 20 miles in 5 days wasn’t the world’s greatest idea” or “Shouldn’t I have learned from my husband’s back going out several times after extended sits in the desk chair that vegging out in that chair is a bad idea?”

    Nope, it was, “OMG, I’m too fat! My body can’t handle carrying around all my weight! All of those dieters I’ve had random encounters with over obesity-related topics on the internet who’ve insisted that, despite my being active and healthy, my body would one day give out under the massive strain of the 200 lbs. on my 5’8″ body were right!” My first conclusion was that the problem must be that I was too fat, and not that anybody, thin or not, who works out a lot for days, fails to stretch adequately, then sits in an uncomfortable chair for hours might cramp a muscle. Because, of course, the bodies of thin 31-year-old women never ache, hurt, cramp up, or give them signals that maybe they should be just a little bit gentler to them.

    Luckily after two days of really mild workouts (just to get my muscles warm and then give me a chance to stretch them) and resting, the pain went away completely, and I’ve been feeling good the last two days doing my normal workouts. My husband, who is far closer to his “ideal” weight than I am, did 45 minutes of Wii Fit the other night then spent the next day on the couch pleading immobility, so that made me feel a bit better, as well. And now, I realize how silly it was for me to attribute to my weight something that was far more easily explained by other things, and my assuming that if I were thin, I’d be routinely doing hour-long aerobic workouts every day without so much as a sore muscle. But at the time, the first explanation that came to my mind was “I’m too fat!” And, given that we’re led to believe that anything and everything that goes wrong with our bodies, if we’re fat, is because we’re fat, I don’t think my conclusion was particularly hard to understand, even if it wasn’t based in reality.

  64. But at the time, the first explanation that came to my mind was “I’m too fat!”

    I have done that. Usually when I’ve been sick, with allergies or a cold, then get winded while doing something I can normally do. My mind always jumps to “ZOMG IT’S BECAUSE I’M FAT!” and only later comes around to “…um, self, you’ve had RESPIRATORY ILLNESS, maybe your lungs aren’t quite back up to their usual capacity yet?”

  65. Because, of course, the bodies of thin 31-year-old women never ache, hurt, cramp up, or give them signals that maybe they should be just a little bit gentler to them.

    Yes, THIS! Ha! As a thin woman, I promise this is not the case. So does my back.

  66. I can heartily agree with the nocebo effect. I have a nocebo, a guy. I have been in a relationship (not the right word, but I can’t think of any other to describe it) with this guy for 3 years. And due to my circumstances, etc., I’m stuck dealing with him. I’ve alluded to him here, and on ning before. He’s mr. privileged white male ™ with a huge insecurity complex on top of it. Since I’ve known him, I’ve become more concerned with my appearance, I compare myself to other women more often, my stress levels have gone up, I’m more irritable and defensive….when I’m around him I have serious heartburn, I want to be lazy, and most time, just want to go to sleep. It took me over a year to realize this, so I have more control of it, in lieu of actually leaving the situation. But it amazed me how quickly I changed from a woman with a pretty good self-image, one more concerned with thoughts and ideals rather than the superficial, to an insecure and unhappy woman. Amazing.

  67. On a semi-related note, as a person with severe depression, every time I hear a report about how much earlier people with depression die than people who don’t, I have to think “And just imagine! By telling me that, you’ve just given me the means, through an exquisitely crafted positive feedback mechanism, to accelerate the process substantially! Thanks a load!”

    I often see these reports offered in the spirit of making people take depression more seriously by pointing out its physical manifestations. That’s fine. (However, isn’t the fact that someone says zie’s suffering significant enough, even without measurable physical manifestations?) But it can be a singularly unhelpful point for me, personally.

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