Podcast 120: Fearing the Black Body Part Two with Sabrina Strings – BMI is not just a bogus measure, it is masking medical sexism and racism

This is part two of our interview. Listen to Part One here.

In my second interview with Sabrina Strings, PhD, author of Fearing the Black Body: The Racial Origins of Fat Phobia, we discuss why only white women’s bodies were subjects of control in historical fat phobia. Dr. Strings shares the history of the BMI development and it’s flaws. We share personal stories for how BMI and weight bias in medicine harms people today. Dr. Strings also shares how she was discouraged from even writing this book.

Sabrina is an Asst. Professor of Sociology at the University of California, Irvine. She was a recipient of the UC Berkeley Chancellor’s Postdoctoral Fellowship with a joint appointment in the School of Public Health and Department of Sociology.

She has been featured in The Feminist Wire, Yoga International, and LA Yoga. Her writings can be found in Signs: Journal of Women in Culture and Society, Fat Studies: An Interdisciplinary Journal of Body Weight and Society and Feminist Media Studies. Sabrina was the recipient of the 2017 Distinguished Contribution to Scholarship Article Award for the Race, Gender and Class section of the American Sociological Association. Fearing the Black Body is her first book.

More Sabrina: Book | Twitter

Listen here to Episode 120 here or read the episode transcript

Transcript

Rebecca: 00:00 Can I share one of the most chilling things to me? The hairs on my arm just stood up. It’s in Chapter 8, Fat Revisited. Maybe this is because this is my time, but it was that… but I was really like, “This ain’t right.” That came out of my mouth. I think it was 1985 was the year that black women were first included in health reports, and you say that until then racial or ethnic… it was seldomly included in any type of medical analysis and I was like, “What? How do you not even include the people that you’re aiming to help?” That just sounded racism and an injustice, and yet it’s very much true. What can you share with us about that?

Sabrina Strings: 00:45 Yeah, so in the early 20th Century through the mid 20th Century, there was this idea that we needed to reform women, but the women that they wanted to reform were white women. Because the idea was that we are trying to create the best possible mothers for our nation, and if that’s the goal they’re not focused so much on women of color, right? So women of color are the people that they’re trying to prevent from reproducing, and there’s fantastic work on this by a number of authors but I’ll just mention Dorothy Roberts and Killing the Black Body. All of the ways throughout the 20th Century that they have tried to sterilize black women to prevent them from reproducing.

It wasn’t until the 1980s in which democratic congress was actually starting to notice that there were tremendous health disparities according to race and ethnicity. And so they thought we need to figure out why it is that minorities, as they would have been called at the time, are experiencing many more negative health outcomes in this country than white Americans.

It wasn’t until after the Civil Rights movement and the feminist movement that people became much more invested and interested in trying to figure out why it is that people of color have worse health outcomes. This is part of the reason why, for a number of years in the medical establishment, very little was known about what was happening in low income and marginalized communities.

Rebecca: 02:10 Can you share whether it was in the book or not what… any sort of what did we come to find out about disparities? I know it was only in the last couple of years where I’ve been able to learn and read that experienced oppression, experienced racism, impacts a person on the cellular level.

Sabrina Strings: 02:36 Yes and there are just so many factors that contribute to health outcomes, which makes the focus on weight all the more egregious. Because one of the things that I point out in the book, one of the consequences of them now deciding that they’re going to shift their focus from largely white populations, populations of color and try to figure out well what is causing poor health outcomes. Was that they thought, or they found rather, oh well their BMIs are elevated so it must be weight. Well tell them to lose weight.

Rebecca: 03:02 Mm-hmm (affirmative).

Sabrina Strings: 03:03 But in reality there are so many factors. In addition to the food security issues that I mentioned previously, although I did not mention that communities of colors, low income communities, female headed households, are far more likely to experience food insecurity than more middle class, wealthier, or whiter communities. When we look at all of the factors that are contributing to health disparities, stress is a major component, poverty, lack of access to safe drinking water and healthy food. It’s such a compounding number of things, and I think that a number of public health scholarship did a fantastic job being able to articulate the ways in which maybe one or two of these things might contribute to worse health outcomes. The difficulty is that it’s such a conglomeration of factors that are embedded that it’s very difficult to be able to say, “If we change one thing then we will change the entire system.” Unless the one thing that we are changing is fundamentally trying to eradicate poverty.

Rebecca: 04:06 Right yeah. I can fully support that, and even again, going back to everything’s going to get solved if we could just get your weight under control as if weight is inherently controllable. And even unhealthy, which brings me to the concept of “normal weight”. We mention the BMI right, the BS measurement of inaccuracy I like to call it. You talk about in the book it did not come from medicine. First of all, normal weight led to weight tables, led to the BMI, and it didn’t even come from medicine. I want you to share the backstory, but I will tell you that I’m working with a teen client now who is active, so still growing teen, active, athletic, female, and she has a gym membership. We had a couple getting to know you sessions just talking about eating patterns and wants to look weight to look good in the prom dress. Just all the thing, right, the heart.

But anyway she’s like, “Yeah so you know, I want to talk to you about something because I went to the gym and this was included in the membership and here’s my BMI.” I think it was probably bioimpedance or something, but I’m like, we’re not talking about, “Oh hey everything’s fine guys. Weight Watchers got rid of the BMI chart.” Or, “Hey guys, everything’s fine because my doctor doesn’t push BMI,” which that would be an amazing thing if you’re lucky to have a doctor like that. It goes deeper than that because at the end of the day today, there are people probably right now calculating their BMI and it is going to impact their sense of self-worth, their sense of wellbeing, and likely impact that they’re going to make a positive self-care choice after looking at that number. What’s the history?

Sabrina Strings: 06:05 That’s a great question, and as it turns out BMI is a tool that was invented in the 19th Century by a man named Adolphe Quetelet. He was a Belgian statistician, and his idea was that he wanted to be able to provide a measure of weights across a population. But he was very clear that this should not be used to measure an individuals adiposity. Nevertheless, when it was introduced in the 1980s by a man named Ancel Keys, that is specifically the way in which he began to use it. And it’s important for people to recognize that not only is the tool being used in a different way than it’s creator intended, but that also its completely faulty. It can’t measure muscle mass, it can’t account for the fact that people who are so called “overweight” often have better health outcomes than people who are “normal weight”.

Also, for whatever reason, they cannot explain to us the reason why the range of normal weight has changed dramatically over the years, which I’m also detailing in the book. At one point it was normal weight was up to a BMI of 30, and then it was 27, and then it was 25. It’s like why does it keep changing? It’s quite clear that it had very little to do with any scientific findings surrounding BMI because BMI’s a problematic measure. Rather, there were a number of stakeholders who would attend meetings with some important figures associated with the World Health Organization, etc., who would decide that here are some guidelines that we believe are best. The we believe being outside of scientific analysis.

Yeah, the BMI is such a problematic measure and I also want to share a story from my own experience because I too am a person who has been privileged, although of course as a black person and privileges undermined by racism, it doesn’t mean that it’s completely eradicated.

Rebecca: 08:08 Absolutely.

Sabrina Strings: 08:09 I went to the doctor I think it was last year, at the end of last year, because I for some reason was having some disruptions with my menstrual cycle and I went to find out what was going on. They gave me a variety of tests, a battery of tests, and nothing came up. It was like, “Well we don’t think that it’s associated with all of these things that we assumed previously, so we don’t quite know yet. And you know women’s menstrual cycles fluctuate.”

That was the conversation I had with my gynecologist. When I went to my primary care physician for a followup, he-

Rebecca: 08:42 I was going to ask.

Sabrina Strings: 08:47 Yeah right. He told me to “keep my weight down”. My mind must of blown because I was like, “Keep it down to what?” I think that BMI is bogus, but even by your own instruments I’m in the “normal range”. I didn’t say any of this, I was too shocked, but I just thought, “What does he want me to keep it down to? Underweight? By this silly measure.” This is how you know what ultimately BMI is first of all not a useful tool, and secondly it’s masking a form of again medical sexism. It’s like we want to be able to figure out how best to tell women to attain their own bodies. Make them small, make them what we would consider typically as men to be aesthetically pleasing, and this is supposed to be both good for health and beauty.

Rebecca: 09:35 Yeah, so a couple things related to that. One is I have a hunch that by getting to say keep your weight down, he got to check his box that say please reimburse me for having a conversation about weight status with this person. That’s just the way… that’s the system in the structure we have. It’s incentivized, that’s why somebody at a higher weight goes in and I have an earache, or I think I sprained my ankle. Well lose weight is the answer. There’s the incentive.

Sabrina Strings: 10:02 [crosstalk 00:10:02].

Rebecca: 10:02 Yeah definitely.

Sabrina Strings: 10:04 Yes.

Rebecca: 10:04 I can relate on the stigma that I’ve experienced, and again white and thin privilege, and it always makes me feel like if I’m dealing with this BS, what in the world is it like to be a higher weight person or a higher weight woman of color? In my pregnancy I also… It was very interesting with my first pregnancy I saw the same doctor at Georgetown at a teaching… was a teaching hospital. Because I felt very protective of my wellbeing because this was going to be a time in my life where I knew weight gain was important and I still knew that I had this sensitive element of how to be kind to myself through this very natural and normal process that I don’t think anybody is ready for. We get, “Get that baby weight off as soon as you can.” Second pregnancy I just went to whoever because I felt cared for, I felt like okay I made it through that experience and I’m fine so this I’ll just take next available, next available.

I had a bunch of different doctors and I remember one time I had a… both were male doctors. One time I was told that I was gaining too much weight between two appointments and I asked, “Do you mind recalculating from when I first came in?” He’s like, “Oh yeah, your rate is fine.” They just weren’t looking at the information. Then in my third trimester I was going to New York, and again you shouldn’t even have to do these things when you’re pregnant but this is just my story, was going to New York to walk, walk a half marathon with a friend. I’ve done 15 marathons so this was not challenging, this was a fun thing with a friend.

I was so excited, baby on board tee shirt. I’m letting you know I have a white male doctor and I’m like, “Okay, I know sports nutrition, I’m going to be fine. I’m going to hydrate, I’ve got gummy bears, I’ve got this fueling planned.” He’s looking at his computer and he just goes, “Well you know, if you were going to be my patient ongoing I would tell you not to gain any more weight this trimester because you’ve gained too much already.”

Sabrina Strings: 12:13 Doesn’t make any sense.

Rebecca: 12:14 No, and just not even looking at you and all the things. I hear it from client stories too, and so it’s like just you and I are having a conversation about our personal experiences and also with the greatest amount of empathy for people who have it way worse on a daily basis. You are not the problem here, the system is what’s messed up.

Sabrina Strings: 12:37 There’s a strange way in which a medical establishment often focused on tertiary care, so meaning that rather than trying to give people the tools to lead healthy lives, they mostly see people when they’re already sick. For whatever reason, even though people are coming in often with existing illnesses, it’s not people centered, it’s not about what is going on with this individual, how can I collect enough information to be able to assess them and then give them valuable feedback about how to become well again. It’s how can I best mitigate sickness based on yeah, a number of different things that we imagine might be mostly likely the cause. It is so much about volume and so much about what insurance companies might cover, and so much about existing tools that might facilitate getting people in and out, that we forget that it absolutely doesn’t make any sense that every single person in America would be healthy if they only maintained weight within a particular range.

Obviously because there are many people in the “normal range”, myself included, who sometimes fall ill. Finding yourself within this narrow range of weight possibilities is not any type of solution. Secondly, we believe in biodiversity, seemingly in every other aspect of life except for when it comes to weight. How come worldwide we expect men and women and Europeans and African and Asians to all maintain the same weight? That just does not make logical sense.

Rebecca: 14:21 That’s rooted in white supremacy.

Sabrina Strings: 14:23 Yes.

Rebecca: 14:24 Made me read the whole book to learn all about that, but that’s ultimately the gist is, right, today we have white supremacy, we still deny our racist histories. Medicine I don’t think is doing a good job at in acknowledging the racist history of medicine or taking action to move on from that.

Sabrina Strings: 14:45 No, it’s such a difficult thing for Americans to do. I find it to be immensely ironic that there were so many decades of American history in which race was discussed openly as a rationale for how much people should eat, how much they should weigh, how they should look. I mean everything you can imagine, and yet now we have those very same cultural values, but the racial signifiers, the racial history has been erased. People are operating under the same motivations without being aware of it.

Rebecca: 15:18 Mm-hmm (affirmative), and that awareness is key right?

Sabrina Strings: 15:18 Yes.

Rebecca: 15:22 You can’t do anything without the awareness, and so just people listening, participating in this conversation, it’s an element of awareness. Picking up your book and reading your book, it’s an element of awareness, and awareness will lead to action. One conversation at a time, or sticking up for yourself at the doctors, or if you’re a person of privilege and can take a meaningful action in your community, do it because it is going to make a difference and we are products of our culture but we also have to work to actively change it.

Sabrina Strings: 15:53 Yes, and I think I feel a lot more excited about the future. I feel that there are many more possibilities than I felt six years ago when I was getting… So many people were telling me that my work is dangerous, which I did hear from public health professionals at that time.

Rebecca: 16:07 Oh.

Sabrina Strings: 16:08 Yeah, and I think that there is now starting to be more momentum and there’s a growing number of people, in fact, who are believing in the value of health at every size.

Rebecca: 16:19 Yeah. Gosh that sounds like calling your work dangerous, verbal abuse. I don’t know if that’s the right term or how you felt, but that sounds abusive?

Sabrina Strings: 16:28 Well I didn’t feel like it was abusive to me, but I did feel like it was deeply problematic and troubling because the individual who sent this to me was a public health professor and they thought it’s very important to tell fat people to lose weight because even minor adjustments of weight can actually improve health outcomes. Which I can understand that there have been some studies that have suggested that, but there have been equally as many studies, if not more, showing that when you encourage people to lose weight they might lose weight for a short period of time but they often gain it back, and that is far worse for health than if they had simply stayed at their originally weight. Not to mention the problem of telling people to lose weight contributes to weight stigma, which in and of itself leads to poorer health outcomes. Yes I do think there’s a growing awareness surrounding those problems.

Rebecca: 17:21 Yeah, that’s the clip that all the medical schools need to hear right there. We just can’t go forward without it in our sectional lens, I mean it just can’t happen. I know we don’t have a ton of time left, and so I might have to get the Cliff’s Notes version of a couple things that I want to talk about, but it’s been so great so far. Let’s talk about religious roots for thinness. What are some of the highlights that people can expect to come to know when they read your book?

Sabrina Strings: 17:48 In a funny way it may not be so much of a surprise to know that the Puritans, giving all that we know about the Puritans already, were deeply invested in making sure that people did not overeat. Just at the moment in which there was a growing availability in sugar in many Western countries as a result of the slave trade, that there was also a rise of Puritanical sense that ah, all of these confections that are now available, all this coffee, this tea, these breads, all of the indulgence that we are seeing in our country must be stopped. We have to put a lid on this.

There were a number of first Puritan in the 16th and then 17th Centuries, but then later sort of more largely Protestant reformers who stepped forward and said, “I’m going to teach people how to lose weight.” They were Protestant proselytizing dieticians, and they were telling people, “You too can lose weight so you can get right with God in time for salvation.”

Rebecca: 18:54 Yeah, it’s what God wants. This is-

Sabrina Strings: 18:56 It’s what God wants yeah.

Rebecca: 18:58 Talk about shame.

Sabrina Strings: 19:00 Yeah, skinniness is next to Godliness was sort of considered one of the taglines, but yes.

Rebecca: 19:07 I mean and again at the time there are going to be people who are born this way, Lady Gaga right, genetic.

Sabrina Strings: 19:14 Yeah.

Rebecca: 19:15 Or socioeconomic differences, and again at the time we were not aware to that but it goes to help us acknowledge how far back that goes and I even still see people of faith today. The Daniel Planner, that was a huge oh I got many congregations to lose X million pounds. It’s like everything old is new again and it’s… I find in the common language what’s so hard for people is well what’s wrong with wanting to lose weight? Usually when I’m with a client I’m trying to help them understand that oh well, there’s a lot of reasons why the want is likely going to be around for a while but let’s talk about what your life is like and what your thoughts are like and what your habits are like. That’s kind of a basis for the work. I think that there’s a lot of people that also feel that they’re not doing harm by helping people lose weight because they assume it’s going to be a side effect of everybody’s habit changes. I wonder what your thoughts are for that.

Sabrina Strings: 20:20 It’s so difficult to move past the entrenched fat phobia. I mean I believe that in the United States it ubiquitous, and all of us I think that who are working within this particular field and moving towards health at every size, are attempting to combat that. But it is so difficult because it is so deeply entrenched culturally. I think that we do have to struggle with this idea that there is a perfect weight for us that’s out there, right?

Rebecca: 20:45 Mm-hmm (affirmative).

Sabrina Strings: 20:45 For me when I was younger in particular, I had the mistaken notion that it was slim thick. If I could just look like that and I would get all the interest from men that I might have wanted at that time as a young person, although that would not be my motivation today as a career person. I can definitely see how it seems like being a certain weight carries with it all of these rewards because in reality it can in American society, but wouldn’t it be better for all of us if whatever weight we were we could accept that and be happy with it and celebrate our bodies for all that they do for us on a daily basis. Letting us move around, processing all of the different foods that we eat, allowing us to breathe and have a tactile experience of the world.

Our bodies are a revelation and if we can simply learn how to honor them, then we wouldn’t have to be concerned about trying to gain favor by losing five pounds.

Rebecca: 21:44 Yeah, yeah, and you mentioned being a yoga teacher and I have to say yoga is something that helped me heal my body image. It was like at two different stages when I got into running. It was like, “Oh I don’t have to hate my legs, I can appreciate them because they’re doing a job for me.” I happened to get in a studio that had no mirrors in D.C. and I think the exposure to the teachers and hearing words like hold yourself with kindness and compassion and I’m writing down those words what’s that? How do I do that? I got to have a gratitude for it, and at the same time I see a lot of problematic yoga, but I think what we’re getting out of this conversation is you must have ways that you choose to practice yoga or self-care boundaries for yourself so you can practice yoga in a way that enhances your wellbeing.

Sabrina Strings: 22:37 I think I hadn’t considered this thoroughly until you just mentioned that, but yoga was one of the ways that I was able to move past some of my more problematic behaviors because I was a runner my entire life, from the age of seven. People used to compliment me for being fast and so I’d like to try to show up by running as fast as I could, and then that turned into a form of escapism and also a form of keeping the type of figure that I wanted to maintain for a number of years. Running just gave me such a great sense of wellbeing on many different registers, and it wasn’t until I had to have foot surgery due to the excessive amount of running that I was doing, because I was running the equivalent of a marathon a week.

Rebecca: 23:19 Oh wow, yeah lots of miles.

Sabrina Strings: 23:20 Yeah yeah, lots of miles. It might end up being two 10 mile runs and then a six… or sometimes three 10 mile runs. It was far too much for my body. After the surgery the doctor told me that if I wanted to keep running I was going to have additional surgeries, not just on my foot but on my knees, and then on my hips. I knew a man who was a runner who had hip surgery in his 20s. I thought, “I have to find a new way.” I took up yoga, and I remember very clearly thinking at the time like, “Well probably because I’m not going to be burning so many calories, I’ll probably gain weight but that’s fine because this is a different way of relating to my body that’s going to be healthier.” And as it turns out, once I got into the space I found that there were so many people who, at least ironically to me, were using yoga to lose weight. Because I had come to it thinking the exact opposite. I was like, “Oh well, it’s just the practice of stretching and meditation.”

No, yoga has really become, in many commodified spaces, a massive industry and it’s being sold specifically as a weight loss mechanism. This is not just in the studio, this is also in the public marketing of main stream publications of Yoga Journal for instance. Which is [crosstalk 00:24:40].

Rebecca: 24:40 Yeah I read… Did you write the paper? I was looking at your research gate too and it was like it’s basically getting thinner and whiter and younger, right?

Sabrina Strings: 24:40 Yes.

Rebecca: 24:47 The images.

Sabrina Strings: 24:49 [crosstalk 00:24:49].

Rebecca: 24:49 Well that’s a fricking mistake, that’s dumb.

Sabrina Strings: 24:53 Right, [crosstalk 00:24:54].

Rebecca: 24:54 It’s not helpful.

Sabrina Strings: 24:55 It’s going in the exact opposite direction of what yoga is supposed to be about, which is allowing people to come to terms with who they are, accepting themselves, loving themselves, so that they might have more loving kindness for others. Because self-love is the beginning. But when yoga is being used as a tool to promote a particular type of body, then it is corrupted to the point where people are seeking it out for the exact opposite reasons that the philosophy would espouse. There’s been so much work that’s been done by… I used to work with a group, lasting work with them, The Yoga and Body Image Coalition. They’ve done some fantastic work surrounding the question of how can we move yoga back from its new main stream messaging that it’s a great way to look cute, and get it back to the historical roots of being about self-love and compassion for others?

Rebecca: 25:53 A hundred percent, and so it’s like finding ways to move your body and being open to different ways and for you they don’t have to be about weight control. They can be about wellbeing enhancement. Don’t go to the yoga studio that is all about shredding, sweating, killing you.

Sabrina Strings: 26:16 Yeah.

Rebecca: 26:17 You got to find a sense of community and something that works for you, whether it’s in yoga or a way of eating that you feel works for you. It’s definitely a lot of hard work because what we’re talking about is unlearning a lot of stuff that was… I mean it was ingrained in our ancestors, so the repair is going to take… When people are listening or feeling a sense of hopelessness, its like I find the acceptance that the repair is going to take a long time and no one really knows how it’s going to repair, is almost comforting because it allows me to say, “Okay, well what can I do in this moment then? What can I do right now?”

Sabrina Strings: 26:53 Yeah, it’s a difficult thing whenever you’re interested in any type of social justice of being attached to doing the work without being attached to the outcome. That’s such a difficult but important lesson to learn because even as I am attached to working toward the end of racism, I cannot be attached to the immediate outcome of racism ending. Because it’s been going on for centuries, and probably it will be continuing throughout the course of my lifetime, but it doesn’t mean that it’s not a worthwhile activity to work on while I’m here.

Rebecca: 27:26 I really enjoyed our conversation today and I know listeners are going to love it, and I just want to make sure that everyone picks up a copy of Fearing the Black Body: The Racial Origins of Fat Phobia. Sabrina, if folks want to find you or follow you do you have a home base where you like to direct people to or are you on social media?

Sabrina Strings: 27:48 Yes, you can find me on academia.edu. You can find me on Facebook and Twitter and Instagram at Race and Yoga. I recently decided to try Twitter out, although it’s a little bit frightening, but I do have a Twitter handle, it’s @sastrings. Yeah, you might see the one tweet that I’ve put up so far.

Rebecca: 28:10 Well I’ll follow you, I’ll be your first follower and I’ll include all the links.

Sabrina Strings: 28:14 Thank you so much for that.

Rebecca: 28:16 Yeah, and all the social links and everything will also be in the show notes for today. Thank you so much again.

Sabrina Strings: 28:20 Thank you for having me.