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There are so many psychological/philosophiocal issues with this topic its hard to know where to begin!
I completely agree with the fact that this is health concern over and above anything else; The abuse of your body in any form is negative on so many levels to your physical as well as mental health.
In regards to the self esteem issue and people who are severly overweight and have good self esteem...This is subjective. Whether someone claims and makes it clear that they are happy with their body image and whether they truly are is debatable. We all use defense mechanisms to protect our self esteem and our self identity, such as denial, repression of unwanted thoughts, displacing your feelings onto someone/thing else. So perhaps these people are using defense mechanisms to protect themselves from the unconscious awareness that they are truly dont have high self esteem, because confronting the truth is "detrimental".
But then there are some that could truly have high self esteem... This is developed from an endless number of experiences throughout life which have helped to shape your own concept/theory of what it means to have good self esteem. So to be proud of who you are=high self esteem, and if there hasen't been people or situations/exexperiences throughput your life that have made you believe otherwise, then you will stick with it.
The topic of happiness has come up a lot in this thread, and that too can be pulled into all different directions. What each person feels that contributes to their happiness is very individualistic and also subject to experiences in our life. For the women who are with men that have a fetishism for extremely overweight/obese women... Perhaps for them a large contributer to their happiness is to be with someone that "loves them for who they are". So because they are already large and their partner "loves/appreciates" them for "who they are" then this just feeds into their definition of what it takes to make them happy.
Whereas with a lot of us here, we just can't imagine being happy being so overweight and unhealthy. To be healthy, to be fit, to be strong, to be awesome, is what constitutes our definition of happiness, so in cases like this it makes it for us almost impossible to see how women could possible live like this.
Looking at this in the light of what people define as improving their self esteem and what makes them happy is what creates these habits, these lifestyles. Its their experiences which have lead them to be where they are. Even if it is terribly not right, this can perhaps help to explain why people engage in this destructive behaviour.
The confrontation that they are wrong in their pattern of thought is so difficult for people to deal with, because it basically makes them feel as if they are unauthentic, completely destroys their self perception of who they truly are, as opposed to who they "think" they are, it is much less threatning to continue living they way they do.
These people need to be faced with the truth, to be exposed to that which scares them the most, to deal with their fears before they can begin to truly undo these badly formed habits.
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