Friday, June 8, 2012

Does Not ‘Medicalizing’ Obesity Promote Weight Bias and Discrimination?

Yesterday, in Ottawa, I participated in a Café Scientifique discussion about whether or not obesity is a disease, which naturally also touched on the issue of whether or not obesity needs to be medicalised.

My co-discussant was Jacqui Gingras, Associate Professor at Ryerson University’s School of Nutrition in Toronto. The discussion was elegantly moderated by Mark Tremblay, Director of the Active Healthy Living and Obesity Research Group, at the Children’s Hospital of Eastern Ontario.

While there was no disagreement that excess body fat can indeed pose a health problem as well as no disagreement that the current definition of obesity, based on simple measures of height and weight, is clinically meaningless (as it does not discriminate between those for whom ‘excess’ body fat is indeed a health problem from those for whom it is not), there were nevertheless differences of opinion on whether or not ‘medicalising’ obesity would be helpful.

Although I am the first to agree that health cannot be determined by simply stepping on a scale, it is exactly because things are not that simple, that it does take a trained and knowledgeable health professional to determine for whom excess body fat is a disease and for whom it is not. Indeed, I am fully aware that it often takes extensive medical knowledge and understanding of the rather complex socio-psycho-biology of weight gain as well as clinical skills, experience, and judgement in its assessment, to decide, when the accumulation of body fat poses a health risk and when it does not.

This, interestingly, is no different from the many clinical decisions that health professionals deal with every day. Indeed, figuring out exactly in which cases a symptom, a clinical sign, or the result of a diagnostic test is an indicator of ill-health and in which cases it is merely a harmless ‘norm-variant’, is what makes the practice of medicine so interesting (and complicated). If diagnosing a ‘disease’ was as easy as taking out a measuring tape or ticking off lab values, then anyone could do it.

Indeed, to take specific examples, deciding when a wave on your ECG is a sign of underlying heart disease and when it is not, or when a mole on your skin is a precancerous growth and when it is not, is exactly what doctors go to medical school to learn.

It is exactly because we do not exclusively leave the diagnosis of obesity (which I define as a condition in which excess body fat threatens or affects health) to trained, licensed, and regulated health professionals, that we have created a ‘free-for-all’ where we continue propagating the myth that everyone with a few extra pounds is unhealthy and needs to lose weight. This is the key downside of not medicalising obesity – if only a trained health professional can tell whether or not your weight is affecting your health then someone without this training, should not be making assumptions about your health simply based on your size – indeed, it will hopefully become common knowledge that only your doctor or nurse can tell whether you have obesity or not.

Unfortunately, it is also because we have failed to medicalise obesity, that we do not pay the same attention to training health professionals in the intricacies and complexities of diagnosing and treating obesity as we do for other conditions. Indeed, would all health professionals understand how to properly diagnose obesity, i.e. be able to determine exactly for whom body fat poses a health problem and for whom it does not, we would go a long way in addressing one of the key issues that ‘people of size’ object to, namely assumptions being made about their health simply based on their shape and size rather than on a comprehensive and professional assessment of their actual health status. With proper training, rather than simply telling everyone to lose weight, health professionals will actually be able to target treatments to those who stand to benefit, while warning those, who will not, against any such efforts.

It is also because we have failed to medicalise obesity, that the billion dollar ‘weight-loss’ industry can continue peddling their snake oil and miracle cures – after all if obesity is not a medical condition, they are not practicing medicine, and therefore do not have to comply with professional standards or underly the same regulations that all licensed health professionals have to abide by (or risk losing their medical license). Nor would they be able to continue advertising their products with unproven health claims or ‘results-not-typical’ anecdotes. Rather, they would need to comply by the (at least in Canada) rather strict rules on how health professionals can offer and advertise their services. Indeed, no one fears the medicalisation of obesity more that the weight loss industry, where currently any self-appointed ‘expert’ can peddle with impunity whatever makes them a quick buck – all based on the claim that they are not actually practicing medicine.

It is because we have failed to medicalise obesity, that insurance companies and healthcare systems can weasel their way out of paying for obesity treatments, rather than support such treatments as they do for other ‘legitimate’ medical conditions. Indeed, were obesity fully accepted as a ‘legitimate’ medical condition requiring professional skills to diagnose and manage, we would probably not be arguing about funding for obesity assessments and treatments.

Finally, no one suffers more from the lack of medicalisation of obesity than those who suffer from obesity. As long as we deny them the respect, care, and attention that we afford to anyone else with any other medical condition, we are perpetuating the bias and discrimination that rests on the trivialization of obesity as a simple matter of will power and poor ‘lifestyle’.

All of this requires a redefinition of obesity – a definition not based on shape or size but solely on whether or not your body fat is affecting your health – if it is, you have obesity, if it is not, you don’t.

If only simple things weren’t that complicated.

AMS
Toronto, Ontario

Big thanks to Zach, Travis, Angela, Megan, Richard, and all the other CON-SNPs for organizing this Café and their kind hospitality.

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13 Responses to “Does Not ‘Medicalizing’ Obesity Promote Weight Bias and Discrimination?”

  1. DeeLeigh says:

    No, you’ve got it backwards. Medicalizing large bodies and calling them “diseased” by definition increases bias and discrimination. We live in a society where people are blamed for their health problems and where people are also blamed and shamed if they’re larger than average. Putting the two together just gives people one more excuse (fake and condescending concern-for-our-health, at that) to discriminate and feel superior. Everyone thinks they know what “overweight” and “obesity” look like, and you won’t convince them otherwise.

    Also, the underlying assumption of this article – that fatness is not already medicalised – is ridiculous.

  2. Dee says:

    Thanks Dr. S for this article. Who is sick and who is not and how can we help define the needs of people with better definition and understanding is essential for so many diseases. I compare all the kinds of cancer and how far medicine has come to treat people and even improve standards of treatment by triaging this disease. There are so many variants to an individual that is suffering ill health. We need to be liberal in the choices in obesity, just the same.

  3. DebraSY says:

    Interesting post. You are careful to say “medicalizing” not “pathologizing.” You are careful to state that if fat does not affect health, then the word “obesity” does not apply. A person with a 40 BMI may be fat, but not medically obese if that person is a 0 or 1 on the EOSS, if I’m understading you.

    Your disagreement with DeeLeigh, I think, is mostly semantic. Sadly, you’re use of the language, Dr. S, is out of the mainstream. Most people do not see a difference between “obese” (a medical term) and “fat” (a common adjective, also a noun).

    I agree with DeeLeigh that lay people have already medicalized and misinterpreted fat, and actually pathologized it. Lay people feel more at ease when they use the words “obese” and “obesity” instead of fat. They think they sound erudite and polite, but, in fact, they’re inaccurate — not that you can blame them, given the state of the media coverage of fat and obesity, which regard the terms as synonymous.

    It might serve you, Dr. S, to consider adopting the word “fat” to refer to people with excess fat who have no medical complications. It takes a while to get used to it, but the Fat Acceptance and Size Acceptance movements have given their imprimatur to the word. They have “reclaimed” it as a neutral descriptor, such as “tall” or “short.” And, goodness knows, a neutral, nonmedical descriptor distinct from “obese” needs to be available and widely accepted if “obese” and “obesity” are to become medical terms subject to the rules and norms of the medical profession.

  4. Anonymous says:

    Re:
    “All of this requires a redefinition of obesity – a definition not based on shape or size but solely on whether or not your body fat is affecting your health – if it is, you have obesity, if it is not, you don’t.”

    “Obesity” is already defined and widely used as “having a large amount of extra fat”.

    If you want to identify a different condition – “body fat which negatively affects health” – it would be better to give that condition a new name.

    Otherwise , all discussions will be distorted by different people using different definitions of the same word. Good for endless talk, not good for getting anything done.

  5. Dr Martin Binks says:

    Excellent Discussion. We all know why we debate / try to use medical terms to describe obesity. One is our desire to understand the nature of the condition; the second and unfortunately more relevant is its a matter of insurance reimbursement. If its a medical condition, then those who wish and or need to reduce adiposity will be able to get expert help from reputable sources instead of getting their medical care from Meditainment sources like Oz and B-Loser…which do more harm than good. I know it can be seen as discriminatory to call all folks of large size “diseased” as was pointed out here, but I do feel that if we approach it as a disease model, then those who are experiencing medical comorbidities; or those who wish to lose weight to prevent these issues (note that musculoskelatally, no matter how healthy one is, there is a point where our bone structure will suffer and joints will be damaged under excess weight regardless of how ‘healthy’ we percieve ourselves to be) can do so. Just my 2 cents in a broad and important discussion. Thanks Dr S.

    Regards, Dr Martin Binks.

  6. Mark Young says:

    I generally agree that obesity should be medicalized in many respects, but frankly, I think you’re throwing the whole fitness industry under the bus.

    I believe that rather than making us foes, you could stand to make us allies in the battle against obesity. While there are certainly some who are only out to make a buck, most people come into this (woefully underpaid) industry with the intent of truly helping people.

    Often many attempts to help overweight and obese clients are misguided because certification agencies don’t have a good handle on the management of obesity and there is no formal regulation.

    Yet there COULD be some regulation of obesity management…or at least forums guided by something like CON to train and direct people to fitness professionals who have the ability to work alongside doctors in managing obesity.

  7. Annie says:

    If it’s just a lot of fat on a healthy person, call it “obesity”.
    If it’s fat related to disease, call it “obesiopathy”.

  8. Jacqui Gingras says:

    Thanks for sharing this topic on your blog, Arya. As co-discussant on Thursday night in Ottawa, I appreciate there is much more to say on the topic than one night of “debating” could ever afford.

    One point I attempted to make on Thursday, but regret I did not explain it well at all, was that of healthism. DeeLeigh is addressing healthism to some degree in her post, too. When a condition is medicalized, there is a much greater chance it will be treated as something that an individual can address. Yes, that individual will be working with medical health practitioners including doctors, nurses, dietitians, OTs/PTs, and so on, it is still that individual who has a condition to be resolved. When the individual is charged with resolving the problem (again, even if s/he is under the care of a doctor), there is a much greater likelihood that if the individual is unable to solve the problem (as is VERY likely with losing weight or reducing abdominal adiposity to achieve health), s/he will be blamed for the outcome (the “non-compliant patient).

    Crawford (1980) coined the term “healthism” to describe the growing “preoccupation with personal health as a primary – often THE primary – focus for the definition and achievement of, well-being” (pg. 386). The emphasis here is on PERSONAL health, which neglects to address the SOCIAL (think Ottawa Charter of Health Promotion) influences on health (and body weight) for that matter. That is my worry.

    And, even those who promote Health at Every Size (HAES) must be aware of being or becoming healthist. Although it is much more difficult, the SOCIAL must inform the INDIVIDUAL determinants of health and vice versa for us as healthcare professionals to offer ethical, appropriate, and evidence-based care.

    Here is my further attempt to simplify:
    Medicalization + Individualization of Care + Victim-Blaming = Healthism
    Healthism + Corporatization (another blog post entirely) = Poor Health Outcomes for Populations

    Thus, IMHO, medicalization is a process of which I am wary and of which I believe has happened already as a previous person has commented.

    De-medicalization is the answer!
    Jacqui

    Ref: Crawford, R. 1980. ‘Healthism and the Medicalization of Everyday Life’. International Journal of Health Services 10, 3: 365-388.

  9. Arya M. Sharma, MD says:

    @ Jacqui – I may be missing the point here, but when body fat affects health – it de facto becomes a health and thus a medical concern. This has nothing to do with who may or may not be responsible for dealing with this. I do not think that in other areas of medicine we should blame patients for failure if the treatment does not work – treatments fail patients, patients don’t fail treatments. I think what applies to treating diabetes, cancer, or anything else, should apply to those with ‘obesity’ (again: defined as body fat affecting health) – anything else is discrimination. There are countless medical conditions for which we do not have cures or even good treatments – this does not make them any less a medical problem than conditions for which we have good treatments. The one has nothing to do with the other. The issue of whether or not obesity is a medical problem also has nothing to do with how to approach it. If a HAES approach is the best management approach for obesity, so be it – then the medical model needs to embrace HAES and offer HAES ‘treatments’ to patients with obesity. Treatments that work are medicine – period. If it’s not a medical problem it does not need treatment – it’s as simple as that.

  10. Anonymous says:

    I weigh 230, BMI about 39.5. My doctor gave me an all-clear at my last routine physical. So, though I’m 230lbs, BMI 39.5, I’m NOT obese. I can honestly check off on my insurance forms that I am NOT obese. Excellent!

  11. DeeLeigh says:

    Anonymous makes an excellent point. Although you may define obesity according to health risks, insurers still define it according to BMI.

    And just to clarify my post, I think that ideally, body size would be considered a neutral aspect of natural human diversity. Some people are fatter (and/or more muscular) than others, just as some people are taller and people naturally have different shapes, hair colours, skin colours, and eye colours. I think it’s crazy that so many people violently object to this idea. After all, if you look at art and early photography, it’s obvious that people of all ages have always had a variety of different builds.

    Fat people are at higher risk for some health problems. So are people with very light skin and people of some ethnic backgrounds. That doesn’t mean that we think it’s a good idea to refer to a particular skin colour or ethnicity as a “disease.”

  12. hopefulandfree (RNegade) says:

    @Jaqui Gingras: Yes, you are right to be concerned about moral consequences resulting from the medicalization of particular conditions, for that social norm (as legitimated by medical discourse) distorts the potential for social analysis of the disease process, by maintaining the focus of rhetorical (medical discourse) analysis at the level of the individual, dominant medical discourse shifts responsibility for health outcomes onto individuals rather than analyzing the social conditions that contribute to (or determine) health outcomes. This analytic shift of focus from social conditions onto factors supposedly within the control of the individual constructs a PROFOUNDLY distorted perspective of social reality and health outcomes—whereby social determinants (including toxic environmental conditions, for example) fade into the background, and are discounted, minimized, or obscured—or they simply disappear from awareness and are invalidated as critical factors in the disease process. The ethical implications of a shift in analysis that has this MUCH POWER to hide relevant disease origins while legitimating tangential factors at the level of individuals, instead, allows medical professionals, such as Dr. Sharma, to unwittingly collude in a significant distortion of health/disease determinants. .

  13. Why Recognising Obesity as a Disease is Only Fair to Those Affected By This Condition | Dr. Sharma's Obesity Notes says:

    [...] readers, who are well aware of my arguments in favour of “medicalizing” obesity, will no doubt guess that my overall response to this move was rather [...]

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