Thursday, June 30, 2011

Obesity As a Social Diagnosis

As blogged before, obesity has long been defined by the World Health Organisation and other bodies as a chronic disease and even bears its own diagnostic code in the International Classification of Diseases (ICD-9: 278.00, ICD-10: E65).

Nevertheless, the notion of obesity as a ‘disease’ continues to be contested with proponents of the medical model being accused of ‘medicalising’ obesity while many would prefer to see it as simply a ‘norm variant’ of body shape distribution in the population.

Such disparities in defining ‘obesity’ reflect the complexity of the sociology of ‘diagnosis’ – a topic that is extensively discussed in a fascinating paper by Phil Brown and colleagues from Brown University, Providence, Rhode Island, published in Social Science & Medicine.

As the authors note:

“The process of diagnosis is carried out by multiple social actors, including medical professionals, researchers, government agencies, private corporations, social movements, and legal institutions.

In addition, the affected individuals themselves have an important say in what they consider to be their own ‘diagnosis’ (or not).

Thus:

Diagnosis is simultaneously a site of compromise and contestation because it is a relational process. When there is a disconnect between the patient and the medical explanatory model, the individual may be unsatisfied with treatment goals, and collectively work to politicize the illness through social movements. This would be the case especially if people were not given a diagnosis for something which they expected to, or when they received a psychiatric diagnosis for something they believe is physical. The greater the symptom severity or the disconnect between lay and professional perspectives on diagnosis, the greater the likelihood of contestation.”

“In contesting diseases and conditions, people often seek to reshape or overturn a shared set of entrenched beliefs and practices about diagnosis, causation, and treatment that is embedded within a network of institutions, including medicine, law, science, government, health charities/voluntaries, and the media. This network is the “dominant epidemiological paradigm” for a given disease.”

In a medical setting, the term ‘diagnosis’ means labeling a condition, which in turn leads to the exploration of causation, pathology and prognosis, ultimately aimed at ‘scientifically based’ prevention and treatment strategies.

In contrast, from a social perspective, ‘diagnoses’ play a very different role in the context of belief systems, ideologies, culture and other factors that go well beyond conventional medical considerations.

In the case of diabetes for e.g.:

“…medicalized approach to diabetes individualizes and depoliticizes the problem. Alternatively, a political ecology framework emphasizes social, economic, and political institutions of human environments where diabetes is emerging.”

Thus, while in a medical context, the diagnosis ‘diabetes’ is associate with a clear pathology and pathophysiology that prompts specific diagnostic and therapeutic measures, in a social context, diabetes can be seen as a ‘social phenomenon’ that results from ecological changes operating well beyond the individual level that have little to do with the specific genetic, hormonal, or organ manifestations of this problem at the individual level.

What applies to diabetes, is perhaps even more applicable to discussions about obesity – especially given the emotionally charged environment that focusses on ‘shame and blame’ strategies and views obesity largely as consequence of personal choice and responsibility.

“In this paper, we have sought to understand the unique context in which social diagnoses are formed—a sociology of social diagnosis. To reiterate, social diagnosis is social in that it considers both larger social structures, as well as the various social actors which contribute to the diagnosis. In other words, a broad range of social factors goes into the making of a diagnosis, which is carried out by a myriad of social actors. The diagnosing of individuals can allow for the broader diagnosis of a group of illness sufferers, and an even broader diagnosing of communities.”

“If medical sociologists work with clinicians and public health practitioners, they may be able to jointly develop effective ways to use social diagnosis for both treatment and prevention.”

Clearly, this issue will continue to be passionately debated as we strive to find the balance between helping individuals (as we do in medical practice) and helping societies (as we do in population health approaches).

Hopefully, this will not be a debate about right OR wrong or even about doing one OR the other – in the end, we have to do both.

AMS
Edmonton, Alberta

Brown P, Lyson M, & Jenkins T (2011). From diagnosis to social diagnosis. Social science & medicine (1982) PMID: 21705128

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18 Responses to “Obesity As a Social Diagnosis”

  1. Anonymous says:

    Concerning seeing obesity as “a consequence of personal choice and responsibility” – or not:

    ONE of the “social phenomena” that influences weight is whether or not it is seen as something that can be affected by what someone chooses to do.

    If the prevailing attitude is that obesity is beyond personal control, then that attitude in itself will affect what people do.
    As obesity has a genetic factor, and/or is affected by external social factors, then even trying to lose weight (or not become obese in the first place), is seen as futile.
    That sense of futility can prevent people from doing even those helpful things which are possible (despite genetic or social problems).
    Feeling futility and hopelessness can also worsen obesity as people eat to feel better – after all, they might as well, because their obesity is inevitable and out of their control.

    This is kind of like a bariatric Heisenberg Uncertainty Principle (in small particle physics, in trying to measure something you change it) If you tell people weight is beyond their control, you decrease their motivation and effort to make better choices, and them it seems like – aha – weight is beyond their control.

    I’m not saying everything is under a person’s control. I’m just saying that telling someone at the start that “you’ll never lose weight, it is out of your control” is likely to actively discourage positive action, and be a self-fulfilling prophecy.

    To the long list of social factors affecting weight add: “the belief that weight is due to genetic and/or external factors and will not be affected by personal choices in diet and activity”.

  2. Razwell says:

    Hi, Dr. Sharma.

    I view obesity as an extremely chronic medical condition/disease state in which much is still not known. I think it should be fought- but fought with what science has shown us so far, rather than the dogma of the commercial diet industry. I also think , as does Urgelt of YouTube , that obese people should be treated as kindly as anybody else. I know you believe this too.

    I believe that fat cells in ” hoard mode” are not necessarily going to cooperate with the body’s needs.

    I have never been obese myself, but my eyes were opened big time by Urgelt’s videos on the subject and we both looked into even more. I never judged the obese, but had my own assumptions. I was floored to learn my assumptions had no evidence. Back in the summer of 2000 I would have said “exercise will cure the obese if they just do the right workout” or something of the sort.

    I suppose you could I say I believed thewy were victims of bad workout information. Now , of course, I realize this is not true.

    Keep up the good work, Dr. Sharma. Your patients are in good hands. I also think it is awesome that you got to introduce Dr. Friedman back in 2008. I hope you had some discussion with him on the subject that was enlightening. I honestly believe it will be he or a scientist of his caliber that will develop a treatment or possible cure to help people like Manuel Uribe live a good life.

    I look forward to the new discoveries science will make on this subject in the coming years.

    Best Wishes,
    Raz

  3. Rachel says:

    Dr Sharma,
    I don’t understand your point here. Can you add some more detail to your argument? I don’t see any point of disagreement in your post or in the article. Its obvious deseases have a social and a physical manifestation. And how are you relating this to obesity? I’m interested so I hope you’ll blog more on this.

  4. Razwell says:

    I think many readers will be surprised to learn that our body fat levels are largely cointrolled beyond conscious control. The brain cells etc. help regulate all of this. We have homestatic systems for just about everything else.

    Both Dr. Stephan Guyenet and Dr. Linda Bacon, as well as yourself, have given proper credit to the body’s wishes and the control it can potentially exert thwarting our best efforts to lose fat. I like Dr. Bacon because she works with the body and honors it, rather than fights it ( e.g. the commercial diet industry)

    I suppose thi sgoes aginst many people’s beief systems, but the good layman scientists out there will acknowledge this piece of gained scientific knowledge.

    This is not to say though that there is nothing in our control. There are things that can help our bodies do their jobs, at least in a health human with no fat cell disregulation.

    Take care,

    Razwell

  5. NewMe says:

    Obesity is the poster-child for a state of being that straddles what you term “a ‘norm variant’ of body shape distribution in the population” and a medical condition that is associated with a host of physical problems. In other words, one can be perfectly healthy while living in a body that carries much more weight than the norm or one can suffer from medical issues associated with a body that carries much more weight than the norm.

    I tend to lean towards a view of overweight that accepts body diversity. It is clear to us both that different bodies react differently to exercise and to foods (both with respect to type and quantity). If our bodies all functioned in the same way, we would probably all develop similarly and weight disparity would not exist. This is the aspect of weight that is indeed out of our control.

    But then, there are the sociological factors that often “help” a naturally heavy person become much heavier:fat bias, blaming and shaming, physical and psychological abuse, trauma. As I’ve noted before, the morbidly obese people we see paraded across our TV screens all seem to have suffered some type of trauma or abuse. They may have started out as being heavy “norm variants” but their additional weight gain can often be attributed to personal pain and anguish of many types…or to the struggle to make their bodies into something they are not (i.e. the classic upward spiral of yo-yo dieting).

    Add to this societal pressures. In North America, we live in a world that pushes us towards fast food (you’ve done some great posts on that, BTW) while viciously criticizing those who eat such food and gain weight (not all do). North America and Britain have a love/hate relationship with food that is quite unique in the world. Is this the result of Puritanism? Just wondering.

    In short, I do not believe we can treat overweight/obesity as purely a physiological condition. Situating it within a societal context is absolutely essential. The more we do so, the more we as a society will come to embrace body diversity while seeing many fewer people suffering from what may possibly (though not always) be obesity-related conditions.

  6. Janis says:

    Honestly, obesity is a result of the average calorie value in a given cubic volume of food having skyrocketed during the past century. Period. That is quite literally IT. Thanks to technology, we can now fit one week’s worth of calories into a volume of food that can fit into a single human stomach in one go. I swear to you, that’s all it is.

  7. DebraSY says:

    The word “disease” carries baggage for lay people. To define obesity as “disease” pigeon-holes it in unhelpful ways and heightens alarm. A cooler approach is more productive.

    It is more helpful, I think, to view obesity as a characteristic. Inconsistently, it may also be a symptom of other diseases or a contributor to joint deterioration and other medical conditions.

  8. DebraSY says:

    @Janis. Energy Density is not the Boogey Man. Here’s a site: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001050

    This is a very complicated issue. There is no one “IT.”

  9. Laurie says:

    Mental health diagnoses have no scientific test that can be done to evidence that these disorders actually exist. In fact, there is a lot of evidence that points to the fact that medical tests can be done to help detect what physical cause may be prompting an unwanted condition. Physical cause, not mental cause.

  10. DeeLigh says:

    I disagree with the disease model of obesity because it doesn’t seem to apply to me or to many other people that I know. Also, as DebraSY said, having one’s body defined as “diseased” because of the way it looks is incredibly stigmatising.

    Ever since I can remember (starting at the age of 7 or 8), doctors have been telling me that I’m too heavy. I’m pretty sure that by the time I was 11 or 12, the word “obese” was being bandied about. However, I’ve never seriously attempted to lose weight. I’m in my early forties now and am still roughly the same size I was in high school. I just got the results of my latest checkup. Blood pressure: normal. Cholesterol: normal. Blood sugar: low side of normal. This is in spite of the fact that my dad has type II diabetes and was diagnosed at around my age.

    All my life, I’ve felt healthy. My body has proven to be capable and resilient. I’m usually able to keep up with my thinner friends at sports and activities: biking, skiing, rollerblading, hiking… When I’m sick or injured, I always seem to surprise the doctors with how quickly I recover.

    So, could you please explain to me how I’m diseased? Because people my size have an increased risk of some real diseases? So do men. So do some ethnic groups. They aren’t considered diseased by definition.

    You may say, “you may be healthy now, but you’ll have something wrong with you later.”

    How much later? Is 30 years of being “obese” not long enough? You say that I’m going to have heath problems in my 60s, 70s and 80s? Well, EVERYONE (including people who have never been fat) will inevitably develop health problems as they age and eventually die of them. But I guess they’re innately healthy people who will eventually become sick. I, on the other hand, will always be considered an innately sick person who is temporarily healthy, even if I die in my eighties or nineties after a long, active and productive life, with no period of decline. And, yes. It could happen.

    I guess that I have a disease that has no negative effects on my life (other than having to deal with other people’s biases and with the fact that I’m not the average person that everything is designed for) and that will not necessarily shorten it. Wow. That makes no sense at all.

  11. Janis says:

    I don’t know — ultimately I think this IS “it.” In the past, obesity was just not the problem it is today. Something clearly has changed. Human genetics has not suddenly leapt into unknown territory. The genetic, hormonal, and behavioral issues that all come together to result in obesity have always existed. There have ALWAYS been people who are addicted to things, who have been subjected to psychological pressures, who have hormonal or genetic tendencies.

    But the environment was such that those “causes” were never expressed as obesity. There were always people with genetic tendencies to eat when full. The thing is, 8,000 years ago when there was no overwhelming presence of super-salty and super-fatty food, those people simply looked the same as those who didn’t have those genes.

    We just live in an environment nowdays that allows those differences to be expressed, differences that for the entire rest of human history, have run under the surface, a harmless variation. In a very real sense, the overwhelming abundance of super-salty and super-fatty food is absolutely “it” when it comes to the suddenly avalanche of obesity among human beings.

  12. DeeLeigh says:

    Janis, you’re talking as if there were no fat people until 20 or 30 years ago. That’s clearly absurd. Look at some old pictures and paintings.

  13. Jennifer says:

    @Deeleigh: You ask when you will start to have health problems because of your weight. Well, if you are to develop any, it will likely be in your forties. That is also when most people find their weight starts to creep up. I know that is what happened to me – I was more or less the same weight all my life until I approached 40. But some people are lucky and it never happens.

    Indeed, I know what you mean about people referring to obesity as a disease, especially when you have no health problems. It’s more complicated than that.

  14. DeeLeigh says:

    Jennifer, I’m already in my forties, and my health is still fine.

  15. Janis says:

    Not in the numbers there are now. Again, two-thirds overweight or obese is definitely a different thing. Old paintings showed some overweight or obese people … rich people only, those who had access to palatable food in larger quantities. Those were almost the only people who did back then. And they were still not in the figures they are now, where it’s roughly two-thirds of the population.

  16. DeeLeigh says:

    Janis, it’s not true at all that only rich people are fat in old paintings. The example that pops immediately to mind is “The Wedding Dance” and anything else by the Pieter Bruegel (1525-1569) or for that matter Rembrandt, or many Italian Renaissance painters. No, the people in those paintings aren’t huge. However, they look a lot like me, and my BMI is solidly and permanently over 30.

    You also have to remember that it wasn’t common for painters to use regular people as subjects, as they couldn’t afford to commission paintings.

    Jennifer, come to think of it, I think you misinterpreted my comment. I was talking about health, not weight. I may well gain a little weight in middle age, as most people do. No big deal. However, I think that if my health was going to fail within the next ten years, I’d have some sign of it already.

  17. Razwell says:

    In an environment that has unlimited access to calories , not everyone becomes obese. Calories are necessary but NOT sufficient to induce obesity. This is coming from Dr. Jeffrey Friedman himself.

    The whole “we have more calories now” argument is wrong. Even in way back in the 1600′s they were claiming “no age has seen more obesity than our own” .

    There are wild animals who remain despite massive abundance. Obesity has ALWAYS been around- at least since 23,000 B.C.

    Even on Dr. Sharma’s blog I have seen several commentors clingining to belief systems rather than reading science.

    I encourage all to watch Dr. Jeffrey Friedman’s lectures all available on YouTube and other places.

    Obesity is much, much more than calories. It is NOT a simple condition of eating too much. Something went wrong in people as large as Manuel Uribe. A single gene defect could cause that, as Dr. Friedman’s work demonstrates. He unfortunately is in a disease state. Hopefullly science will advance to help him.

  18. Razwell says:

    I forgot to mention anyone mentioning obesity is “only among the rich” etc., completely ignores valid scientific data Gary Taubes has brought up.

    Obesity is IMMENSELY connected to malnutrition. Gary Taubes cites example after example of obesity in extreme poverty areas.

    Belief systems run roughshod about obesity. Stick to science. This is not a morality issue. In America, it is hard to drop the whole puritanical values thing. I encourage all to look much deeper into this.

    Most people have assumptions about obesity which have absolutely no basis at all. I did before I looked into this. I never judged them. but I thought it was simple.

    Obesity is anything but simple. It is a major scientific challenge for which there are no simplistic solutions. The heritiablity of obesity is absolutely massive. It is almost equal to height.

    Those who understand the science do not speak of obesity as a morality issue.

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