Right Goal – Wrong MessageTuesday, June 21, 2011
Yesterday, the Public Health Agency of Canada (PHAC) and the Canadian Institute for Health Information (CIHI) jointly released a thoughtful, insightful, and thorough report on Obesity in Canada.
Unfortunately, the media release announcing this report promoted the rather misleading and simplistic notion that millions of Canadians are overweight and obese simply ‘because’ they are inactive and do not eat enough fruit and vegetables.
This, as becomes clear when reading the actual 62-page report, was probably neither the intention of the authors nor that of the reviewers and consultants, who contributed to this report.
Indeed, the actual report goes to great lengths to explain that obesity is complex and multifactorial.
Thus, the report points out that:
“Research has identified a number of determinants associated with obesity, including physical activity, diet, socioeconomic status, ethnicity, immigration, and environmental factors”
“…the patterns involved are complex, and determinants are interconnected.”
The report is particularly sensitive and cautious when it comes to the drivers of obesity in Canada’s Aboriginal communities:
“Aboriginal populations have distinct histories, but they share common experiences of colonialism, racism and social exclusion. Reflecting these histories and a more holistic cultural perspective on health, for Aboriginal peoples the range of determinants of health may also include factors such as cultural continuity and the relationship to land.”
“…the historical experiences of Canada’s Aboriginal peoples provide important context in considering the determinants of Aboriginal health, including obesity.”
With regard to the proximal determinants (like diet and physical activity), the report acknowledges research findings on familial and environmental factors that may affect dietary choices and behaviours:
“For example, snacking or eating dinner while watching television, consumption of sugar-sweetened beverages between meals and skipping breakfast have been associated with an increased risk of obesity in children and youth. As well, a study of middle-school-aged children found that a greater frequency of family dinners was associated with less soft drink consumption, more frequent breakfast eating, less concern over high bodyweight and higher self-efficacy for healthy eating at home and during social times with friends.”
Other determinants, about which there is still much more to learn, include:
“the effects of biological or genetic influences and pre- and post-natal effects, including birth weight and breastfeeding”.
“There may also be a relation between psychiatric conditions and excess weight, although this may be confounded by that fact that some psychotropic medications can contribute to weight gain”
Unfortunately, while the authors were clear and cautious in the presentation of their findings, the press release essentially throws all of this to the wind with its opening sentence:
“Eliminating all physical inactivity among Canadian adults (defined as less than 15 minutes of low-impact activity a day) could avert the equivalent of 646,000 cases of obesity in women and 405,000 cases in men……Similarly, improving poor-quality diets—as measured by the frequency of fruit and vegetable consumption—could result in the equivalent of 265,000 fewer cases of obesity among men and 97,000 fewer cases of obesity among women.”
Not surprisingly, this is exactly the message that most of the media picked up and splashed across front pages, TV screens and websites, not to mention radio shows and every other possible outlet – with a few sparse and notable exceptions.
What I imagine most Canadians heard yesterday was that,
“if only all these fat slobs would simply get off their butts for just 15 mins of low-impact activity a day and perhaps eat the odd extra serving of fruit and vegetables, one million Canadians would no longer be obese and we could instantly save all those billions of dollars in health care!”
Never mind that the term ‘avert’ (meaning avoid or prevent) was widely interpreted by the press to mean ‘reduce’.
Never mind that the report actually explains in length that these calculations are purely theoretical and do require the assumption of causality.
Never mind that the authors caution that,
“….because these analyses use cross-sectional data and rely on a number of assumptions, they cannot be used to make inferences about the causes of obesity”.
Never mind that,
“Relatively few population-level obesity prevention and management interventions – especially public policy approaches that target broader environmental factors – have been systematically evaluated in terms of their effectiveness or cost-effectiveness.”.
And, never mind that my back-of-the-envelope calculation tells me that even if these number were true, ‘averting’ 1,000,000 (extra?) cases of obesity would still leave us with over 6,000,0000 Canadians, who are obese today and are unlikely to be dropping those extra pounds simply by adding 15 mins of low-impact exercise to their daily routine or reaching for a few servings of fruit and veggies.
My guess is that the authors of this report were probably both surprised and appalled by the media release and the response to it.
At least I hope they were, given that in their report they are were careful to note that,
“…..decisions about how best to address obesity at a population level….may benefit from careful analysis of the feasibility of possible interventions, the available scientific evidence, the cost/benefit ratio (including the potential for unintended or negative outcomes such as stigmatization or increased inequities), as well as potential value for money.” [emphasis mine]
Unfortunately, “the potential for unintended or negative outcomes such as stigmatization”, apparently escaped the analysis that went into deciding how to communicate this report to the media.
Needless to point out, the press release was also rather ‘light’ on the issues of ‘feasibility’, ‘availability of scientific evidence’ and ‘value for money’ for the proposed ‘intervention’.
All of this is sad and disheartening, because the report itself is so carefully worded, balanced and insightful.
It is indeed hard to align one of the major conclusions of this report:
“There is unlikely to be a single solution that will reverse the rising prevalence of obesity in Canada; rather, a comprehensive, multisectoral response may be needed.”
with the rather simplistic message that folks will now remember every time they see someone carrying a few extra pounds:
“Why can’t you just get off your butt for even 15 mins and simply eat those five fruit and veggies – then you’ll have no business being obese and I won’t have to pay so much for your health care.”
Sadly, not a happy day for the 6,000,000 Canadians facing the bullying, emotional pain and despair caused by pervasive negative stereotyping and anti-fat discrimination.