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Right Goal – Wrong Message


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”

and that:

“…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.”

and

“…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.

AMS
Edmonton, Alberta

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11 Comments

  1. Sad that such an opportunity to dispel myths has been missed. I applaud the Toronto Star for their recent series on obesity: it is one of the most throughtful and balanced approaches to the issue that I’ve seen in the media. However, once again the comments section is dominated by bigotry and several cruel versions of “stop eating junk and get off your a**”…its’ puzzling though – if 60% of us are overweight, who is making these comments? It seems that even many of us who are overwieght believe the same biases and misinformation: a formula for a self-perpetuating cycle that adds to the problem.

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  2. I was upset when I read the headline.
    “Lack of exercise main factor in high obesity rates”
    http://www.cbc.ca/news/health/story/2011/06/20/obesity-physical-inactivity.html

    There are a lot more factors at play and while lack of exercise is part of the problem, there are a lot more issues to address, a lot of which are mentioned in the actual press release.

    The headline does not fit the article and is misleading. As an obese person myself,
    I feel like it is saying, Overweight people are lazy. And I am anything but lazy.

    As you said Dr. Sharma, “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.”

    This type of Headline only makes things worse for the obese.

    Thanks for listening,
    Rosemary in Edmonton

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  3. I share the frustration with the media coverage of this report. I think it’s a good reminder though, that the media and the public require very simple, basic messages. Scientists often make this mistake. The subtle, scientifically cautious, non committal, “research suggests but we can’t be sure” type of communication does not translate well to the public. Therefore the media will try to simplify it and usually get it wrong. It’s preferable to have the authors either “plain language” their findings themselves for the media or hire someone to do it for them. There’s a better chance of the right message getting out there.

    Dr. Sharma you are on the right track to reaching the public, I think. Items like your “10 rules” for Dr.s checklist and your PowerPoint “Never eat when you are hungry” are reader friendly.

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  4. Eating a proper diet and taking some exercise may not be SUFFICIENT to control weight, but they are NECESSARY.

    Even if all the contributing factors were resolved, people would still have to eat right and get some exercise.

    Officialdom can’t even define a healthy diet (see weighty matters blog by yoni freedoff talking about the canada food guide.)
    Focus on extra factors is useless if at the end of it all people are still given inaccurate information on what a proper diet actually is.

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  5. People know what healthy and unhealthy foods are. Its been done to death already. It is time to get off the diet/excercise band wagon and onto the facts of obesity.

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  6. I appreciate the work you and Yoni do but all the facts in the world are not going to overcome the fear of growing old in people who were at their prime in high school. I can tell you the day I became comfortable within my own skin. Sitting around me at a high school football game were mothers who had the bone structure and body shape of former cheerleaders. When the team came off the field, we were all just somebody’s mother. The guys were just as happy to see obese me as they were any other mother spectator. The kind of guy who wasn’t interested in me as an obese teenager wasn’t turning his head to look at the mother of a teenage football player. Youth lasts a minute for all of us but some people build their lives around trying to stop the passage of time – a losing battle.

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  7. It’s truly unfortunate that this type of crap is reported by the media.

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  8. I guess Brenda and I have not been reading the same Toronto Star series on obesity.

    The series I have been following is replete with the usual “sky is falling! run for the hills!” statements, completely assimilates slimness with health, relies on the usual stereotypes concerning fat people (while not directly calling them lazy, junk food eating slobs, the people featured in the articles come off as just that) and even makes serious factual errors meant to drive home just how dangerous overweight can be (to wit, polycystic ovarian syndrome, according to journalist Michele Henry, is caused by being overweight–the truth is quite the opposite: overweight and extremely difficulty in losing weight [as if it isn’t already incredibly hard] are *symptoms* of PCOS).

    I sent an e-mail directly to Michele Henry. I have received no reply.

    I am waiting for the series to end before sending a letter to the editor expressing my deep disappointment and concern over how the Star is simply rehashing all the stereotypes regarding obesity and providing absolutely no new insight into this complicated issue.

    Now, back to our regularly scheduled programming: Great post today, Dr. S.!…though extremely depressing.

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  9. Speaking of right goal wrong message, can you speak more of the formula you mentioned the other day? To paraphrase, you said something to the effect that a person who loses 20 pounds to now weigh 150lbs really now has consume the calories a 130 pound person would to maintain their new weight of 150 pounds. That sounds like a mathematical formula to me. So are you then saying that a person who loses 100 pounds and now weighs 160 pounds has to consume the same amount of calories that a 60 pound person would need to maintain their new weight of 160 pounds? I don’t know any 60 pound adults. That’s about a 1/2 a cup of dog food three times a day for my dog. Even anorexics can’t maintain a weight of 85lbs without dying. And what about those who lose 200 pounds? Then you get into a mathematical result with a negative calorie balance? I would appreciate it if you could go delve into this more Dr. Sharma.

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  10. I haven’t read the report but I think these kind of faulty conclusions stem partly from the fact that we most often define obesity as a fixed threshold (BMI of 30). It’s probably true that 15 minutes extra activity could take a whole lot of people from BMI of 30 (obese) to BMI of 29.9 (not obese) but that is not the way anyone thinks of obesity personally or socially. This might be meaningful for the researchers but to the judgemental person on the street or the individual, they are all just as “fat” as they ever were.

    Therefore 15 minutes extra activity a day might “cure” a million people of their obesity (a statistical/technical measure) but not of their fatness (a social/personal measure).

    I believe that this threshold effect has been widely abused by researchers, the government and big business to induce a sense of panic/urgency.

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  11. As a health care provider, I am far more concerned with the internalized oppression and shame resulting from widespread discrimination than someone’s choice to eat less or more. For many people, far more harm arises from bias and hate, including self hate, than from weight status itself; unfortunately the former are difficult (or impossible) variables to eliminate; much more physiological harm may arise from oppressive conditions while we tend to believe the harm is somehow “just” psychological. Thanks Dr. Sharma, in particular, for underscoring forces of domination and oppression driving health disparities for Aboriginal populations.

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