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Obesity: What’s in a Name?



The News Section of this week’s edition of the Canadian Medical Association Journal (CMAJ) features an article by Roger Collier, in which I am extensively quoted with regard to wether or not health professionals should use the term “obesity”.

Regular readers of these pages will be quite familiar with my views on this issu. Readers may also recall that there is indeed a medical definition of obesity and that this condition has long had its own code in the International Statistical Classification of Diseases (ICD 10 E66.0).

Here a few quotes from the CMAJ article:

Doctors are also aware that patients don’t like to be labelled as obese, even if the label is accurate. Dr. Arya Sharma, chair for cardiovascular obesity research and management at the University of Alberta in Edmonton, says he never refers to a patient as an obese individual, which implies they are defined by their condition. Instead, he will use phrases such as “person with obesity.” He also prefaces the word “obese” with “medically.”

“When you put the word ‘medically’ in front of it, it implies you are talking about a medical condition,” says Sharma, who is also the scientific director of the Canadian Obesity Network.

In a recent paper, Sharma explored historical approaches to classifying obesity. Some descriptive terms once used in medicine, he noted, were far from kind. “Although some earlier descriptions of obesity used less pejorative synonyms such as stout and corpulent (meaning excessively fat), other terms such as mammoth, monstrous and grotesque clearly reflect societal stigmatization against the obese individual and, although the stigma remains, these terms have long been abandoned,” he wrote.

Though he takes care not to offend patients, Sharma advocates for the use of the word “obesity” because it has a precise clinical definition. In fact, he was one of the few founding members of the Canadian Obesity Network who insisted the word be included in the organization’s name. Others, Sharma says, feared it would repel sponsors and harm funding, and suggested names along the lines of “The Healthy Network.”

Sharma also says the word “obesity” should be entered into medical records if a person’s BMI is 30 kg/m2 or higher. To just record the BMI, he says, would be akin to recording a patient’s blood pressure without noting the presence of hypertension.

Some health experts believe the stigma associated with certain conditions can have a positive effect, serving as a powerful motivator for people to improve their health. But when it comes to obesity, Sharma says, stigma does nothing but harm. It can deter people from seeking medical care and lead to depression, anxiety, poor body image and suicidal thoughts.

“These are concrete health risks,” says Sharma. “It’s not just about not being kind to people.”

But of course not everyone agrees with these views.

The article goes on to quote a Dr. Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute in Washington, DC, who has the following views with regard to stigma (at least in the context of addiction):

In an article titled “In Praise of Stigma,” she argued that stigma reflects a societal norm and can motivate people to change their behaviour. Though “stigma abolitionists” have good intentions, for the most part, Satel wrote that the fear of attributing blame for destructive behaviour can itself be destructive. There is much about addiction that is voluntary, she writes, and to dispel the concept of willpower will only deter the recovery process.

“There is nothing unethical — and everything natural and socially adaptive — about condemning the reckless and harmful behaviours that addicts commit,” she wrote. “This need not negate our sympathy for them or our duty to provide care.”

I would beg to argue that I yet to see any evidence in favour of the notion that societal stigma is an effective tool in getting people to live healthier. If this was true, given the widespread bias and discrimination that people with excess weight experience everyday, we should truly be a nation of rakes.

I wonder what my readers have to say about this.

For a link to the full article click here

AMS
Edmonton, Alberta

p.s. You can now also follow me and post your comments on Facebook

Sharma AM, & Kushner RF (2009). A proposed clinical staging system for obesity. International journal of obesity (2005), 33 (3), 289-95 PMID: 19188927

14 Comments

  1. “There is nothing unethical — and everything natural and socially adaptive — about condemning the reckless and harmful behaviours that addicts commit.”

    The problem with this statement when it is applied to so-called obesity, is that many obese people don’t engage in reckless and harmful behaviour, and are not addicts. And of course, many don’t have any health problems that need to be dealt with. I wonder if the general public realizes just how many people that they see every day are technically obese? I think that many people believe this term only applies to people who are so fat that they can barely walk, need to take two seats on the bus, etc. In reality, if you apply the current BMI standards, a great many people who only seem to be moderately overweight are in fact obese. Are all these people reckless? Do they all need to be chastened by stigma?

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  2. I agree that the term obese is a clinical term and should be used in the context to educate patients about their own health. In the clinic, doctors shouldn’t sugar coat any scientific facts and obesity is highly correlated with various cardiovascular risk factors as research has clearly demonstrated. BMI scale is carefully designed tool that reflect one’s risk. So even if many people who are in fact obese may not be showing any symptoms of physical distress, they are seriously in the danger zone and might be experiencing inflammation and insulin resistance which can be asymptomatic for a long time.
    What I don’t agree with is having the term “reckless” associated with obesity… because there are many reasons for obesity and even though the formula of energy in< energy out seems very simple to follow.. in application and in the context of disturbed metabolic milieu is very complicated and needs urgent attention.

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  3. The formula of energy in and energy out is not an effective approach to weight loss in any context. In fact, there appears to be no effective approach at present. No one has been able to devise a method to help people lose a large amount of weight (say, more than 15lbs) and keep it off permanently. Even bariatric surgery doesn’t have that many long-term sucesses. And I disagree that the BMI has been “carefully designed” to allow people to know when their weight threatens their health. It’s actually an arbitrary scale that is maintained by some academics at Harvard (e.g. Walter Willett) who believe that good health is only possible if you are quite thin, even though there is quite a bit of evidence that this is not true.

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  4. For want of nail…

    Where do I begin?

    I could start with Dr. Satel’s statement that “stigma reflects a societal norm and can motivate people to change their behaviour”. Given this position, I suspect that Dr. Satel might also feel people who are tossed in the water with a boat anchor tied to their feet will drown only if they don’t try hard enough to swim? Societal ‘norms’ may have their place but they are a very poor substitute for science. Like much of mythology, ‘norms’ are often little more than an excuse to pretend we know what we don’t know. An excuse to look no further.

    I’m 52. All my life, I have dealt with the stigma of obesity. All my life I have been highly motivated to change my behavior. Until recently, I had never been able to do so successfully. What changed? Was it the gastric bypass surgery I had last year? No. Weight loss surgery (WLS) can be a very useful tool but it does not change your head and it rarely if ever changes the things that made us obese in the first place. WLS in the absence of more comprehensive evaluation and treatment is a recipe for yet another failure on the road to healthy weight management.

    So just what did change? What changed was what I learned about myself subsequent to my surgery. What I hadn’t known – and what I hadn’t understood – was that I have ADHD (predominantly inattentive subtype). Understanding how my undiagnosed and untreated ADHD has intertwined its way throughout my life has put many things into focus, not the least of which is my obesity. Seemingly unconnected threads in my life emerged as parts of a whole…

    And now, having my ADHD treated in combination with my surgery? Golden. Learning how to work my ADHD rather than against it? Golden. Having a normal BMI, a normal A1C, normal blood pressure? Being off insulin? Priceless.

    People treat me VERY differently today. No longer fat, I was just beginning to enjoy my new stigma-free existence when I was suddenly jerked back into harsh reality. Turns out – and who could have ever imagined – that there is apparently a stigma associated with ADHD? Sigh. The more it rains…

    Given that we now know that ADHD is far more prevalent among the obese than it is among the general population, I have to wonder if Dr. Satel also believe people with ADHD just aren’t trying hard enough to change their behavior?

    ——

    For people who really want to understand the many ways in which the stigma of obesity impacts our lives, there is no better place to start than the review published by Puhl and Heuer in Obsesity in January 2009:

    The Stigma of Obesity: A Review and Update
    by Rebecca M.Puhl and Chelsea A. Heuer

    http://www.nature.com/oby/journal/v17/n5/full/oby2008636a.html

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  5. I am so happy for you Jerry! and It is wonderful that you took a lead in your own health.

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  6. Jennifer you are free to believe whatever you wish, but how much can it help you?
    I just want to say that academics don’t haphazardly come to conclusions without intensive reviews and years of research_ especially Dr. Willett who is a renown epidemiologists in the world of academia, studying health and how it is distributed in the population at large.

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  7. How much will a lifetime of dieting help me, if I end up even fatter than I was to begin with? This is the result of dieting, and it is well known. This is what is advocated by Walter Willett and many other world-class, highly educated researchers. Unfortunately, almost all of the doctors who advocate the kind of weight loss required to conform to the standards of the BMI scale receive funding from businesses that make money from the weight loss industry. But even if they did not receive such funding, it would still be wrong-headed to encourage people to lose massive amounts of weight when there is no evidence that they can successfully keep it off, and little evidence that it will increase their life span.

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  8. I am loath to use the word obese when discussing post assessment results with obese patients. It implies defeat as a human and causes such a negative reaction among patients, its like I have to pick them up off the floor. They say things like, “i’m a fat pig”, or “can you believe how fat I am” or “I can’t believe how gross that is”. Its these comments from them, not my own thoughts that have me worried about OBESITY as a diagnosis or term to describe a disease. Diagnosis like Type ll and Hypertension don’t have the same stigma of “you’re not thin”. Obesity is deadening in the thin thing. I know you can say “call a spade a spade” and that should be true. In today’s society, kids, adults and parents just don’t want to take responsibility for their condition. Obesity should be termed what it is and not sugar coated, even if I don’t have the courage to do it.

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  9. Weight management is simple. Behavior is complicated. Lets not mix the two.

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  10. Walter Willett and many other world-class, highly educated researchers advocate healthy behavior and lifestyle change towards reaching better health which include reaching healthier weights. Even a 10% wt. drop could modify CVD risk factors. Changing behavior is a life long commitment to change one’s frame of mind and lifestyle for good.

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  11. It is also entirely possible to achieve excellent health without weight loss. And while there is nothing wrong with a small amount of weight, the Harvard folks advocate a BMI of under 22 as being ideal. There is no good evidence that it is healthier to be that thin, and for many (most?) people, it is an impossible goal. Walter Willett’s BMI is 23.5, and I don’t believe he is dieting to reach his own goal. Should he?

    Glenn Gaesser and Steven Blair’s research indicates that most people can eliminate all the health problems normally associated with overweight or obesity by being physically active and eating well, even when they don’t lose any weight.
    http://www.washingtonpost.com/wp-dyn/content/article/2004/11/26/AR2005032305542.html

    In fact they question the link between overweight and ill health. Being overweight correlates to some health problems but seems not to cause the problems. High blood pressure, diabetes, etc are probably caused by lack of exercise and poor diet. And indeed many fat people are inactive and eat badly. However many “normal” weight individuals also eat poorly and don’t exercise and have these same health problems.

    We live in a society where it is common for people who are fat (especially women) to hate themselves because of their weight, and to experience discrimination and ill treatment because of it.

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  12. bottom line is: if someone comes in the clinic who is obese with CVD risk factors, doctors should let that person know it. Most patients who are obese and in poor health rarely admit that they are eating badly and living unhealthy lifestyle so it does no body any good to try to pamper feelings or make one argue how research is misleading everyone to think better towards their own health goals. Exercising and Healthy diet is of course prerequisites to healthy lifestyles. But if someones weight is escalating every doctor visit then they have to wake up and reassess what their doing before its too late. and it is the doctor responsibility to do that. and no….this won’t be discriminating or belittling any one. It is a plain professional opinion.

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  13. Depression in “medically obese” people is common enough that I must agree with Dr. sharma that avoiding the term obese or adding medically with it is helpful. I especially like adding medical because it may encourage people seek medical help…as they should.

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  14. If a person’s weight is going up and up and they have serious health problems, of course you need to address it. But it’s possible that the treatment required is better diet and exercise, regardless of whether it leads to weight loss – weight stablization is a worthy and more achievable goal for many.

    If you want to use the word “obese” go ahead. In the minds of most lay people the word “obese” conjures up the image of a lazy, ugly, disgusting fat person, lacking in self-restraint. Hardly a fair assessment of most fat people, I think.

    I am sure that when doctors treat “thinner” people who have diet and lifestyle related health problems, they tell them to change their diet and lifestyle to improve their health (avoid a heart attack or improve insulin resistance, for example). This strikes me a good advice, regardless of your BMI.

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