Wednesday, April 16, 2014

Shame And Blame Has No Role In Addressing Obesity

Balancing the scales Kirk et alAs a regular reader you will be well aware of my recent excursions into the use of comedy to promote a better public understanding of obesity.

A very different (and I dare say more scientific) approach to harnessing the performing arts to promote a discourse on obesity is that taken by Sara Kirk and colleagues, Balancing The Scales, now described in a paper published in Qualitative Health Research.

Their approach is based on the recognition that,

“…individuals living with obesity are caught in the middle, facing judgment by society if they fail to manage their weight successfully and exposing themselves to health professionals who are unable to fully support them…if an individual is unable to make the changes prescribed for weight loss, resentment builds on both sides of the therapeutic relationship.”

This led Kirk and colleagues to extensively explore the issue of obesity from a variety of perspectives resulting in rather unique insights into similarities, differences, points of consensus, and tension associated with values, beliefs, perceptions, and practices among key stakeholders.

The 42 semistructured interviews were conducted in 22 individuals living with obesity, 4 policy makers, and 16 health professionals (8 dietitians, 4 family physicians, and 4 nurses).

Three major themes emerged from the analysis of the interviews:

Blame as a Devastating Relation of Power

“Individuals living with obesity shared feelings of shame and embarrassment with their inability to control their weight on their own. This blaming discourse can easily be seen in messages of “eat less, move more” promoted by health professionals, the health system, and wider society.”

“Individuals living with obesity spoke about the complexities of trying to lose weight, inclusive of cultural, social, and organizational barriers. Despite this insight, however, they placed the final explanation for their weight status on themselves and expressed immense feelings of guilt and shame.”

“All of the individuals living with obesity had tried multiple methods to manage their weight, with limited or no success. This was extremely frustrating for them and compounded their tendency, wholly or at least partially, to blame themselves for this perceived failure.”

“Similar to individuals living with obesity, health professionals struggled to understand the complexity of the issue, which often led to blaming the individual. Health professionals commented on the unrealistic expectations of people who wanted to lose weight quickly and how their role as a health professional could not possibly be supportive of this.”

“The health professionals we interviewed also blamed themselves for not having the answers, and described feeling ill-equipped to assist individuals to make successful changes.”

Tensions in Obesity Management and Prevention

“Both the individuals living with obesity and the health professionals did not feel supported by the health care system. Health professionals [and policy makers] also struggled to know how to approach the issue.”

“Individuals living with obesity also experienced exclusion when attempting to find appropriate support within the health care system. Most individuals in the study began to access this system when they believed they could no longer manage their weight by themselves.”

The Prevailing Medical Management Discourse

“Health professionals experienced many frustrations and contradictions in their experiences with obesity management, and at times questioned the notion of obesity as a disease. Being obese was often in itself not enough to receive health care. Health professionals in this study found it easier to work with individuals living with obesity when they also had another diagnosed chronic condition, such as diabetes or cardiovascular disease. They could then more confidently prescribe a specific treatment regime.”

As for policy makers,

“[One] policy maker questioned whether medical treatment for individuals living with obesity is necessary…. As an alternative to medicalizing obesity, the policy maker suggested addressing the issue of population health and using health promotion to support the majority of people who are not morbidly obese but are still struggling with weight problems.”

“Overall, individuals living with obesity sought validation for requiring support in a system that currently does not provide the support they need.”

Based on these findings, the authors note that,

“…our findings highlight the need to reframe the public debate on obesity. However, we suggest that rather than choosing one discourse over another (management vs. prevention; system vs. individual), we should engage aspects of both. This requires not only consideration of socioecological perspectives, but also a greater awareness among health professionals of the need to offer support, not advice.”

“Furthermore, relationships between patients and health care providers should be supportive (not blaming), recognizing the widespread prevalence of weight bias in society and working hard to challenge the stereotypes that dominate the discourse on body weight”

“It was also evident in the language and experiences provided by health care providers that training, resources, and support for weight management were a substantive part neither of their professional training nor of the health care system.”

To facilitate improved training of health professionals, the authors have developed the rich narratives obtained in this study into a dramatic presentation, depicting the relationship between a health professional and an individual living with obesity.

This narrative can be viewed here.

For interviews with the researchers – click here.

Clearly, it is work like this that is essential to understanding the current discourse (or rather lack of it) about obesity and finding strategies that do justice to those living with obesity.

There is simply no room for “shame and blame” in such a discourse.

@DrSharma
Edmonton, AB

ResearchBlogging.orgKirk SF, Price SL, Penney TL, Rehman L, Lyons RF, Piccinini-Vallis H, Vallis TM, Curran J, & Aston M (2014). Blame, Shame, and Lack of Support: A Multilevel Study on Obesity Management. Qualitative health research PMID: 24728109

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Monday, April 14, 2014

Can Video Games Make You Eat Too Much?

sharma-obesity-videogame-pacmanGenerally, TV viewing and playing video games are blamed for weight gain because of their sedentary nature (as opposed to more active recreational activities).

However, as has been argued before, the key impact of TV viewing and video gaming on body weight may well lie in their effect on food intake.

An elegant randomised controlled trial by Jason Gan and colleagues, published in APPETITE shows that vide0 gaming can lead to an increased intake of foods, particularly sweets.

The study involved 72 overweight/obese adult males, divided into three equal groups, randomised either to one hour of (i) watching TV; or playing (ii) a non-violent video game; or (iii) a violent video game.

This was followed by a 25 minute rest period with free access to a selection of sweet and savoury snacks/drinks. D

Heart rate, blood pressure, and stress measured by visual analogue scale (VAS)) were all significantly higher when playing video games compared to watching TV.

This increase in stress levels was associated with a 170 higher caloric intake and a preference for sweets and fatty foods in the video game group compared to the TV watchers.

In addition, the violent video games led to even higher stress levels with an even stronger preference for sweet foods.

Thus, the authors conclude that, compared to TV viewing, playing video games (especially violent ones) is associated with a stress response, and increased calorie intake.

This phenomenon may well confound previous findings that show associations between playing video games and weight gain, leading to the assumption that it is the sedentariness of video gaming that promotes weight gain, when it fact it may well be the associated impact on snacking.

@DrSharma
Edmonton, AB

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Friday, April 11, 2014

Does Eating More Protein Help Keep The Pounds Off?

sharma-obesity-diogeneslogoAs a regular reader, you may remember the DIOGENES trial, which studied the impact of different levels of protein intake on sustaining a weight-loss induced by eight weeks of a low-calorie formula diet (800 Kcal resulting in an average weight loss of about 11 Kg).

The original paper showed that individuals on a high-protein diet (providing 12 % more energy from protein that the low-protein diet) were about half as likely to discontinue the 26 week trial than those on a low-protein intake.

Now, a new paper from DIOGENES, published in the International Journal of Obesity, reports on the weight outcomes in participants, who were followed for up to 12 months in two of the participating centres (n=256).

The five ad libitum diets (no caloric restrictions) that followed the low-calorie diet (resulting in an average weight loss of about 11 Kg) were:

1) a low-protein and low-glycemic index diet,

2) a low-protein and high-glycemic-index diet,

3) a high-protein and low-glycemic-index diet,

4) a high-protein and high-glycemic-index diet,

5) a control diet.

While average weight regain over the 12-months was about 4 Kg (of the 11 Kg lost initially), the subjects on the high-protein diets kept off almost twice as much weight as those on the low-protien diets (glycemic index did not appear to make any significant difference).

Thus, the authors conclude that following a higher-protein ad libitum diet improves weight loss maintenance in overweight and obese adults over 12 months.

Clinicians may wish to stress the importance of maintaining a high-normal protein intake to clients trying to avoid regaining pounds that they have lost.

@DrSharma
Edmonton, AB

 

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Thursday, April 10, 2014

Managing Weight Loss Expectations

sharma-obesity-great-expectationsWhile there are almost no limits to short-term weight loss goals (anyone can starve themselves thin) – the reality of long-term weight loss is rather sobering.

While diet and exercise generally provide an average long-term (3-5 years) sustainable weight loss or about 3-5% of initial weight, even bariatric surgery patients tend on average to sustain a weight loss of only 20-30% of their initial weight.

Surgery, although much safer than generally thought, still bears a risk of complications and the question is how much risk patients are willing to assume if they really knew and understood how much weight they are likely to lose with surgery.

This was the subject of a study by Christina Wee and colleagues, published in JAMA Surgery, in which they examined weight loss expectations and willingness to accept risk among patients seeking bariatric surgery.

The researchers interviews 650 patients interested in bariatric surgery at two bariatric centres in Boston.

On average, patients expected to lose as much as 38% of their weight after surgery and expressed disappointment if they did not lose at least 26%.

In fact, 40% of patients were unwilling to undergo a treatment that would result in only 20% weight loss.

Most patients (85%) accepted some risk of dying to undergo surgery, but the median acceptable risk was only 0.1%.

On the other hand, some patients (20%) appeared more desperate, willing to accept a risk of 10% or greater.

As one may expect, there were important gender differences in these findings: while women were more likely than men to be disappointed with a 20% weight loss, they were also less likely to accept a greater mortality risk.

An important finding for clinicians was that patients with lower quality-of-life scores and those who perceived needing to lose more than 10% and 20% of weight to achieve “any” health benefits were more likely to have unrealistic weight loss expectations.

This study not only shows that most patients seeking bariatric surgery have rather unrealistic weight loss expectations but also that   a substantial number may well be be disappointed with their weight loss after surgery.

It is also evident that many patients believe that they need to lose a rather substantial amount of weight to derive “ANY” health benefits, when in reality even rather modest (and certainly the average 20-30% weight loss seen with surgery) carries substantial health benefits for patients. (Many patients would in fact benefit substantially if they simply stopped gaining weight).

I certainly wonder what educational efforts may be necessary to align expectations with the clinical reality of bariatric surgery and whether better managing expectations is likely to alter current practice?

@DrSharma
Edmonton, AB

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Wednesday, April 9, 2014

Reserve Your Spot At The Obesity and Mental Health Conference, Toronto, May 14, 2014

smaller_CON_OMH_program_2014_2_Page_014614As a regular reader you may recall a previous conference on obesity and mental health which saw the release of the Toronto Charter on Obesity and Mental Health.

A follow up to this conference will be held in Toronto on May 14, 2014.

This time the focus is on clinical management of people with mental health issues presenting with weight gain as well as people with obesity presenting with mental health problems.

This one-day program features a rather distinguished roster of speakers, the full program can be downloaded here.

Registration for the conference is now open to all health professionals with an interest in obesity and/or mental health – click here

For more information on this conference – click here

@DrSharma
Edmonton, AB

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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