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.

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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Wednesday, October 3, 2012

Why Comments on What Christina Aguilera Did Not Say Still Matter

Yesterday, the popular media threw a hissy fit after Christina Aguilera was first reported by US Weekly to have told Billboard magazine that she is through with being a “skinny white girl” (or words to that affect), which Billboard magazine then said never happened, leading to a retraction by US Weekly and other outlets that picked up this quote.

More interesting than the ‘who-said-what-to-whom’ episode are the comments left on Billboard magazine’s website.

Here are two examples of the diametrically opposing views on this issue:

Mac: Oh COME ON!!…she was never “skinny”…she had a PERFECT body. But now she’s just plain FAT! Face it Christina, you got lazy, stopped working out, and have just been stuffing your face with junk food. And now this is your B.S. way of justifying it.”

Linda: She looks great. Big ups Christina!!!! I love how she is embracing her body at its natural state for her at this point in her life. We need more women in the limelight to do just that, it frees society and humans to be themselves and happy. Haters are gonna hate. Love will eventually set us all free.”

These comments pretty much sum up the public discourse on body weight.

One camp thinks it is all self-inflicted (lazy, stuffing your face), the other is in the positive body image size-acceptance (embracing her body, natural state, good for you) camp.

Like it or not, these discussions in the context of Christina Aguilera’s (or for that matter any celebrity’s) shape and size, do more to shape the public discourse and perception of what body weight may or may not be, than any academic discussions that we may be having about this issue at public health agencies or elsewhere.

Ignoring this discourse means being irrelevant – you cannot influence a discussion if you refuse to join it.

Edmonton, Alberta

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Tuesday, October 2, 2012

Lady Gaga Found This First: ‘Fat’ Poem

Caroline Rothstein Performing 'Fat'

Caroline Rothstein Performing 'Fat'

In case anyone thought that yesterday’s post on me venturing into theatre was the first sign of me going ‘gaga’, today’s post takes it even further.

The following (e-mail readers will have to head to the site to see this) is a short poem called “Fat” by Caroline Rothsteiin, a 29-year old spoken-word poet and writer who lives in New York.

This raw and personal poem, in which Rothstein describes her struggles with her bulimia and body-image issues, was ‘discovered’ by Lady Gaga and has since received over 30,000 hits on YouTube.

As anyone moved by this piece will appreciate, the power of art (in this case a poem) to change heads and hearts is far greater than any scientific study that I could ever hope to publish.

Please feel free to repost this video so that others can see it – appreciate your comments.

Edmonton, Alberta

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Tuesday, July 17, 2012

Mental Health And Childhood Obesity: A Note to Policy Makers and Clinicians

Earlier this month, the Canadian Obesity Network, in partnership with IASO and CAMH, released the Toronto Charter on Obesity and Mental Health.

Although the Charter acknowledges the importance of recognising the rather close relationship between obesity and mental health both in adults and children, the focus of this Charter (and the conference leading up to it) was largely on adults.

Now, Shelley Russel-Mayhew (U of Calgary), who spoke a the Toronto Obesity and Mental Health Conference, and colleagues, publish a comprehensive overview of mental health, wellness and childhood overweight and obesity in the Journal of Obesity.

The researchers performed a systematic literature search of peer-reviewed, English-language studies published between January 2000 and January 2011 on this issue. They identified 759 unique records, of which 345 full-text articles were retrieved and 131 articles included in their analyses.

Based on these findings, they propose a theoretical model that reflects the current state of the literature and includes psychological factors (i.e., depression and anxiety, self-esteem, body dissatisfaction, eating disordered symptoms, and emotional problems); psychosocial mediating variables (i.e., weight-based teasing and concern about weight and shape), and wellness factors (i.e., quality of life and resiliency/protective factors).

Based on their findings, they recommend a number of possible solutions to addressing the rise in childhood obesity rates without (importantly!) further marginalize overweight and obese children and youth.

These include increasing mental resilience, stopping the focus on weight, recognising that many weight-related issues are socially constructed and maintained, promoting healthy body images (regardless of size or shape), and targeting positive adult role models.

Thus, the authors conclude that,

“…intervening for the psychosocial emotional health of overweight/obese children should be a focus in and of itself and not just an “add-on” measure to a primary outcome that is targeting weight reduction or the cessation of weight gain. Public health policy in the area of childhood obesity needs to encourage healthy body image, advocate that healthy behaviours come in every shape and size, and consider weight bias and weight and shape concerns as fundamental. In terms of mental health and wellness, this type of shift in paradigm could benefit all children and youth potentially for generations to come.”

Readers will find many of these thoughts reflected in the Toronto Charter and will certainly recognise many of these principles in many of the posts throughout these pages.

Edmonton, Alberta

ResearchBlogging.orgRussell-Mayhew S, McVey G, Bardick A, & Ireland A (2012). Mental Health, Wellness, and Childhood Overweight/Obesity. Journal of obesity, 2012 PMID: 22778915


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Friday, June 29, 2012

Obesity and Mental Health, Day 3: First Do No Harm

The 3rd and final day of the Hot Topics Conference on Obesity and Mental Health focussed on the potential obesogenic side effects of medications commonly used to manage mental health disorders.

As pointed out by Rohan Ganguli (Toronto), persons with schizophrenia, bipolar disorder, and other psychotic illnesses, have rates of obesity 2-3 times that of the general population. They also have 2-3 times the rates of diabetes, heart disease, and premature mortality, when compared to the general population. The increased prevalence of these chronic conditions are due to multiple factors, but it has become clear that certain antipsychotics, particularly some of the newer antipsychotics, mood stabilizers, and antidepressants, contribute to the increased risk of obesity. His presentation provided a succinct overview of the evidence from controlled clinical trials regarding the risk of weight gain for different psychotropic medications. He also proposed prescribing strategies, which would minimize the exposure to these risks. This presentation was nicely complemented by Tony Cohn’s (Toronto) talk on the importance of metabolic monitoring for adults prescribed antipsychotic medications

This problem, unfortunately, is also relevant in the treatment of mental health disorders in kids. In her presentation on the Canadian Guidelines on Monitoring and Management of Metabolic Side Effects of Second Generation Antipsychotic Medications in Children, Tamara Pringsheim (Calgary) discussed the considerable evidence that second generation antipsychotic medications are associated with metabolic side effects in children, including weight gain, increased waist circumference and body mass index, as well as elevations in cholesterol, triglycerides, glucose and insulin levels. These metabolic complications can have long-term adverse effects on cardiovascular health. With the more widespread use of antipsychotic medications in children, there is a need for formal guidelines on how to monitor children for adverse effects of these medications.

The Canadian Alliance for monitoring Safety and Effectiveness of Antipsychotic medications in Children (CAmESA) guidelines seek to provide health care providers with evidence based recommendations on what, when and how to monitor children started on an antipsychotic medication for metabolic and extrapyramidal side effects. Companion guidelines have also been created which provide evidence based recommendations on the management of metabolic and extrapyramidal side effects if they are detected over the course of monitoring drug safety in kids.

The considerable problem of obesity and mental health in the Aboriginal population was discussed by Piotr Wilk from London, Ontario.

The issue of first doing no harm, especially in public messaging about obesity, was addressed by Gail McVey (Toronto). She noted that in our quest to prevent childhood obesity it is imperative that we avoid the costly mistake of triggering the competing public health issues of disordered eating, weight-related bullying and associated depression, anxiety and social exclusion. Professionals need to capitalize on opportunities for greater integration by agreeing to adopt a common set of child and youth health indicators and to settle on an integrated approach to prevention across the broad spectrum of weight-related problems. nowhere is this common vision more important than in the messaging delivered to children and youth about healthy weights.

Similarly, as pointed out by Annick Buchholz (Ottawa), dialogue between researchers and clinicians from the fields of eating disorders and obesity can take advantage of evidenced-based frameworks and key treatment approaches from the field of eating disorders and discuss its applications to working with individuals and families struggling with weight management issues. Treatment approaches such as externalizing the problem, promoting positive body image, de-emphasizing weight as a goal in treatment, understanding ambivalence, and working closely with families in treatment are all important approaches to this problem.

On a slightly different note, Peter Selby (Toronto) discussed the potential learning from tobacco prevention. Given that behaviours are determined by the net effects of the current and embodied opportunities and constraints in global, macro, mezzo, and micro environments interacting with biological and psychological abilities of the individual, disorders of consumption such as smoking and excess eating share common pathways and are modifiable through policy and clinical interventions. High reach interventions focussing on policy and legislation are likely to have a bigger impact on health than only a high risk approach to obesity. However, mitigation of unintended consequences of such measures must also be considered in order to prevent disparity in the disease burden.

Thus, after 3 days of intense presentations and discussions, I believe that the participants left with a much better appreciation and understanding of the links and commonalities between obesity and mental health.

I, for one, certainly felt very pleased to see many of the concerns and approaches discussed by the participants at this conference, nicely reflected in the 5As of Obesity Management.

Presentations from this conference are available for download here.

Edmonton, Alberta

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