The short answer, for the vast majority of Canadians, would simply be, “no one”.

Last year, the Canadian Obesity Network undertook a representative survey to examine how Canadians manage their weight.

It turns out that over 65% of overweight Canadians have never talked to a licensed health professional (family doctor, dietitian, pharmacist, etc.) about losing weight. The same is true for over 40% of Canadians, who meet the clinical definition of obesity, i.e. have a BMI greater than 30.

This may probably be as well, because most health professionals are in fact ill-equipped to support individuals struggling with excess weight. Although, health professionals often cite lack of time and resources as the main reason for not broaching the topic, I suspect that the key problem is simply a lack of knowledge and training in weight management.

As I have said before, most health professionals have little more than a layman’s understanding of the complex socio-psycho-biology of energy homeostasis and have virtually no formal training in even the basics of behavioural, medical or surgical management of excess weight.

Add to this an (un)healthy dose of anti-weight prejudice and discrimination and it is probably no surprise why anyone who has ever solicited weight management advice from their health professional is more likely to receive simplistic slogans along the lines of “eat less and move more”, than a meaningful analysis of the problem with a personalized evidence-based management plan.

Indeed, weight management plans too often follow along the lines of well-meant but often ineffective diet or exercise recommendations, that virtually always fail to address the actual root of the problem (see my post - overeating is a symptom).

It should hardly come as a surprise when simply providing an impulsive overeater with a diet plan proves to be about as effective as providing a drinking plan to an alcoholic.

In contrast, teaching time-management skills to people who regularly fall back on fast food for lack of time or offering stress management classes to people who use food as a coping strategy may well be far more effective than simply educating them on healthy choices or handing them recipe books.

Of course patients can always turn to the billion-dollar weight-loss industry, that peddles everything from magical weight loss supplements to crash diets. While some of these program may well be better than others, there is no way a consumer can tell which of these many products and services are likely to be effective or just a waste of money.

Even if patients “successfully” lose weight with any of these products or services, this is rarely more than temporary “symptomatic” relief with a one-in-twenty chance of weight regain within weeks or months of stopping the program.

Rarely do these products or services truly diagnose and address the root cause of the problem - that would require far more than a cursory “one-size-fits-all” business model and is unlikely to deliver the same lucrative profits.

Perhaps, it is time to promote a better public understanding of the many societal and individual level drivers of excess weight and it certainly appears high time health professionals and health care systems seriously took on the challenge of addressing the greatest health problem of our times.

When the problem is excess weight, not helping patients deal with this issue is simply palliative care.

AMS
Edmonton, Alberta

While I am enjoying a few days away from the office, I will be reposting some of the most popular past postings new readers may have missed.

Rudd Centre for Food Policy & Obesity

Readers of these pages are well aware of my concern about weight bias and discrimination. This is not only a problem with the general public, but also explains much of the negative attitudes of health professionals, administrators and policy makers towards addressing the real plight of individuals with obesity - no one appears to be immune.

Unfortunately, weight bias jeopardizes patients’ emotional and physical health - it is therefore important for all health professionals (and any one else, who is interested) to determine and become fully aware of their own level of weight bias.

To address this issue, the Rudd Center for Food Policy & Obesity (Yale University, New Haven) has now released a toolkit, which is specifically designed to help clinicians across a variety of practice settings to test their own weight bias and which provides easy-to-implement solutions and resources to improve delivery of care for overweight and obese patients.

The resources are designed for busy professionals and customized for various practice settings. They range from simple strategies to improve provider-patient communication and ways to make positive changes in the office environment, to profound ones, including self-examination of personal biases.

The resource kit, consists of the following 8 modules:

MODULE 1: Increasing Self-Awareness of Weight Bias

MODULE 2: Improving Provider-Patient Interactions

MODULE 3: Overview of Weight Bias in Health Care Settings

MODULE 4: Office Environment Strategies to Reduce Weight Bias

MODULE 5: Weight Bias Resources for OBGYN Providers

MODULE 6: Weight Bias Resources for Pediatricians

MODULE 7: Weight Bias Resources for Bariatric Surgery Clinics

MODULE 8: Resources for Overweight Patients

I hope that all health professionals and individuals concerned about the discimination of overweight and obesity will explore these modules and help spread the word.

AMS
Ucluelet, BC

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

Regular readers of these pages will be well aware of the very real problems caused by weight-bias and discrimination.

As noted previously, anti-fat prejudice has direct implications for the health of those struggling with excess weight as it can increase vulnerability for depression, low self-esteem, anxiety, suicidality, maladaptive eating behaviors, avoidance of physical activity, poorer outcomes in behavioral weight loss programs, and hesitation to seeking preventive health-care services.

In most countries (including Canada), it is within the legal rights of most employers to discriminate against their employees on the basis of weight, and those who experience weight discrimination have no means for legal recourse.

But is the public ready to accept laws that will prohibit weight-based discrimination?

This question was addressed by Rebecca Puhl and Chelsea Heuer from the Rudd Center for Food Policy and Obesity, Yale University, New Haven, CT, in a paper just published online in OBESITY.

The study was conducted online in a national sample of 1,001 adults to examine public support for six potential legislative measures to prohibit weight discrimination in the United States:

Surprisingly, the researchers found substantial support (65% of men, 81% of women) for laws to prohibit weight discrimination in the workplace, especially for legal measures that would prohibit employers from refusing to hire, terminate, or deny promotion based on a person’s body weight.

Perhaps not so surprisingly, the likelihood of agreement with antidiscrimination laws was higher among individuals who were obese, 35–49 years of age, with a political ideology identified as Liberal or Moderate (or who identified themselves as Democrats), and those with lower education (high school vs. college or graduate degrees) and lower annual income (<$25,000).

In addition, although only 9% of the sample reported having experienced weight-based discrimination in the workplace, these individuals were 2–4 times more likely to endorse agreement with laws than individuals who had not reported workplace discrimination.

Similarly, participants who reported that their family members had been targets of weight-based victimization were more likely to express agreement for laws compared to participants who did not report victimization toward family members.

On the other hand, there did not appear to be much support for laws that proposed extending the same protections to obese persons as people with physical disabilities.

Thus, while it appears that there may be some acceptance and room for legislation against weight-based discrimination (especially in the workplace), there may also be important limitations to both the extent and acceptance of such legislation amongst the US population.

While this is a US study, I am not convinced that public opinion in favor of legislation against weight-based discrimination would be very different in Canada. Although, there have been legal precedents in Canada for rulings in favor of obese individuals (e.g. the airline seat ruling), there remains a strong public bias against people with excess weight.

Have you or someone you know been affected by weight-bias? I’d love to hear your story.

AMS
Edmonton, Alberta

p.s. Join my new Facebook page for more posts and links on obesity prevention and management

Puhl RM, & Heuer CA (2010). Public Opinion About Laws to Prohibit Weight Discrimination in the United States. Obesity (Silver Spring, Md.) PMID: 20508626

I have previously blogged about the problem of weight bias amongst health professionals and how this can possibly lead to poorer health care for people with excess weight.

A new study by Virginia Chang and colleagues from the University of Pennsylvania, just published in the Journal of the American Medical Association (JAMA) suggests that the quality of health care may not necessarily be worse for obese people compared to normal weight folks.

The reserachers examined eight different performance measures in two US national-level patient populations: (1) Medicare beneficiaries (n = 36 122) and (2) recipients of care from the Veterans Health Administration (VHA) (n = 33 550).

The performance measures included diabetes care (eye examination, glycated hemoglobin [HbA(1c)] testing, and lipid screening), pneumococcal vaccination, influenza vaccination, screening mammography, colorectal cancer screening, and cervical cancer screening.

Based on these data, the researchers found no evidence that obese or overweight patients were less likely to receive recommended care relative to normal-weight patients.

In fact, comparing obese vs normal-weight patients with diabetes, obese patients were more likely to receive recommended care on lipid screening (72% vs 65%) and HbA(1c) testing (74% vs 62%).

Obese patients were also more likely to receive pneumococcal vaccinations (53% vs. 49%).

In fact, there was no measure in which obese people were less likely to receive care compared to people with normal weight.

Of course, this study says nothing about attitudes or bias amongst health care professionals, which continues to be a concern, and it should perhaps be noted that the patients in both of these data bases tend to be older.

While the authors interpret these findings as evidence that perhaps more attention is now being paid to health in people presenting with excess weight, they also suggest that previous reports on poorer care for obesity may in part be due to self-reported recall biases in retrospective studies.

I wonder what my readers think about this issue: any personal stories or anecdotes are most welcome.

AMS
Edmonton, Alberta

p.s. Join my new Facebook page for more posts and links on obesity prevention and management

Chang VW, Asch DA, & Werner RM (2010). Quality of care among obese patients. JAMA : the journal of the American Medical Association, 303 (13), 1274-81 PMID: 20371786