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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Tuesday, April 8, 2014

Join The Crowd: Support Pom Pom – A Flightless Bully Tale

Screen Shot 2014-04-07 at 1.13.00 PMThis week, my daughter’s crowdsourcing campaign to fund her second children’s book Pom Pom – A Flightless Bully Tale (her first one was Our Canadian Lovestory) is in its final stages – only 5 days left to meet her funding goal (over 85% there).

Please visit her site and join the “crowd” of 250 supporters to secure your very own personal copy(s) of this delightful anti-bullying children’s book (will make a great Christmas gift for your kids or grandkids – there are also school packages available for your local school library).

To visit the crowdsourcing site click here.

To hear Linnie read her story click here.

Thank you for helping her cross the finish line!

@ProudDad
Saskatoon, SK

 

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Thursday, April 3, 2014

Why Coverage Of Anti-Obesity Medications For Federal Employees Is Only Fair

OPM-logo

One of the rather explicit biases that has hindered greater investment into finding more effective obesity medications, has been the unwillingness of many health care plans to cover the cost of such medications for their members.

Indeed, many private and public health plans around the world explicitly exclude obesity medications (and other obesity treatments) from coverage.

This is clearly a double standard, given that the very same plans have no problem covering medications for other “lifestyle” diseases such as type 2 diabetes, hypertension, or high-cholesterol.

Now, in a rather dramatic move last month, the US Office of Personnel Management (OPM), responsible for health insurance coverage for  over 2.7 million Federal Employees, ruled in support of health coverage for FDA-approved weight-loss treatments stating that obesity exclusions are no longer permissible in health plans for federal employees.

This move should set an important precedent for other health plans to follow.

In the March 20th letter to all FEHB carriers, John O’Brien, the Director of Healthcare and Insurance at OPM, agrees that while

“diet and exercise are the preferred methods for losing weight, …drug therapy can assist [those] who do not achieve weight loss through diet and exercise alone.”

In the letter, O’Brien provides further clarification:

“It has come to our attention that many FEHB carriers exclude coverage of weight-loss medications. Accordingly, we want to clarify that excluding weight loss drugs from FEHB coverage on the basis that obesity is a “lifestyle” condition and not a medical one or that obesity treatment is “cosmetic”- is not permissible. In addition, there is no prohibition for carriers to extend coverage to this class of prescription drugs, provided that appropriate safeguards are implemented concurrently to ensure safe and effective use.”

This ruling should end the long-standing practice of discrimination against people with obesity who require and are willing to take medications for their condition.

Obviously, medications for obesity need to always be used as an “adjunct” to diet and exercise, in the same manner that medications for diabetes, hypertension or high-cholesterol should always be used as an adjunct to diet and exercise.

It goes without stating that prescription medications for obesity, diabetes, hypertension or high-cholesterol should only be made available to those who fail to control their weight, blood sugar, blood pressure, or cholesterol levels with diet and exercise alone. (there is no “special case” for the role of diet and exercise in obesity management that does not also apply to these other conditions).

And of course, as for any prescription drug, means and measures must be in place to avoid misuse and monitor safety of such treatments.

That said, recognizing that prescription obesity drugs, deemed both effective and safe by the FDA should be made available to patients in the same manner as drugs for other chronic conditions, is only fair to patients and represents a major step towards decreasing bias and discrimination against those suffering the health consequences of excess weight.

@DrSharma
Edmonton, AB

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Tuesday, March 25, 2014

Challenges in Pediatric Obesity Management

sharma-obesity-kids-scale2If treating obesity in adults is challenging, managing obesity in kids is even more daunting.

Now, a seminal paper by Jill Avis and colleagues (representing a virtual who-is-who of pediatric obesity management in Canada), published in Expert Reviews in Diabetes and Metabolism, with the fitting title, “It’s like rocket science…only more complex“, explores the many challenges in pediatric obesity management in Canada.

The thoughts and analyses presented in this narrative review are largely based on the responses to a national survey of folks providing pediatric “weight-management” services across Canada. Responses were sought to a range of questions, including:

In regards to managing pediatric obesity in Canada, what lessons have you learned related to: Caring for children?; Collaborating with clinicians and/or researchers?; and Working within the health care system? In addition, what do you consider to be important future directions for clinical care and research in Canada?

Apart from noting the importance and challenges of adopting a family centred approach, the paper highlights the importance of factors that go well beyond “eat-less-move-more” platitudes.

Thus, the authors note that,

“Internalizing (e.g., anxiety, depression) and externalizing (e.g., hyperactivity, aggression) disorders are common in children and adolescents with obesity, which can make management strategies more difficult to implement…..these realities highlight the need for mental health professionals to assume active roles in pediatric obesity management to explore, identify and manage families’ unique mental health concerns.”

With regard to the importance of weight bias, the authors state,

“Many parents in our care have experienced shame and blame from other family members, friends, coworkers and health professionals regarding the weight status of their children….The underlying assumption in this instance is that individuals with obesity just need to eat less and move more….a sentiment that demonstrates a lack of understanding and empathy.”

Thus,

” There is a clear need to shift from a singular focus on physical weight status to define the health of individuals with obesity to a nonjudgmental and unbiased appreciation of the complex causes and consequences
of obesity.”

Despite all efforts, the authors describe the outcomes of childhood obesity interventions as “modest”.

This has prompted a number of collaborative research initiatives including the Canadian Pediatric Weight Management Registry (CANPWR), the Should I Stay or Should I Go study and (in partnership with the Canadian Obesity Network) the development of a national network called Treatment and Research of Obesity in Pediatrics in Canada (TROPIC), whose purpose is to promote knowledge translation and dissemination of issues related to pediatric obesity management in Canada.

All of these activities demonstrate a high degree of collaboration and coordination among the pediatric obesity management community in Canada.

The paper also addresses the challenges of providing childhood obesity management services within the health care systems (which vary across provinces).

“…there is substantial heterogeneity across the multidisciplinary clinics we lead and work within; some are well-resourced (i.e., physical space, clinical, and administrative personnel), while others struggle with limited budgets to provide comprehensive and long-term care for families.”

“…relatively small numbers of patients (compared with other outpatient pediatric clinics [e.g.,general pediatrics]) and a lack of substantial weight loss for most children and adolescents with obesity…necessitate education, contextualization and justification to colleagues and administrators within the health care system so that obesity is viewed not as a simple problem that requires a quick fix in order to achieve weight loss, but as a chronic disease that requires ongoing support and management.”

Important work to aid clinicians include the adaptation of the Edmonton Obesity Staging System for pediatric populations (EOSS-P), the family centred adaptation of the 5As of Obesity Management for managing pediatric obesity in primary care, and CONversation cards, a tool to facilitate discussions between clinicians, parents and kids on issues related to healthy lifestyle changes.

Finally, the paper discusses the many barriers to accessing timely obesity management including costs (travel, parking, time off work), geography (distances) and wait times.

Clearly, despite all progress, significant challenges remain to be addressed – “it’s like rocket science…only more complex.”

@DrSharma
Edmonton, AB

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Thursday, March 13, 2014

Is Weight Stigma Making Us Fat?

sharma-obesity-weight-bias-conduit1Regular readers will be well aware of my concerns around the issues of weight stigma and anti-fat messaging and policies that blame, shame and otherwise bully those of us, who happen to be larger.

Apart from the emotional and economical toll, we are now seeing more and more evidence to support that notion that weight bias and discrimination have significant biological effects on metabolism.

Thus, a study by Natasha Schvey and colleagues from Yale University, published in Psychosomatic Medicine, shows that exposure to weight stigma can significantly increase cortisol secretion.

A 123 lean and overweight adult women were randomized to watching either a 10-minutes of a stigmatizing or neutral video.

The stigmatizing video consisted of a compilation of 24 brief clips from recent popular television shows and movies in which overweight and obese women were depicted in a pejorative manner, or portrayed in stereotypical ways (e.g., overeating, wearing ill-fitting clothing, struggling to exercise, dancing in a comical manner, etc). These clips were primarily taken from comedic films, situation comedies, or reality television shows, (e.g., The Biggest Loser, Drop Dead Diva, Say Yes to the Dress, Friends, etc) and are strongly representative of how obese individuals are depicted in film, television, and news media.

The neutral video depicted 20 emotionally neutral scenes such as clips about the invention of the radio, commercials for household products, car insurance, and so on.

Exposure to the stigmatizing video resulted in a marked increase in salivary cortisol levels (a marker of stress) compared to watching the neutral video.

Interestingly, the increase in cortisol was seen in both normal and overweight women.

Similarly, viewers of the stigmatizing video were more likely to feel upset, anxious, angry, and dislike the way that obese characters were portrayed and would prefer not to view media that depicts obese characters in this way.

Thus, as the authors report,

“…not only do women of all weight strata object to stigmatizing depictions of overweight and obese individuals, but also these negative depictions result in increased neuroendocrine stress as measured by salivary cortisol.”

“Given the high levels of media consumption among Americans, it is likely that millions of individuals are frequently exposed to weight-stigmatizing content that may promote neuroendocrine stress and subjective distress, signaling a public health concern. Finally, this study directly challenges recently proposed strategies to combat obesity with the use of stigma and negative social pressure. In fact, the present findings suggest that weight stigma may induce physiological stress and contribute to adverse health, thereby underscoring the importance of removing stigmatizing content from public health efforts to address obesity.”

As stress and negative emotional states are well-recognised risk factors for weight gain, the prevalence of stigmatizing messages about obesity should concern us all.

@DrSharma
Copenhagen, DK

ResearchBlogging.orgSchvey NA, Puhl RM, & Brownell KD (2014). The stress of stigma: exploring the effect of weight stigma on cortisol reactivity. Psychosomatic medicine, 76 (2), 156-62 PMID: 24434951

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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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