Dr. Sharma's Obesity Notes

Regular readers will be well aware of the emotional, physical and economical impact of weight bias and discrimination. This issue is often further propagated by the use of stereotypical messages (eat-less-move-more) and images (disheveled headless fat person, shiny happy skinny people) in the media.

That these attitudes are perhaps amenable to change is suggested by a paper by Gail McVey and colleagues published in Prevention of Chronic Disease.

The paper presents the results of a pilot interactive workshop to raise awareness about 1) weight bias and its negative effect on health, 2) ways to balance healthy weight messaging to prevent the triggering of weight and shape preoccupation, and 3) the incorporation of mental health promotion into healthy weight messaging.

The pilot full-day workshop was delivered to 342 Ontario public health promoters and resulted in a significant reduction in antifat attitudes and the internalization of media stereotypes and to significant increases in self-efficacy to address weight bias.

As the authors note,

“Participants reported that the training heightened their awareness of their own personal weight biases and the need to broaden their scope of healthy weight promotion to include mental health promotion. There was consensus that additional sessions are warranted to help translate knowledge into action. Buy-in and resource support at the organizational level was also seen as pivotal.”

Thus, the authors suggest that professional training in the area of obesity prevention should include education on weight bias and the internalization of media stereotypes around thinness.

Such efforts may particularly avoid weight and shape preoccupation or unhealthful eating practices among children and youth.

As an organisation, addressing weight bias and discrimination remains the number one strategic objective of the Canadian Obesity Network and this topic will be widely discussed at the upcoming 3rd Canadian Obesity Summit in Vancouver next month (May 1-4).

AMS
Edmonton, Alberta

McVey GL, Walker KS, Beyers J, Harrison HL, Simkins SW, & Russell-Mayhew S (2013). Integrating weight bias awareness and mental health promotion into obesity prevention delivery: a public health pilot study. Preventing chronic disease, 10 PMID: 23557637

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Regular readers may be aware that 278.00 stands for the ICD-9 classification “Obesity: not otherwise specified”.

A thoughtful essay by Elizabeth Toll from Brown University, Providence, Rhode Island, in JAMA, warns about how even the “appropriate” use of such diagnostic labels could affect patient-client relationships.

This is specially true in an era, where patients may have full and access to their records, often with no explanation or context. (I recently heard a story about a patient complaining that their doc had referred to them as SOB (common medical jargon for ‘Shortness-of-Breath’)).

But, irrespective of who has access to what information, the point that Toll rightly makes is that the use of such diagnostic labels and jargon, only serve to further “dehumanise” medicine:

“We need to remember that people skills directly affect clinical outcomes. Human qualities like intuition, warmth, and emotional intelligence are profoundly important to effective communication and successful care. It behooves us to ally with our patients in order to speak out against the pervasive labels and numbers that lull administrators and legislators into a false sense that they can evaluate and track true quality and success using such limited parameters…..The focus should remain on knowing our patients and their problems in the full context of daily living rather than pigeonholing them into drop-down phrases and diagnostic codes like 278.00 Obesity, Not Otherwise Specified.”

While I agree that communication skills and sensitivity should be an essential part of medical practice and that medical diagnoses and jargon can be shocking and hurtful to patients (irrespective of whether or not these are accurate or misunderstood), I do recognise that diagnostic labels (whether numbers or otherwise) serve an important function in medical communication and record keeping.

So while the label “obese” does not describe all (or even the most relevant) aspects of my patients, neither do the labels “diabetic”, “hypertensive”, or “arthritic” but I’d me amiss to not note them in my records.

I have previously written on the importance that there is a big difference between having something and being something. The implications of being “obese’ are different from those of having “obesity”. This is why I try to avoid using the words overweight or obesity as nouns (as in “the obese”) or even as adjectives (as in “obese patient”) – I personally prefer to speak of the patient as someone having obesity.

I agree with the author that it would be nice to,

“Imagine a diagnostic system built on composite knowledge of a patient’s unique clinical situation, including information about age, experience, responsibilities, motivation, and previous health challenges and successes.”

This, however, will never be described in numbers or labels but only in thoughtful narratives.

In the context of obesity, this is exactly why we introduced the Edmonton Obesity Staging system, because it describes so much more about the patient (mental, physical and functional health) than BMI alone.

AMS
Edmonton, AB
Toll E (2013). A piece of my mind: 278.00 Obesity, not otherwise specified. JAMA : the journal of the American Medical Association, 309 (11), 1123-4 PMID: 23512059

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Rudd Centre for Food Policy & Obesity

Many regular readers are probably with the Rudd Centre for Food Policy and Obesity, which has long championed the issue of weight bias and discrimination.

This centre was an important partner in the Canadian Obesity Network’s own efforts to address this issue during the Toronto Summit on Weight Bias and Discrimination and is again partnering with the Network on a study to assess cross-cultural public opinions about body weight, health and related policies.

Readers in Canada, US and Australia can take part in this study by responding to the short study survey by clicking here.

You can further support the study by e-mailing and reposting this link to your friends and colleagues – the more diverse the people who respond to this survey, the more representative the results.

As a small incentive individuals (from Canada) who complete the survey will be entered into a drawing with a 1-in-20 chance of winning a $20 gift certificate to www.amazon.ca (there may be other incentives for readers in the US and Australia).

Your help and support is very much appreciated.

AMS
Edmonton, AB

Regular readers will be well aware of my concerns about weight bias and discrimination as well as the problem of weight-based bullying. In fact, there are few patients I see in my clinic, who do not recount traumatic bullying about their weight as one of their most vivid childhood memories.

I am therefore happy to see mention of bullying in the Ontario Healthy Kids Panel’s report, released earlier this week.

Indeed, the report quotes parents, who express their concern about this issue,

“If their weight is not proportionate with their friends, then they feel different, they look different, they may even behave different or be treated differently, and feel like they won’t fit in. If they’re on a team, then they’re not performing the same. Then they look in the mirror and feel like there is something wrong with them.”

And,

“My son tells me that he didn’t see anything wrong with himself until his first day of school when he saw that he looked different than everyone else. As he went through elementary school, he was mercilessly bullied and he bullied back. When he reached high school, he had to wear a uniform but the company didn’t even make them in my son’s size. So, I found a similar shirt and sewed the school decal on it. That made [the bullying] worse.”

It is important to note that the report does point out that,

“Many of the severe physical problems associated with being overweight or obese as a child – such as heart disease – may not appear until adulthood, but the social and emotional problems start early.”

This is not something that obesity prevention programs can address – indeed, the greater the focus on the problem of childhood obesity (in media, through schools, parents, social media, or anyone else), the worse the consequences for the kids, who happen to carry a few extra pounds.

Thus, unfortunately, there is little talk in the panel’s recommendations about promoting “size acceptance” and cautioning government and others to not discriminate against those, who do happen to be larger.

Personally, I would have loved to see a cautionary word or even a specific recommendation to address weight-based bullying as one of the first recommendations or even as a preamble to the entire document (and not simply stuck in one of the last few pages, almost as an afterthought).

While I fully support the fact that we need to take the issue of childhood obesity seriously and make every effort to prevent it (and provide treatments where necessary), let us also make sure that we do not throw out the baby with the bath water.

AMS
Edmonton, AB

Here is a brief video excerpt from a recent talk on the issue of accepting the reality of living with obesity.

(e-mail subscribers will have to visit my website to watch).

Appreciate your comments.

AMS
Edmonton, AB