This week’s edition of JAMA features a most interesting essay by Nitin Kapur, a physician associated with Yale university in New Haven, CT.

Dr. Kapur describes his interactions with a Mr C., a 5-foot 7-inch patient weighing 320 lbs (BMI=50). As Dr. Kapur points out, he himself is about the same height and carries 245 lbs (BMI=38), which led him to ponder whether he could indeed be of any help to his patient.

While Mr. C. gained his considerable stature (and continued gaining weight during his interactions with Dr. Kapur) after replacing his heroin addiction with bacon double-cheeseburgers, Dr. Kapur attibuted his weight problem to his stressful life as a medical resident and the demanding nature of physicianhood.

So here, as Dr. Kapur puts it, we have the morbidly obese drug addict and the severely obese Ivy League graduate, both struggling with their weight problem.

“So”, asks Dr. Kapur, “am I a hypocrite offering help to this patient, even though I couldn’t help myself?”

As Mr. C. continues gaining weight, Dr. Kapur begins to feel responsible and wonders it if would have been better to send Mr. C. to someone unencumbered by a 40-inch waist.

Finally, one day, Dr. Kapur asks Mr. C. whether it would indeed have been more inspirational for him to have seen someone thinner.

But Mr. C. dismisses any such concerns, responding that only Dr. Kapur could have truly understood what it felt like to be fat and that he very much enjoyed the care and had no doubt that he would eventually lose the weight.

This most insightful and touching story raises an important issue: can health professionals, who themselves struggle with excess weight, really provide help to their obese patients? Or are obese health professionals perhaps the only folks who can really understand the extent to which excess weight affects their obese patients’ lives.

What do my readers think? Does the weight of the health professionals giving weight management advice matter one way or the other?

AMS
Edmonton, Alberta

Hat Tip to Tobias Pischon for bringing this essay to my attention.

Yesterday the news wires were swamped with reports on a new recommendations by the U.S. Preventive Services Task Force to screen school kids for obesity:

“The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to intensive counseling and behavioral interventions to promote improvements in weight status.“

The recommendation appears largely based on a paper by Evelyn Whitlock and colleagues who performed a systematic review on the effectiveness of weight management interventions in children just published in Pediatrics. The review concludes that despite important gaps, available research supports at least short-term benefits of comprehensive medium- to high-intensity behavioral interventions in obese children and adolescents.

In their recommendations, the USPSTF includes the previous American Medical Association Expert Committee recommendation on childhood obesity, namely to use

“a stepwise approach that divides treatment into several stages including counseling, providing a structured weight management plan, and using a comprehensive multidisciplinary intervention/ tertiary care intervention delivered by multidisciplinary teams with expertise in childhood obesity.“

So the recommended response to a “positive” screen is not 20 extra minutes of phys-ed per day or sitting through a class on healthy eating; no, the recommended response to a “positive” screen is comprehensive medical and behavioural intervention by a multidisciplinary team with expertise in childhood obesity…

…and herein lies the problem!

How many overweight and obese kids will actually have access to this kind of multidisciplinary weight management?

Indeed, it is only too easy to screen kids, label them as overweight or obese, and thereby destroy whatever is left of their self-esteem while amplifying their existing body-image concerns. Screening can probably also also point fingers and help heap blame on the parents, who may or may not be able to deal with these results in a constructive fashion.

Nowhere in the recommendations do I see any concern expressed about how these screening recommendations could possibly affect weight-bias and discrimination, have the potential to promote weight-based bullying and teasing, or result in potentially devastating outcomes including setting the poor kids off on unsustainable weight-loss attempts and weight cycling.

As I have blogged before, there is increasing evidence that weight bias and discrimination can increase depression and unhealthy eating behaviours - blame and ridicule has never been a good motivator for lifestyle change.

While I am as concerned as the next guy about the catastrophic increase in childhood obesity, I do not for a minute believe that screening and labeling 6 year-olds is the solution.

I can only imagine what some of my readers may have to say regarding this post.

AMS
Edmonton, Alberta

Last week, according to the New York Times, GlaxoSmithKline (which sells the weight-loss drug Alli in many countries) announced that it will provide a yet-undisclosed sum of money to the Creative Coalition for a documentary on obesity - a film that is already being compared to “An Inconvenient Thruth”. Although a budget has not been set, an Academy Award-winning director will be named on Jan. 25 at the Sundance Film Festival

The Creative Coalition is the premier nonprofit, nonpartisan social and political advocacy organization of the entertainment industry. In an interview to Sharon Waxman, Robin Bronk, the executive director of the Creative Coalition had this to say: “It’s reverse product placement. It’s issue placement. It’s organic for us. We’re using filmmaking to promote a film message. Art influences. Look at Al Gore; he could not move the needle on global warming until he went Hollywood. And he was the vice president.”

As to GSK’s role in the documentary? “They have absolutely no creative control. Zero.”

Sure, GSK, as the maker of Alli, has a vested interest in obesity. So is this just going to be a pricey infomercial for Alli? Probably not. As pointed out in the New York Times, “As a rule, documentary makers are an aggressively anticorporate crowd.”

Personally, I very much hope that this documentary will also take on the issue of weight-bias and discrimination that faces obese people and will not simply portray obesity as the result of stupid lazy slobs making poor choices. Based on the generally negative depictions of obese people and the abundant discriminatory fat jokes in Hollywood films, I will be watching keenly to see how much finger pointing and blame will find its way into the final cut.

AMS
Edmonton, Alberta

What is not shocking is that according to a report on CNN, a US college (Lincoln University, Pennsylvania) has mandated a fitness course that its students have to pass in order to get their degree. 

What is shocking, however, is that only students with a BMI greater than 30, who fail to lose weight during their time at that school are required to take and pass this course.

The underlying assumption of course is that fat people are apparently too stupid to know about healthy eating and exercise and that requiring them to take and pass a course on this will make them drop those excess pounds and become healthy and successful human beings.

Apart from the fact that you would expect college educators to know that wasting resources on well-intended but largely useless weight interventions based solely on “healthy” eating and exercise are not an evidence-base approach to weight management (due to their rather modest effectiveness), assuming that it is even remotely possible to identify individuals in need of “lifestyle education” by simply calculating their BMI (or measuring their waist circumference), is ridiculous.

Perhaps the folks who came up with this idea are unaware of the fact that there is indeed no shortage of “thin” people frequenting fast food restaurants, living sedentary lifestyles or simply using cigarette smoking (if not other drugs), unhealthy dieting, purging, and/or excessive exercise to control their weight.

Singling out students based solely on weight for intervention is nothing else than stereotyping individuals who meet population-based BMI cuttoffs as unhealthy or unfit.

Not only is this discriminatory practice reflective of a limited understanding of the determinants of health, it is also an insult to anyone who’s BMI is greater than 30 despite trying their best to manage their excess weight in this obesogenic environment.

If excess weight is truly affecting a students’ health (and it takes more than a scale or measuring tape to determine this), I have nothing against these students being offered appropriate counseling and interventions by a licensed health professional.

Dictating “lifestyles” to people identified only by virtue of an arbitrarily defined “excess” weight is neither helpful nor supported by scientific evidence.

Perhaps, as one reader comments on the CNN website in response to the college’s response that they are less concerned about health than about the fact that obese students may be less successful in life, “the ones voted as ugly should take a beauty class as this is also related to success”. 

As always, I appreciate any comments on this topic.

AMS
Frankfurt, Germany

p.s. Hat tip to Gabriela Tymowski for drawing my attention to this story

One of my favourite medical blogs is written by Kevin Pho (KevinMD), a Boston internist and avid blogger. KevinMD was voted the best medical blog of 2008 and has over 21,000 subscribers and 16,000 followers on Twitter.

While I agree with much of what Kevin blogs about, yesterday’s post got me up in arms (or rather the responses to a poll he posted on his site did).

The post was in regard to the question of whether or not obese patients should pay more for ambulance rides?

Understandably, ambulance workers say that patients weighing over 350 pounds present additional challenges to transport, and require specialized equipment and additional workers. Not unexpectedly the ambulance industry wants to pass on the expenses to insurance companies and even individual patients.

It turns out (accoding to Kevin) that some US states already charge more for transporting extremely overweight patients.

So what is my response to this poll?

My regular readers will probably already guess that I voted “No” and with that differently than the 78% of responders who opted for “Yes”:

While I fully appreciate that extremely large patients pose important challenges for amublance workers, I still maintain that (as with airline seats) the only fair rule can be one patient - one ride - one fare!

The whole notion that obese people should pay more, is nothing other than another expression of the widely held weight bias against overweight people that is entirely based on the assumption of choice and fault. As I have argued previously, neither choice nor fault (even if they were relevant to obesity) can be a criterium for deciding about costs.

If fault is a criterium, then how about charging people more who get into DUI accidents, injure themselves during risky outdoor activities or even just have heart attacks from smoking too much?

If this is about “fair” distribution of cost, I wonder if ambulances will next offer discounts on rides for people who walk to the ambulance and lay themselves down on the gurney (less work - less pay?).

Or will they also be charging higher rates for tranporting other folks who create more work, like people who don’t speak English, are psychotic, aggressive, or just making a mess of themselves by spilling blood and guts all over?

As a significant proportion of the population gets bigger, it is up to ambulances to up-size and adapt their services by providing the right equipment and the right personnel. If this costs more (as it probably will), the costs should be spread amongst all who require ambulance services and not simply passed on to a vulnerable minority that is already hit hard by the utter lack of access to obesity prevention and treatment options that work.

We all bear responsibility for creating an obesogenic environment in which some people will gain weight - no matter what.

Weight-based discrimination (like all forms of discrimination) are inhumane, cruel and not a solution to the problem.

To take Kevin’s poll and perhaps correct the voting balance in favour of fairness and compassion click here.

AMS
Orlando, Florida