Arya M. Sharma, MD

Canadian Obesity Network

This morning, I am speaking on the issue of weight bias and discrimination at the Journées annuelles de santé publique (Québec), in a session called: Regard sur la discrimination et les préjugés à l’égard du pods.

It is perhaps only fitting, that today also marks the launch of an image gallery by the Canadian Obesity Network, Canada’s national network of obesity researchers, health professionals and other stakeholders.

The image gallery features the first set of a, hopefully growing, collection of non-stereotypical images representing Canadians living with overweight and obesity, which are intended for use by media and others, who report on or talk about obesity.

As noted in a previous post, the stereotypical depiction of ‘headless’ torsos that generally accompany mediate reports on obesity (and unfortunately even find their way into talks by obesity researchers and health professionals), are not only demeaning but very much promote and propagate the negative image of people living with excess weight, a key driver of the widespread weight bias and discrimination that obese people face everyday.

The purpose of the image gallery according to the Network’s website:

“In an effort to reduce pejorative portrayals of overweight and obese persons in media reporting, we have created an Image Gallery that provides a collection of photographs that portray obese individuals in ways that are positive and non-stereotypical. These images provide a fair and non-biased representation of youth and adults who are overweight and obese. Our gallery can help promote accurate coverage of obesity-related topics in news reporting and challenge harmful weight-based stereotypes.”

All of the depicted individuals have most enthusiastically volunteered their images to the Network (see terms of use). They are to be commended as it requires a considerable courage and commitment to step forward for such a cause.

The Network is also grateful to photographer Robert Tinga, who generously gave his time and expertise to these shoots.

My sincere hope is that we will soon start seeing more images like these, that reflect the fact that the obesity discussion is about real people, real families, real Canadians - not just anonymous headless torsos.

AMS
Montréal, QC

One can perhaps argue about the causes, scale, and consequences of the increasing number of overweight and obese kids and there is no doubt often parental ‘denial’ about the potential impact of excess weight on their offspring.

Yet, even amongst those, who do recognize the issue, there appears to be a widespread reluctance to seek advise from their family doctors or other health professionals.

The possible reasons for this, from the perspective of parents, was explored by Katrina Turner and colleagues from the University of Bristol, UK, in a paper just published in Family Practice.

The researchers conducted in-depth interviews with 15 parents of obese children aged 5-10 years, to explore their views and experiences of primary care childhood obesity management.

Although parents clearly saw primary care as an appropriate setting in which to treat childhood obesity, they were reluctant to consult their family doctor due to a fear of being blamed for their child’s weight and a concern about the impact of raising this issue on their child’s mental well-being.

“If we’re going to get things like ‘we are going to take your child away if they’re fat’, you’re not going to get a parent in the door. That was the worst bit of publicity they ever did [media reports about children going into care] … parents thought, I’m not going anywhere near the doctor’s surgery because they’re going to take my child away from me.”

“He [the GP] said in front of [daughter], ‘God she’s obese, how on earth can you let her get that size?’ You know, ‘You’ve just simply got to cut down, you’re giving her the wrong foods,’ and ‘Do you realise how much health issue that is?’ You know, ‘She shouldn’t be that size,’ … I took the kids out, went back in and said it was absolutely disgraceful, no way would I take the children back there again.”

In addition, the parents had considerable doubts as to whether practitioners had the knowledge, time and resources to effectively manage childhood obesity.

“I don’t think the GP has ever really had very much constructive to say about my weight … so I suppose I just think well, if I went to the GP they’d probably just say ‘well, just get them [her twin daughters] to eat less and do more.’”

Thus, there was a wide range of responses in terms of how helpful parents had found consulting a practitioner helpful.

Explicit in these findings, is how much of this parental concern leads back directly to the issue of weight bias and the culture of ‘blame and shame’ that health professionals (and everyone else) often perpetuate, largely due to their poor understanding of the complex psychosocial and biological drivers of excess weight and their inability to provide professional advise that goes beyond ‘eat-less-move-more’ platitudes.

“They [the GP] just says ‘oh, give her exercise, make her walk more.’ But she walks to school every day and its right down the bottom, and she walks home, goes to the park on her way home. “

Not surprisingly, the researchers conclude with a most important message to practitioners:

“To encourage parents to seek help about their child’s weight, practitioners should be accessible, discuss childhood obesity in a non-judgemental manner, tailor advice and give attention to broader issues, such as low self-esteem, where necessary.”

Unfortunately, we are still graduating health professionals who do not have the least idea on how to begin addressing this issue.

AMS
Edmonton, Alberta
Turner KM, Salisbury C, & Shield JP (2011). Parents’ views and experiences of childhood obesity management in primary care: a qualitative study. Family practice PMID: 22117082

Reader may recall that the H1N1 flu outbreak in 2009 was particularly deadly to obese individuals.

This increased severity and fatality of H1N1 infections in obese patients became apparent early during the spring outbreak of the epidemic and prompted the Public Health Agency of Canada to recommend that individuals with severe obesity should be included amongst those to be given first access to the H1N1 influenza vaccine.

A paper by Chris Kaposy from Memorial University of Newfoundland, published in VACCINE, suggests that this PHAC recommendation was largely ignored by the provinces, who bear the responsibility for health care delivery in Canada.

In fact, only one province (Manitoba) followed the PHAC recommendations and considered all people under 65 with severe obesity eligible for H1N1 influenza vaccination on October 26 2009 – early in the vaccination campaign.

Alberta, Nova Scotia, and Saskatchewan, did list individuals with severe obesity, but placed narrow age restrictions on those who were given early access.

New Brunswick and Ontario listed severe obesity as a sequencing category late in the vaccination campaign (as late as November 2009).

In British Columbia, Newfoundland and Labrador, Prince Edward Island, and Quebec, obesity (or ’severe’ obesity) was never specifically listed as a chronic health condition that qualified one for early access to the H1N1 influenza vaccine. In fact, it appears that ‘obesity’ was specifically removed from the list of eligible chronic conditions that warranted early access.

The author provides at least two pieces of evidence that weight bias may have played a role in the provinces’ decisions:

“First of all, consider that in every single province the H1N1 influenza vaccine was available to pregnant women over 20 weeks gestation very early in the mass vaccination campaign. In most provinces, the vaccine was available to this group from late October 2009 onward. Clearly there was a pan-Canadian commitment during the H1N1 influenza pandemic to offer early vaccine access to pregnant women – who were also listed in the PHAC categories as a vulnerable group. Every Canadian province could have similarly chosen to vaccinate people with severe obesity early in the campaign, but they did not.”

Secondly, the delay in access cannot be explained by scarcity of vaccine - in fact, in each of the four provinces (British Columbia, Newfoundland and Labrador, Prince Edward Island, and Quebec) that never listed people with severe obesity as eligible for early vaccination, school children were vaccinated early – prior to the availability of the vaccine to the general public despite the fact that the PHAC guidelines did not list school children as a vulnerable group and computer modelling did not support the priority use of vaccination in school children ahead of high-risk individuals.

Thus, this commentary argues, Canadian provinces demonstrated an ambiguous commitment to the early vaccination of people who were severely obese, despite clear and strong early evidence that individuals with severe obesity presented an especially vulnerable group and despite clear and timely recommendations by the federal public health agency to consider severely obese individuals for priority access.

Given that H1N1 influenza ultimately did result in significant number of fatalities (especially amongst people with severe obesity), I wonder if public outrage would have been greater had any other group of ‘vulnerable’ individuals been as overtly ‘overlooked’.

AMS
Edmonton, Alberta

Kaposy C (2011). The influence of the stigma of obesity on H1N1 influenza vaccine sequencing in Canada in 2009. Vaccine PMID: 22041304

Who, in the light of the obesity epidemic and its myriad consequences, could possibly object to public health messages and other measures that would target obesity?

Aren’t messages to increase physical activity and eat healthier, even if provided with a ‘nudge’ (fat tax, BMI report cards, etc.), a reasonable and necessary step in the interest of promoting public health and tackling obesity?

It turns out that things are less clear than you may think, especially if you consider the ‘ethics’ of such measures and their implications for those, who these measures seek to educate and change for the better.

Thus, a comprehensive analysis of the surprisingly problematic ethics of some of the public health approaches to obesity prevention, by the medical ethicist Inez de Beaufort and colleagues, from the University of Rotterdam, published in the latest issue of OBESITY REVIEWS, makes a most enlightening and thought-provoking read.

In their paper, the researchers look at 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluate their ethically relevant aspects.

As the authors point out, while efforts to counter the rise in overweight and obesity, such as taxes on certain foods and beverages, limits to commercial advertising, a ban on chocolate drink at schools or compulsory physical exercise for obese employees, may appear ‘ethical’ as they are aimed at improving individual and public health, enabling informed choice and diminishing societal costs, they also raise potential ethical objections against such efforts.

The long list of potentially ethically problematic aspects identified include:

• Effects on physical health (of proposed interventions) are uncertain or unfavourable;
• There are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination;
• Inequalities are aggravated;
• Inadequate information is distributed;
• The social and cultural value of eating is disregarded;
• People’s privacy is disrespected;
• The complexity of responsibilities regarding overweight is disregarded;
• Interventions infringe upon personal freedom regarding lifestyle choices and raising children, regarding Freedom of private enterprise or regarding policy choices by schools and other organizations.

Whether or not the ‘ethical’ incentives to combat the obesity epidemic should ‘automatically’ override the potential ethical constraints, is less than clear.

The complexity of some of these ‘well meant’ initiatives can have unintended ethically problematic consequences: e.g. ‘demonizing’ candy, fast food, or chocolate milk can ostracize the child, who consumes these foods because of socioeconomic or other constraints. Oversimplistic and unrealistic messages about the benefits of diet and exercise can not only reenforce obesity bias and stigma but also lead to disengagement by the very individuals, for whom these messages are intended.

Blame, shame, and punish (tax) approaches to combatting obesity (implicit in many public health interventions) are ethically problematic not only because of lack of evidence of their effectiveness but also because such measures are unlikely to lead to positive and constructive solutions for the targeted individuals.

Thus, the authors recognise an urgent need to develop an ethical framework to support decision makers in balancing potential ethical problems against the need to do something.

Clearly, the need to kicking tires around the ethics of programmes to target obesity, is not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a program may hamper its effectiveness.

As I have noted before, the principle of First Do No Harm, should apply as much to public health interventions as to individual care.

AMS
Edmonton, Alberta

ten Have M, de Beaufort ID, Teixeira PJ, Mackenbach JP, & van der Heide A (2011). Ethics and prevention of overweight and obesity: an inventory. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 (9), 669-79 PMID: 21545391

Regular readers may recall a previous post showing that educating medical students on the complex nature of obesity, with a focus on genetics and biological determinants of ingestive behaviour, can reduce weight bias, whereas lecturing them about the benefits of diet and exercise serves to increase it.

A study by Phillippa Diedrichs and Fiona Kate Barlow from the University of Queensland, Australia, suggests that the same is true for psychology students.

In this paper, just published in the British Journal of Health Psychology, the researchers challenged undergraduate psychology students’ beliefs about the controllability of weight by presenting them with a lecture on obesity, weight bias, and the multiple determinants of weight.

Control groups consisted of lectures focusing on the behavioural determinants of weight (diet and exercise) or no lecture at all.

Beliefs about the controllability of weight and attitudes towards overweight and obese people were assessed 1 week pre-intervention, immediately post-intervention, and three weeks post-intervention showing that the students, who receive the intervention lecture were less likely to believe that weight is solely within individual control and were also less likely to hold negative attitudes towards overweight and obese people and rate them as unattractive.

In contrast, there were no such changes in the attitudes of the control or comparison groups.

To my knowledge, this is the second study demonstrating that education on obesity to budding health professionals should focus on promoting a better understanding of the complex environmental and biological determinants of body weight homeostasis rather than simply perpetuating ‘diet and exercise’ platitudes.

Not only is this closer to what we now understand about this complex condition but is also likely to reduce anti-weight bias and stereotypical beliefs amongst the next generations of health professionals.

AMS
Paris, France

Diedrichs PC, & Barlow FK (2011). How to lose weight bias fast! Evaluating a brief anti-weight bias intervention. British journal of health psychology, 16 (4), 846-61 PMID: 21988068