If you’re wondering why, the answer is rather simple.
According to a paper by Robert Kushner and colleagues published in the journal Teaching And Learning In Medicine, competencies in obesity prevention, assessment, and treatment are apparently not really required, at least not based on the questions that young doctors can expect to be asked in licensing exams.
The researchers examined the coverage and distribution of obesity-related items on the three step United States Medical Licensing Examination (USMLE), which every practicing US physician (irrespective of the specialty or discipline) has to pass to qualify for licensing.
Although the USMLE question panel did include over 80o multiple-choice items containing obesity-related keywords, 58% of these items were represented by only 4 of 17 organ systems, and 80% of coded items were represented by only 6 of the 107 American Board of Obesity Medicine subdomains.
While the majority of obesity-coded items pertained to the diagnosis and management of obesity-related comorbid conditions, they did not directly address the prevention, diagnosis, or management of obesity itself.
In medicine (as in any other discipline), students focus on topics that they can expect to encounter in their exams – clearly, diagnosing obesity and managing it, is not one of them.
So, has increased recognition of this problem resulted in the incorporation of this topic in health care training programs?
This was the topic of a study by Shelly Russell-Mayhew from the University of Calgary and colleagues, published in the Canadian Journal for the Scholarship of Teaching and Learning.
The environmental scan looked at teaching curricula from 67 Alberta training programs (26 diploma programs, 41 degree programs) from 22 training institutions (16 colleges, 6 universities) in medicine (MD, MSc, PhD), family medicine residency, nursing (DPN, BN, BSc, MN, MSc), dietetics (BSc), pharmacy (BSc, PharmD), physical therapy (MSc), occupational therapy (MSc), clinical and counselling psychology (MEd, MSc, PhD), school psychology (MSc, PhD), and social work (DSW, BSW, MSW).
Despite including general course work on obesity (mainly about diet and exercise), only social work students and students in one graduate level nurse practitioner program included coursework specifically dedicated to bias, discrimination, or social justice issues.
As the authors note,
“These results provide preliminary support for previous assertions that systematic training in obesity and weight bias is overlooked, and that the training provided fails to meet the needs of practitioners once they enter the health care field.”
Although the study was limited to Alberta, there is little reason to hope that the situation elsewhere in Canada is any better.
Thus, it appears that training programs have yet to embrace the importance of preparing future health care workers for addressing the needs of clients living with obesity with appropriate sensitivity regarding weight and size.
Childhood obesity is a grave concern and so far community based interventions to prevent it have been rare and far between, with little evidence that any changes (however meagre) are in fact sustainable over time and will actually lead to a reduction in adult obesity.
Thus, the Australian team of Steven Allander and colleagues must be commended on embarking on what I believe will be the first cluster randomized trial in ten communities in the Great South Coast Region of Victoria, Australia to test whether it is possible to: (1) strengthen community action for childhood obesity prevention, and (2) measure the impact of increased action on risk factors for childhood obesity.
According to the trial design published in the International Journal of Environmental Research in Public Health, the WHO STOPS intervention will involve a facilitated community engagement process that: creates an agreed systems map of childhood obesity causes for a community; identifies intervention opportunities through leveraging the dynamic aspects of the system; and, converts these understandings into community-built, systems-oriented action plans.
Ten communities will be randomized (1:1) to intervention or control in year one and all communities will be included by year three.
The primary outcome is childhood obesity prevalence among grade two (ages 7–8 y), grade four (9–10 y) and grade six (11–12 y) students measured using established community-led monitoring system (69% school and 93% student participation rate in government and independent schools).
An additional group of 13 external communities from other regions of Victoria with no specific interventions will provide an external comparison.
All of this makes sense and is highly commendable.
What is shockingly lacking however – at least I see no mention of this in the published study design – is the inclusion of an explicit focus on what such community interventions aimed at reducing childhood obesity, will do to self-esteem and body image of the kids involved and weight bias in the communities overall.
Indeed, I see no mention of anyone with an explicit expertise in weight bias or kids mental health on the panel of researchers involved in this study.
This is concerning, as we now understand well that body image concerns and both implicit and explicit weight bias begin in kindergarten-age kids and must acknowledge that the “moral panic” created around childhood obesity has been accused of further promoting eating disorders, body image issues and weight bias.
Thus, we have here the unique opportunity to study the potential harm that could be done by school “surveillance” programs that assess body weight in kids or by the well-meant education on “healthy activity and healthy eating” that may teach kids that obesity is simply a result of making poor choices and not moving enough (rather than a complex biopsychosocial chronic disease, that is highly resistant to lasting effects of time-limited interventions).
I would sincerely appeal to the researchers involved to amend their study protocol to include changes in weight bias, unhealthy weight obsessions, body image issues, and eating disorders both at the level of the kids and the community overall, to ensure that the well-meant interventions do not inadvertently replace one problem with another – as always, the Devil of public health interventions lies in the unintended consequences.
In fact, if I was on the ethics committee tasked with approving this study, I would insist that an in-depth assessment plan for the potential harm of this intervention be in place before commencement of any study related activities in the relevant communities.
If the overall goal of the WHO STOPS intervention is to have a healthier generation of kids, nothing is more important than fully understanding the potential impact of this intervention on mental health and social attitudes towards kids and adults living with obesity.
Unfortunately, bullying is a tactic that is all too often used even by people who should know better – people, who have made it their mission to promoting a health agenda, and should be well aware of the health consequences (not to mention the humanistic or moral consequences) of bullying.
Now, a thoughtful article by Michael Sanger and colleagues, published in Progress in Cardiovascular Research, discusses why bullying tactics and ad hominem attacks against fellow scientists can only be detrimental to scientific progress.
As they point out,
“The acquisition of beneficial new knowledge is difficult, and it is even more challenging in an environment of incivility. Abusive name-calling and bullying can become a regular part of the life of a scientist, all the more so since the advent of the Internet and social media. Moreover, the likelihood of communicative discord increases according to the potential impact of a scientist’s work. Such ad hominem attacks neither aim nor succeed at advancing science, and can have adverse consequences on a personal level and for science in general.”
Bullying in science can take many forms, the most common including accusations of conflict of interest or ulterior motives, right down to outright personal attacks and name calling.
“Personal attacks work via the halo effect, a cognitive bias in which the perception of one trait is influenced by the perception of an unrelated trait, such as relating the private debt of a person to professional unreliability. Oftentimes, people tend to idealistically see others as all ‘good’ or all ‘bad’; thus, if one can attribute a bad (if unrelated) trait to a scientist, this may invariably raise doubts about the quality of his/her work.”
“Ad hominem attacks often aim at rediminishing a scientist’s credibility or implying a conflict of interest that makes the scientists statements seem invalid. For example, there is a common – indeed, near universal – view that those who are linked with for-profit companies are heavily conflicted whereas those employed in public or academic institutions, generally speaking are not. People who work for public sector institutions regard themselves (and are often regarded) as being neutral and unbiased supporters and defenders of the public interest. There is, however, a large literature by economists and political scientists known as ‘public choice theory’ that demolishes this pretension.Public institutions and the individuals who work for them are found to be self-interested, much like industries and their employees. Individuals working for public institutions with a certain culture know that their career prospects may be advantaged by being a part of that culture rather than iconoclasts.”
Whereas genuine experts debating content is an intrinsic part of the scientific method, when non-experts (or self-proclaimed experts) imply improprieties, merely because they disagree with the findings, or have potential conflicts of interest themselves, they are are a hindrance to it.
As the authors discuss, the media loves nothing better than when a scientist is called out because of some perceived conflict of interest or opinion that does not set well with the attacker.
In this context, bystanders who chose to remain silent are anything but “innocent”.
“Silence can make bullying the norm; it implicitly validates the behavior. A scientist or researcher who is bullied (or sees other being bullied) will often remain silent, fearing that speaking out may incur additional abuse and/or negative media coverage. Staying silent often allows the bullying to continue and even escalate. Attacking the individual expressing a novel idea is neither constructive nor productive, and may substantively impede the free-thinking required to achieve scientific advancements.”
We live in a time that has been described as the era of anti-science.
This label does not just apply to overt anti-vaxxers, creationists, and climate change deniers – there is indeed a growing chunk of the general public, that increasingly views all science (and all scientists) with scepticism and deep mistrust.
It does not help that all scientists are seen as having their hands in the pockets of industry – big food, big pharma, big energy, big whatever – no matter what their actual science tells us.
No one can be trusted, everyone has been bought, your scientific fact carries the same weight as my personal (uninformed) opinion.
Scientific progress (and funding for it) is at stake.
This is not about creating “safe spaces” – it is about civility and respect for the scientific process and for your fellow scientists.
The public mistrust of science is great enough – we certainly do not need scientists or health experts joining the fray.
These are the 10 Commandments of Obesity Management for health professionals presented by the Pennington Biomedical Research Centre’s Dr. Donna Ryan, who also happens to be the President Elect of the World Obesity Federation:
- Thou shalt use BMI as part of the electronic health record, but thou shalt not use it as a diagnosis that directs treatment;
- Thou shalt consider the patients’ genetic/ethnic background as part of the BMI and waist circumference risk assessment;
- Thou shalt not treat on BMI alone. Thou shalt remember that waist circumference is a risk factor and use it and other health risks to direct treatment;
- Thou shalt not worship at the shrine of ideal weight, but rather extoll the virtue of good health and set a weight goal based on a health target;
- Nor shalt thou worship at the shrine of any one diet;
- It is your job to teach the skills training in behaviors to produce weight loss or to refer the patient to someone who can;
- Thou shalt not impugn thy patient’s willpower, but rather prescribe aids to help thy patient adhere to the diet and exercise plan;
- Thou shalt prescribe medications according to the label, and if the patients lose 5% or more, thou shalt continue those medications.
- Thou shalt refer patients for bariatric surgery, especially if they suffer metabolic complications of obesity;
- Thou shalt expect a relapse if treatments are stopped.
New Orleans, LA