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

The Canadian Obesity Network certainly does a lot of things - one of them is to provide its clinician members (and anyone else who may be interested) with an automatic e-mail alert and link every time a “high quality” article on obesity prevention or management is published in the medical literature.

This service is called OBESITY+ (which stands for Online Best Evidence Service in Tackling obesitY PLUS) and is available online for free.

The engine behind this extraordinary service (that cuts through and eliminates about 98% of all published literature on obesity) is McMaster University’s Health Knowledge Refinery.

The features of OBESITY+ include:

• A systematic review of over 130 journals (including quarterly updates of the Cochrane Library) with selection of articles by expert research staff concerning the cause, course, diagnosis, prediction, prevention, treatment, and economics of obesity, according to explicit criteria, with high reproducibility and periodic quality assurance checks.
• Ratings of each eligible article for clinical relevance and newsworthiness by at least 3 practitioners with an interest in obesity.
• E-mail alerts about new evidence, adjusted to the user’s preset levels of relevance, newsworthiness, and frequency. Each alert includes clinical ratings and comments, and electronic links to the article’s abstract on PubMed (if available) and to the fulltext article on PubMed or the publisher’s site (if available for free).
• A cumulative searchable bibliographic database of the alerts that is continuously updated.
• A user interface allowing each user to register for a subset of the accumulating database by practitioner type.
• A link to EvidenceUpdates, a service from the BMJ Group and McMaster University’s Health Information Research Unit that provides access to current best evidence from research, tailored to the user’s health care interests, to support evidence-based clinical decisions.

This service, now used by thousands of obesity professionals around the world, is available to all members of the Canadian Obesity Network but does require a separate registration and log-in to set your personal alerting threshold and frequency. As a clinician, you can even opt in as a rater for new articles.

If there is only one place where you have time to go for the best in obesity research - it is certainly OBESITY+

I always find it interesting to see how practitioners rate these new articles and am often surprised to note which articles turn out to be most popular.

Now that OBESITY+ has been online almost 5 years, I’d certainly love to hear from anyone using this service.

If you are not yet a subscriber, register for OBESITY+ now!

AMS
Edmonton, Canada

For today’s kids, walking or biking to school has become the exception rather than the rule.

A study by Anna Price and colleagues, published in the Journal of School Health, now explores the perceptions of school administrators in South Carolina regarding the factors that influence childrens’ active travel to school.

According to their survey of 314 school and district leaders of elementary and middle schools, the two most commonly raised issues were concerns about the safety of crossing streets (54%) and the availability of sidewalks (54%).

Additional factors included distance to school (46%), traffic volume (42%), parental attitudes (27%), traffic speed (27%), neighborhood condition (24%), and student attitudes (10%).

Some respondents also expressed concerns about liability issues related to students’ active travel to school.

Overall, the survey left no doubt about the considerable concerns of schools administrators about the safety of students while walking to school.

Based on these findings, the researchers suggest that active travel to school may be increased by addressing the (perceived?) safety of street crossing and the number of sidewalks, and by educating school and district leaders about liability and safety issues related to students walking to school.

If my readers can think of other barriers or novel ideas how to address them, I’d certainly love to hear them.

AMS
Edmonton, Alberta

Price AE, Pluto DM, Ogoussan O, & Banda JA (2011). School Administrators’ Perceptions of Factors That Influence Children’s Active Travel to School. The Journal of school health, 81 (12), 741-748 PMID: 22070505

This question appears almost a ‘no-brainer’ and many readers will once again put the very fact that I touch on this topic down to ’sports-bashing’ - but, the ‘uncomfortable truth’ for youth sports enthusiasts is that the answer to this question is far less clear than one would perhaps expect.

Given the rather mixed literature on whether or not (organized) youth sports can provide a solution to the obesity problem, Toben Nelson and colleagues from the University of Minnesota, Minneapolis, have taken a careful look at the published literature on this issue - their findings are published in the latest issue of Current Sports Medicine Reports.

While their review of 19 studies on this topic showed that kids participating in sports were indeed more physically active than kids who did not participate, overall they found no clear relationship between participation and weight status. While 12 studies did note some (albeit small) differences in body weight in selected subgroups (but not the entire study population in these studies), the other 7 studies found no differences in body weight at all.

Further analyses of these studies revealed some ’surprising’ findings that may well explain these findings:

Firstly, there were substantial disparities between the overweight and obesity rates between sports: sports with a higher level of obesity included rugby, swimming, judo, and tennis, and sports with lower levels of obesity included gymnastics, handball, horse riding, and dance.

Thus, as the authors note:

“The lack of a clear difference in weight status between participants and nonparticipants observed in some of the studies reviewed may be attributed to the type of sport studied and the specific body type suited for that sport.”

Secondly, although kids participating in sports tend to have more activity than non-participating kids, the overall differences are not as large as one would assume. While in one study, on the days on which kids participated in sports added about 30 mins of moderate to vigorous physical activity to that day, another study that objectively assessed physical activity of youth sport participants in soccer, baseball, and softball, found that fewer than one in four met recommended levels of activity during their sport team practice.

“It is not clear from these studies how much of the sedentary time in sport was spent in these sport-related activities and it is also not clear what extent to which physical activity can be optimized in these settings without sacrificing instruction and skill development.”

Thirdly, it is very possible that participation in youth sports can negatively affect both the quality and quantity of food and drink consumed, potentially resulting in net positive energy balance.

Thus, although one study found that youth involved in sport had better overall nutrient intake than youth not involved in sport, several other studies showed that total caloric intake often exceeded actual expenditure. One study of middle and high school youth found a positive association between sports team participation and frequency of fast food consumption and that sport team participation during middle school predicted greater fast food consumption into the high school years. In other studies, sport participants were more likely than nonparticipants to consume sports drinks and fruit juice and were equally likely to consume soft drinks.

As the authors point out:

“Candy, confectionary, sugar-sweetened beverages (including sport drinks), and ice cream are commonly sold at youth sport events or brought to the event by contestants and parents. Youth sport marketing is a key part of food and beverage marketing strategies, and voluntary industry guidelines may actually encourage food and beverage companies to associate those products with health and fitness activities such as youth sport.”

“Among some sport teams and leagues, the practice of providing snacks and beverages is institutionalized, wherein volunteer parent coordinators develop and assign a snack schedule. The snacks and beverages provided are often packaged convenience food (e.g., sport drinks, soda pop, candy bars, cookies, chips, “fruit” snacks) and, in combination, could total 300 to 500 calories or more.”

This is certainly problematic as,

“Youth, parents and coaches may have little or no awareness of the large number of calories contained in snacks and beverages commonly offered in youth sport settings or the relatively small number of calories children expend during sport.”

The authors also discuss the observations that:

“In addition to direct access to excess calories available in sport settings, participants are subject to time pressures associated with attending sport practices and events. Time pressures may lead to more consumption of fast food and other processed food, which tend to be convenient but less healthy options. Regular family meals are associated with healthful dietary behaviors but may be sacrificed due to sport participation. Parents of youth sport participants report that sport-related time pressures influence meal planning and preparation, interfering with family meals.”

Another issue concerns the almost inevitable discontinuation of sporting activity, which may occur for numerous reasons including personal factors such as lack of enjoyment or motivation, time constraints, pressure to perform, and low achievement orientation and organizational factors such as coaching issues, lack of playing time, and lack of opportunities to participate.

“Regardless of the reason for dropping out of sport, decreasing energy expenditure without replacement with other forms of physical activity and/or decreasing caloric intake can promote energy surplus and weight gain. Childhood eating patterns help establish adult dietary habits, and these findings highlight the importance of promoting good nutrition in conjunction with youth sports.”

Overall, the authors conclude that:

“Given the limited available research, there is not sufficient evidence to conclude that sport participation protects against the development of obesity. Additional research is needed to understand weight status and weight gain among sport participants and to determine whether, and under what conditions, sport can effectively prevent unhealthy weight gain.”

At a minimum:

“Additional discussions among key stakeholders are needed, and interventions to reduce the exposure to the excessive calories and other unhealthy food and beverage options available in youth sport must occur before the promise of obesity prevention in youth sport can be realized.”

As I have discussed before, it appears that both the potential benefits and downsides of sports as a means to tackling obesity have more to do with the impact of sports (and sport settings) on caloric intake than expenditure.

AMS
Edmonton, Alberta
Nelson TF, Stovitz SD, Thomas M, Lavoi NM, Bauer KW, & Neumark-Sztainer D (2011). Do youth sports prevent pediatric obesity? A systematic review and commentary. Current sports medicine reports, 10 (6), 360-70 PMID: 22071397