While at the level of the individual, clinicians are beginning to acknowledge the vast body of research now showing that “lifestyle” approaches to managing obesity (“eat-less move more”) result in minimal outcomes (3-5% sustainable weight loss at best), public health attempts to address the obesity epidemic continue to perpetuate the myth that obesity (and its prevention) is simply about getting people to eat better and move more (with very little evidence to show that such measures can be implemented at a population level to effect any noticeable change in obesity rates).
In an article I co-authored with Ximena Ramos-Salas, published in Current Obesity Reports, we provide an in-depth overview of current public health policies to address obesity in Canada and argue that the “narrative” underlying these policies is an important driver of weight-bias and discrimination and significantly hindering efforts to provide Canadians living with obesity better access to obesity prevention and treatment efforts.
As we state in the article (based on original research by Ramos-Salas and others),
“A critical review of Canadian obesity prevention policies and strategies revealed five prevailing narratives about obesity: “(1) childhood obesity threatens the health of future generations and must be prevented; (2) obesity can be prevented through healthy eating and physical activity; (3) obesity is an individual behavior problem; (4) achieving a healthy body weight should be a population health target; and (5) obesity is a risk factor for other chronic diseases not a disease in itself”. These narratives create the opportunity for Canadian obesity policy recommendations to focus mainly on individual-based healthy eating and physical activity interventions. By simplifying the causes of obesity as unhealthy eating and lack of physical activity, these policies may be contributing to the belief that obesity can be solely controlled through individual behaviors. This belief is a fundamental driver of weight bias.”
This “world-view” of obesity at the level of policy makers has a significant impact on the willingness and capacity of health systems to provide access to evidence-based obesity treatments to the nearly 7 million Canadian adults and children living with this chronic disease – in fact, the unwillingness to even consider obesity a chronic disease is a big part of the problem.
“..the conceptualization of obesity as a risk factor in public health policies has implications for government action, by prioritizing prevention over treatment strategies and potentially alienating Canadians who already have obesity. The review concludes that existing Canadian public health policies and strategies (a) are not sufficiently comprehensive (i.e., solely focused on prevention and mainly focused on children; exclude evidence-based management approaches; are not person-centered); (b) are based on reductionist obesity models (i.e., models that cast shame and blame on individuals by focusing on individuals’ responsibility for their weight); and (c) do not account for individual heterogeneity in body size and weight (i.e., generalize weight and health outcomes at the population level).”
In contrast we suggest that,
“Adopting a chronic disease framework for obesity would imply that both prevention and management strategies need to be implemented. Within this chronic disease context, public health should ensure that strategies do not have unintended consequences for individuals and populations, such as perpetuating weight bias. There is now sufficient evidence demonstrating that weight bias and obesity stigma are fundamental drivers of health inequalities. Public health has an opportunity to leverage existing health promotion frameworks such as the health for all policy framework and the global plan of action on social determinants of health to address weight bias and obesity stigma”.
Based on the analyses presented in this paper, we make the following recommendations:
Canadian provincial and territorial governments, employers, and the health insurance industry should officially adopt the position of the Canadian Medical Association and the World Health Organization that obesity is a chronic disease and orient their approach/resources accordingly.
Canadian provincial and territorial governments should recognize that weight bias and obesity stigma are significant barriers to helping people with obesity and enshrine rights in provincial/territorial human rights codes, workplace regulations, healthcare systems, and education policies.
In an era of people-centered health care, public health and health system decision makers should engage people with obesity in the development of policies and strategies. Having active participation of individuals with obesity can help change negative attitudes and beliefs about obesity and facilitate the development of compassionate and equitable health promotion strategies.
Employers should recognize and treat obesity as a chronic disease and provide coverage for evidence-based obesity treatments for their employees through health benefit plans.
Provincial and territorial governments should increase training for health professionals on obesity prevention and management.
Existing Canadian Clinical Practice Guidelines for the management and treatment of obesity in adults should be updated to reflect advances in obesity management and treatment in order to support the development of evidence-based programs and strategies by health systems, employers and health insurance companies.
Given the limited effectiveness of “lifestyle” interventions and the lack of access to medical treatments, many adolescents struggling with severe obesity are left with no option but to consider having bariatric surgery.
Now, a paper by Marc Michalsky and colleagues on behalf of the Teens LABS Consortium, in a paper published in Pediatrics, describes the effect of bariatric surgery on cardiovascular risk factors in adolescents undergoing these procedures.
The study includes 242 adolescents (76% girls, 72% white, mean age 17 ± 1.6 y, median BMI 51) undergoing bariatric surgery (Roux-en-Y gastric bypass (n = 161), vertical sleeve gastrectomy (n = 67), or adjustable gastric banding (n = 14)), at five centers.
At 3 years following surgery, weight was significantly lower in all groups (28%, 26%, and 8% for RYGB, VSG, and AGB, respectively).
Hypertension, observed in 44% of participants, declined to 15% at 3 years.
Dyslipidemia observed in 75% of participants, declining to 27% by 1 year and 29% by 3 years. This improvement was largely due to decrease in triclycerides and increases in HDL cholesterol.
Baseline diabetes was present in 13% of participants with major metabolic improvement (0.5%) by 3 years. Similarly, baseline impaired fasting glucose (26%) and hyperinsulinemia (74%) dramatically improved by year 3 (4% and 20%, respectively).
Improvements in these parameters were related to the degree of weight loss.
Remission rates were negatively correlated to higher age and positively correlated to female sex and white race.
Overall, the authors conclude that this study documents the improvements in cardiovascular risk factors in adolescent bariatric surgery.
Unfortunately, the study does not present any information on surgical complications or reoperation rates, an obvious matter of concern when it comes to surgery in this young population.
While there may well have been no alternative to surgical treatment in these kids, we can only hope that eventually medical treatments will become available for this population, hopefully with similar outcomes. Unfortunately, that may well still be a long way off.
Yesterday (World Obesity Day), the European Regional Office of the World Health Organisation released a brief on the importance of weight bias and obesity stigma on the health of individuals living with this condition.
The brief particularly emphasises the detrimental effects of obesity stigma on children:
“Research shows that 47% of girls and 34% of boys with overweight report being victimized by family members. When children and young people are bullied or victimized because of their weight by peers, family and friends, it can trigger feelings of shame and lead to depression, low self-esteem, poor body image and even suicide. Shame and depression can lead children to avoid exercising or eatng in public for fear of public humiliation. Children and young people with obesity can experience teasing, verbal threats and physical assaults (for instance, being spat on, having property stolen or damaged, or being humiliated in public). They can also experience social isolation by being excluded from school and social activities or being ignored by classmates.
Weight-biased attitudes on the part of teachers can lead them to form lower expectations of students, which can lead to lower educa onal outcomes for children and young people with obesity. This, in turn, can affect children’s life chances and opportunities, and ultimately lead to social and health inequities. It is important to be aware of our own weight-biased attitudes and cautious when talking to children and young people about their weight. Parents can also advocate for their children with teachers and principals by expressing concerns and promo ng awareness of weight bias in schools. Policies are needed to prevent weight-victimization in schools.”
The WHO Brief has important messages for anyone working in public health promotion and policy:
Take a life-course approach and empower people:
Monitor and respond to the impact of weight-based bullying among children and young people (e.g. through an -bullying programmes and training for educa on professionals).
• Assess some of the unintended consequences of current health-promo on strategies on the lives and experiences of people with obesity. For example:
- Do programmes and services simplify obesity?
- Do programmes and services use stigmatizing language?
- Is there an opportunity to promote body positivity/confidence in children and young people in health promotion while also promoting healthier diets and physical activity?• Give a voice to children and young people with obesity and work with families to create family-centred school health approaches that strengthen children’s resilience and consider positive outcomes including but not limited to weight.• Create new standards for the portrayal of individuals with obesity in the media and shift from use of imagery and language that depict people living with obesity in a negative light. Consider the following:
- avoiding photographs that place unnecessary emphasis on excess weight or that isolate an individual’s body parts (e.g. images that dispropor onately show abdomen or lower body; images that show bare midri to emphasize excess weight);
- avoiding pictures that show individuals from the neck down (or with face blocked) for anonymity (e.g. images that show individuals with their head cut out of the image);
- avoiding photographs that perpetuate a stereotype (e.g. ea ng junk food, engaging in sedentary behaviour) and do not share context with the accompanying wri en content.
Strengthen people-centred health systems and public health:
• Adopt people-first language in health systems and public health care services, such as a “patient or person with obesity” rather than “obese patient”.
• Engage people with obesity in the development of public health and primary health care programmes and services.
• Address weight bias in primary health care services and develop health care models that support the needs of people with obesity.
• Apply integrated chronic care frameworks to improve pa ent experience and outcomes in preventing and managing obesity. In addition:
- recognize that many patients with obesity have tried to lose weight repeatedly;
- consider that patients may have had negative experiences with health professionals, and approach patients with sensitivity and empathy;
- emphasize the importance of realistic and sustainable behaviour change – focus on meaningful health gains and
- explore all possible causes of a presenting problem, and avoid assuming it is a result of an individual’s weight status.
- Acknowledge the dificulty of achieving sustainable and significant weight loss.
Create supportive communities and healthy environments:
- Consider the unintended consequences of simplistic obesity narratives and address all the factors (social, environmental) that drive obesity.
- Promote mental health resilience and body positivity among children, young people and adults with obesity.
- sensitize health professionals, educators and policy makers to the impact of weight bias and obesity stigma on health and well-being.
Hopefully, these recommendations will find their way into the work of everyone working in health promotion and clinical practice.
The whole brief is available here.
This morning, I am presenting a plenary talk in Berlin to about 200 colleagues involved in childhood obesity prevention.
The 1-day symposium is hosted by Plattform Ernährung und Bewegung e.V. (Platform for Nutrition and Physical Activity), a German consortium of health professionals as well as public and private stakeholders in public health.
Although, as readers are well aware, I am by no means an expert on childhood obesity, I do believe that what we have learnt about the complex socio-psycho-biology of adult obesity in many ways has important relevance for the prevention and management of childhood obesity.
Not only do important biological factors (e.g. genetics and epigenetics) act on the infant, but, infants and young children are exposed to the very same societal, emotional, and biological factors that promote and sustain adult obesity.
Thus, children do not grow up in isolation from their parents (or the adult environment), nor do other biological rules apply to their physiology.
It should thus be obvious, that any approach focussing on children without impacting or changing the adult environment will have little impact on over all obesity.
This has now been well appreciated in the management of childhood obesity, where most programs now take a “whole-family” approach to addressing the determinants of excess weight gain. In fact, some programs go as far as to focus exclusively on helping parents manage their own weights in the expectation (and there is some data to support this) that this will be the most effective way to prevent obesity in their offspring.
As important as the focus on childhood obesity may be, I would be amiss in not reminding the audience that the overwhelming proportion of adults living with obesity, were normal weight (even skinny!) kids and did not begin gaining excess weight till much later in life. Thus, even if we were somehow (magically?) to completely prevent and abolish childhood obesity, it is not at all clear that this would have a significant impact on reducing the number of adults living with obesity, at least not in the foreseeable future.
Let us also remember that treating childhood obesity is by no means any easier than managing obesity in adults – indeed, one may argue that effectively treating obesity in kids may be even more difficult, given the the most effective tools to managing this chronic disease (e.g. medications, surgery) are not available to those of us involved in pediatric obesity management.
Thus, I certainly do not envy my pediatric colleagues in their struggles to provide meaningful obesity management to their young clients.
I am not sure how my somewhat sobering talk will be received by this public health audience, but then again, I don’t think I was expected to fully toe the line when it comes to exclusively focussing on nutrition and activity (as important as these factors may be) as an effective way to prevent or even manage childhood obesity.
Wow, what a week!
Just back from the 5th Canadian Obesity Summit, there is no doubt that this summit will live long in the minds (and hearts) of the over 500 attendees from across Canada and beyond.
As anyone would have appreciated, the future of obesity research, prevention and practice is alive and kicking in Canada. The over 50 plenary review lectures as well as the over 200 original presentations spanning basic cellular and animal research to health policy and obesity management displayed the gamut and extent of cutting-edge obesity research in Canada.
But, the conference also saw the release of the 2017 Report Card on Access to Obesity Treatment for Adults, which paints a dire picture of treatment access for the over 6,000,000 Canadians living with this chronic disease. The Report Card highlights the virtually non-existant access to multidisciplinary obesity care, medically supervised diets, or prescription drugs for the vast majority of Canadians.
Moreover, the Report Card reveals the shocking inequalities in access to bariatric surgery between provinces. Merely crossing the border from Alberta to Saskatchewan and your chances of bariatric surgery drops from 1 in 300 to 1 in 800 per year (for eligible patients). Sadly, numbers in both provinces are a far cry from access in Quebec (1 in 90), the only province to not get an F in the access to bariatric surgery category.
The presence of patient champions representing the Canadian Obesity Network’s Public Engagement Committee, who bravely told their stories to a spell-bound audience (often moved to tears) at the beginning of each plenary session provided a wake up call to all involved that we are talking about the real lives of real people, who are as deserving of respectful and effective medical care for their chronic disease as Canadians living with any other chronic disease.
Indeed, the clear and virtually unanimous acceptance of obesity as a chronic medical disease at the Summit likely bodes well for Canadians, who can now perhaps hope for better access to obesity care in the foreseeable future.
Thanks again to the Canadian Obesity Network for hosting such a spectacular event (in spectacular settings).
More on some of the topics discussed at the Summit in coming posts.
For an overview of the Summit Program click here