Arya M. Sharma, MD

CBC Commentator, Rex Murphy

Regular readers will recall a host of previous posts on the issue of weight bias and discrimination.

Canadian Obesity Network members will hopefully also be aware that for the past four years, addressing weight bias and speaking out against weight-based discrimination has been the #1 strategic goal of the network.

Rather than listing all of the activities that the Network has undertaken to address this issues (the latest one being the launch of the image gallery “Picture Perfect at Every Size“), in today’s post I would like to share a story and explain why I continue to believe that this is the central problem at the the very heart of finding solutions to the obesity issue.

I remember this as though it was yesterday. I had just arrived with my family in Canada, having accepted a Tier 1 Canada Research Chair in Obesity at McMaster University. I was just discovering Canadian television and was quite impressed the first time I saw Peter Mansbridge on the CBC’s “The National”.

Interestingly, that evening one of the news items that caught my attention was an announcement by then Health Minister Anne McLellan, that the Government would spend $15 million to support obesity research - certainly good news for an obesity researcher just arriving in Canada.

This brief sense of having arrived in the right place at the right time, however, was shaken by what followed - a scathing, derisive, and contemptuous commentary by Rex Murphy, Canada’s premier TV commentator - not known to mince words.

In brief, as far as I can recall, the gist of his commentary was that this funding for obesity research was another perfect example of wasteful spending of tax-payer dollars.

To paraphrase his words, “so now the Government of Canada is spending millions of dollars to show that Canadians get fat by eating fast food and lounging in front of their TVs“.

I don’t remember the exact wording or the many ‘humorous’ angles that Rex Murphy took in this typical meandering monologue but I do recall the immediate effect it had on me. In my mind I could see Canadians across the country nodding and agreeing with Murphy, that spending any money on obesity research was indeed a complete waste - we already know the reasons: ‘gluttony and sloth’ - what’s there to research?

It became blindingly obvious that Rex Murphy was simply stating aloud what most people think - no wonder governments would be hesitant to support obesity research, or worse still, actually consider providing obesity treatments to Canadians.

I admit that prior to hearing this commentary, I had not given much thought to the issue of how weight bias ultimately stands in the way of finding solutions to the obesity epidemic.

Unfortunately, while Rex Murphy could perhaps be forgiven for failing to recognize the true psychosocial and biological complexity of this problem, I continue to be baffled that so many of my professional colleagues continue to trumpet simplistic notions of “eat-less-move-more” as a solution to the problem.

Frankly, I do not believe that they fully appreciate how, by reducing the entire problem of obesity to simply a matter of diet and exercise, they do little more than reinforce what most people already believe - obesity is simply a matter of ‘gluttony and sloth’.

No talk of food insecurity, abuse, depression, stress, time-pressures, addiction, genes, incretins, adipokines, hypothalamic pathways, adipostats, mitochondrial inflexibility, medications, or any of the other countless ’scientific’ intricacies that may indeed result in the ’symptoms’ of overeating or undermoving.

By reducing obesity simply to a matter of ‘lifestyle’, they provide the perfect excuse for funding agencies to rather fund research on ‘real’ health problems, for regulators to tighten the criteria for obesity medications, for payers to deny or limit the access to obesity treatments, and for health professionals to not see obesity management as part of their job.

This is why there will be no solution to obesity without first solving the issue of weight bias and discrimination.

This is why, addressing this issue remains the #1 strategic priority of the obesity network.

To anyone unhappy about how much funding is going towards supporting obesity research, unhappy about availability or access to obesity treatments, unhappy about lack of obesity training for health professionals, unhappy about reimbursements to health professionals for obesity counselling, unhappy about integrations and accommodation of people struggling with severe obesity, or even just unhappy about the surprising fact that Canada’s only national obesity organisation receives virtually no government funding to sustain its efforts - I have one simple suggestion: begin by showing zero-tolerance for ‘fat jokes’ or ‘fat talk’, do not use language, images, or messages in your presentations and writings that further promote stereotypes or reduce this complex problem to simply a matter of ‘lifestyle’, and please do stand up and speak out on the issue of weight bias and discrimination.

If the Canadian Obesity Network does nothing else but bring awareness to this aspect of the obesity problem  - it will have well been worth the ride.

AMS
Edmonton, Alberta

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

This week, while I am attending Obesity 2011, the 29th Scientific Meeting of The Obesity Society here in Orlando, back home, the Canadian Obesity Network is busy conducting a photo shoot with the goal to create a library of images of people with obesity that can be used by the media and others reporting on this issue.

As readers will recall, I have previously commented on the fact that ‘obese people have heads too‘ - a fact that could easily be missed given the usual depiction of headless fat people in the media. Together with the usual images of these anonymous torsos sitting on couches and eating chips, this typical depiction of obesity not only serves to reinforce the stereotypical image of the gluttonous and slothful obese person but is in fact simply wrong in that it does not show the true face of obesity (no pun intended).

As outlined in the “Guidelines for the Portrayal of Obese Persons in the Media” developed by the Rudd Center for Food Policy and Obesity at Yale University and The Obesity Society (TOS):

When selecting an image, video, or photograph of an obese person, consider the following questions:

1. Does the image imply or reinforce negative stereotypes?

2. Does the image portray an obese person in a respectful manner? Is the individual’s dignity maintained?

3. What are the alternatives? Can another photo or image convey the same message and eliminate possible bias?

4. What is the news value of the particular image?

5. Who might be offended, and why?

6. Is there any missing information from the photograph?

7. What are the possible consequences of publishing the image?

Media aside, I think these guidelines should be considered by anyone given a talk on obesity that involves the use of media (slides, videos, etc.).

Unfortunately, as I know all too well, it is not easy to find such images.

This is why, the Canadian Obesity Network has invited volunteers to be photographed in pictures that will be offered to the media and anyone else for non-commercial use in reports, talks, presentations, and publications on obesity. This royalty free library will soon be available through the Canadian Obesity Network.

For more details and examples of some of the shots, head over to a post by DR EyeCandy, who co-ordinate this shoot for the Network.

Thanks to everyone involved - it looks like you had a great time for a great cause.

AMS
Orlando, Florida

Yesterday, the Public Health Agency of Canada (PHAC) and the Canadian Institute for Health Information (CIHI) jointly released a thoughtful, insightful, and thorough report on Obesity in Canada.

Unfortunately, the media release announcing this report promoted the rather misleading and simplistic notion that millions of Canadians are overweight and obese simply ‘because’ they are inactive and do not eat enough fruit and vegetables.

This, as becomes clear when reading the actual 62-page report, was probably neither the intention of the authors nor that of the reviewers and consultants, who contributed to this report.

Indeed, the actual report goes to great lengths to explain that obesity is complex and multifactorial.

Thus, the report points out that:

“Research has identified a number of determinants associated with obesity, including physical activity, diet, socioeconomic status, ethnicity, immigration, and environmental factors”

and that:

“…the patterns involved are complex, and determinants are interconnected.”

The report is particularly sensitive and cautious when it comes to the drivers of obesity in Canada’s Aboriginal communities:

“Aboriginal populations have distinct histories, but they share common experiences of colonialism, racism and social exclusion. Reflecting these histories and a more holistic cultural perspective on health, for Aboriginal peoples the range of determinants of health may also include factors such as cultural continuity and the relationship to land.”

and

“…the historical experiences of Canada’s Aboriginal peoples provide important context in considering the determinants of Aboriginal health, including obesity.”

With regard to the proximal determinants (like diet and physical activity), the report acknowledges research findings on familial and environmental factors that may affect dietary choices and behaviours:

“For example, snacking or eating dinner while watching television, consumption of sugar-sweetened beverages between meals and skipping breakfast have been associated with an increased risk of obesity in children and youth. As well, a study of middle-school-aged children found that a greater frequency of family dinners was associated with less soft drink consumption, more frequent breakfast eating, less concern over high bodyweight and higher self-efficacy for healthy eating at home and during social times with friends.”

Other determinants, about which there is still much more to learn, include:

“the effects of biological or genetic influences and pre- and post-natal effects, including birth weight and breastfeeding”.

“There may also be a relation between psychiatric conditions and excess weight, although this may be confounded by that fact that some psychotropic medications can contribute to weight gain”

Unfortunately, while the authors were clear and cautious in the presentation of their findings, the press release essentially throws all of this to the wind with its opening sentence:

“Eliminating all physical inactivity among Canadian adults (defined as less than 15 minutes of low-impact activity a day) could avert the equivalent of 646,000 cases of obesity in women and 405,000 cases in men……Similarly, improving poor-quality diets—as measured by the frequency of fruit and vegetable consumption—could result in the equivalent of 265,000 fewer cases of obesity among men and 97,000 fewer cases of obesity among women.”

Not surprisingly, this is exactly the message that most of the media picked up and splashed across front pages, TV screens and websites, not to mention radio shows and every other possible outlet - with a few sparse and notable exceptions.

What I imagine most Canadians heard yesterday was that,

“if only all these fat slobs would simply get off their butts for just 15 mins of low-impact activity a day and perhaps eat the odd extra serving of fruit and vegetables, one million Canadians would no longer be obese and we could instantly save all those billions of dollars in health care!”

Never mind that the term ‘avert’ (meaning avoid or prevent) was widely interpreted by the press to mean ‘reduce’.

Never mind that the report actually explains in length that these calculations are purely theoretical and do require the assumption of causality.

Never mind that the authors caution that,

“….because these analyses use cross-sectional data and rely on a number of assumptions, they cannot be used to make inferences about the causes of obesity”.

Never mind that,

“Relatively few population-level obesity prevention and management interventions – especially public policy approaches that target broader environmental factors – have been systematically evaluated in terms of their effectiveness or cost-effectiveness.”.

And, never mind that my back-of-the-envelope calculation tells me that even if these number were true, ‘averting’ 1,000,000 (extra?) cases of obesity would still leave us with over 6,000,0000 Canadians, who are obese today and are unlikely to be dropping those extra pounds simply by adding 15 mins of low-impact exercise to their daily routine or reaching for a few servings of fruit and veggies.

My guess is that the authors of this report were probably both surprised and appalled by the media release and the response to it.

At least I hope they were, given that in their report they are were careful to note that,

“…..decisions about how best to address obesity at a population level….may benefit from careful analysis of the feasibility of possible interventions, the available scientific evidence, the cost/benefit ratio (including the potential for unintended or negative outcomes such as stigmatization or increased inequities), as well as potential value for money.” [emphasis mine]

Unfortunately, “the potential for unintended or negative outcomes such as stigmatization”, apparently escaped the analysis that went into deciding how to communicate this report to the media.

Needless to point out, the press release was also rather ‘light’ on the issues of ‘feasibility’, ‘availability of scientific evidence’ and ‘value for money’ for the proposed ‘intervention’.

All of this is sad and disheartening, because the report itself is so carefully worded, balanced and insightful.

It is indeed hard to align one of the major conclusions of this report:

“There is unlikely to be a single solution that will reverse the rising prevalence of obesity in Canada; rather, a comprehensive, multisectoral response may be needed.”

with the rather simplistic message that folks will now remember every time they see someone carrying a few extra pounds:

“Why can’t you just get off your butt for even 15 mins and simply eat those five fruit and veggies - then you’ll have no business being obese and I won’t have to pay so much for your health care.”

Sadly, not a happy day for the 6,000,000 Canadians facing the bullying, emotional pain and despair caused by pervasive negative stereotyping and anti-fat discrimination.

AMS
Edmonton, Alberta

One of the consequences of the obesity epidemic is the proliferation of “reality based” media aiming to lay bare and expose the unhealthy behaviours that lead to obesity and tout “solutions” primarily aimed at changing individual lifestyles.

Notable examples of this ‘”entertainment” genre include television programmes such as Jamie’s School Dinners and Jamie’s Ministry of Food, You Are What You Eat, Honey, We’re Killing the Kids, Supersize and Superskinny, Fighting Fat Fighting Fit, and The Biggest Loser. In Canada we have our own examples like X-Weighted and the most recent CBC addition, Village on a Diet.

Given the mass audiences that these shows command, it is worth considering how the causes, consequences, and possible solutions to obesity are portrayed in these shows. Perhaps even more importantly, the implicit and explicit portrayal of  people with obesity in these shows and the “narrative” around obesity deserves exploration.

This is the topic of a paper by Emma Rich from Loughborough University, UK, just published in the latest issue of HEALTH, which explores how reality media portrays and perpetuates the interdependent connections between parenting, social class and broader political discourses of parenting and health risks relevant to obesity.

As Rich points out:

“Reduced activity and poor diets are repeatedly reported as leading to escalating rates of overweight or obese populations and related mortalities resulting from associated conditions such as hypertension, diabetes, stroke, heart disease and cancers. This is asserted without reference to work which reveals that many of the ‘certainties’ populating obesity are based upon scientific evidence which others claim is either inconclusive or incorrect. Within this discourse, it is routinely declared that the health of western society is facing imminent decline unless measures are taken by individuals to eat less, lose weight and exercise more.”

Furthermore:

“The imperatives around ‘eating well’, exercising regularly and monitoring our bodies, carry powerful moral overtones about how individuals ought to behave. These imperatives are strongly associated with body size, such that the thin or slender body is taken to represent not only a state of ‘good health’ but also reflect control, virtue and good citizenship.”

Drawing on specific examples, Rich looks at how these shows reduce the complexity of obesity to rather simplistic messages often with strong moral and judgmental overtones. These simple solutions are offered by so-called “experts”, who seldom appear to fully appreciate the reality of the participants lives.

To illustrate this point, Rich cites a dialogue from an episode of Jamie Oliver’s Ministry of Food, in which

“Jamie returns to Natasha’s house to find that she is once again feeding her daughter cheese-chips. ‘Sorry, I’m just embarrassed’, Natasha says eventually. ‘I don’t know how it gets like this. I really try with money, I do.’ Jamie, looking confused replies ‘Look’, he begins, ‘I’m not going to say to you that I understand, because … well, erm, I don’t.’ Natasha gets tearful, and explains that during the week she had spent all of her benefit money on bus fares and overdue bills, and had little left to buy the ingredients for the recipe that Jamie had taught her. As Jamie stands in the kitchen Natasha cries. ‘Come here’, he says, moving towards her to hug her. ‘Get off’, she says, pushing him away.”

Or an episode in which another woman explains to Oliver ‘The thing with you, Jamie, is you live in a bubble. You’ve got no bloody idea what it’s like for us.’

As explained by Rich:

“Natasha’s rejection reveals how public pedagogies such as those functioning with Jamie’s Ministry of Food can be at odds with the realities of individual lives when health is abstracted from the social contexts which shape it.

For example, the class association of food choice is given little regard in Jamie’s Return to School Dinners when he routinely inspects teachers’ and children’s bags for junk food, telling one young teacher caught with junk food ‘That’s no way to live, darling. You’ve got to have some pride in yourself.’ There is no acknowledgement of the cultural value that chips (albeit in the British context) as ‘a white working class food’ might have for Natasha, or that they might ‘be cheap and filling’ thus meeting her financial needs.”

Similarly, Rich draws on specific examples from other reality shows with similar narratives.

Rather than theorizing these interventions as imposed or regulated by neoliberal ideals of ‘responsible individualism, consumerism and self improvement’, Rich examines how these shows lead the participants

“to know themselves in relation to dualistic body knowledges which ‘abolishes multiplicities and variation’; as either fat or thin, healthy or unhealthy, failing or morally right/wrong.”

These discourses not only position individuals as blameworthy, but moralize and decontexualize health inequalities by glossing over the social and structural contexts that come to bear upon this.

…self-management is at the heart of reality television, thus as is revealed in Jamie Oliver’s School Dinners, a child’s diet becomes a reflection of parenting choice, rather than antecedent gender, class, cultural or ethnic localities. Those parents who do not comply with the sanctioned behaviours of the Oliver campaign become the figures through which affects associated with bad parenting choices flow (‘you’re an idiot’) within an obesity assemblage.

The complexities of health disparities which so strongly come to bear upon health, are often obfuscated in this discourse…reality TV positions the working classes as a maligned and ‘abject’ social category to be managed, controlled and ‘taught’ how to live better lives.”

However, as Rich also points out:

“This is not to suggest that all media focusing on weight and health are assembled in this way….Indeed, some media may lead to more critical or creative public pedagogies perhaps even disrupting neoliberal discourses on health.”

Perhaps it helps to always remind ourselves that even the best-intended tv shows need to capture the interest of its viewers.

Or, as Dr. Ali Zentner, the physician on CBC’s Village on a Diet, so succinctly summarized in her comment on my blog,

“what is “good tv” is not always perfectly accurate science.”

AMS
Edmonton, Alberta

Rich E (2011). ‘I see her being obesed!’: Public pedagogy, reality media and the obesity crisis. Health (London, England : 1997), 15 (1), 3-21 PMID: 21212111