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.
A recent CMAJ article, by Ian Mosby and Tracey Galloway from the University of Toronto argues that one of the key reasons why we see obesity and diabetes so rampant in Canada’s indigenous populations, is the fact that widespread and persistent exposure to hunger during the notorious residential school system may have metabolically “programmed” who generations toward a greater propensity for obesity and type 2 diabetes.
There is indeed a very plausible biological hypothesis for this,
“Hunger itself has profound consequences for childhood development. Children experiencing hunger have an activated hypothalamic–pituitary–adrenal stress response. This causes increased cortisol secretion which, over the long term, blunts insulin response, inhibits the function of insulin-like growth factor and produces long-term changes in lipid metabolism. Through this process, the child’s physiology is essentially “programmed” by hunger to continue the cycle of worsening effects, with their bodies displaying a rapid tendency for fat-mass accumulation when nutritional resources become available.”
While the impact of hunger may well have been one of the key drivers or metabolic changes, the authors failed to acknowledge another (even more?) important consequence of residential schools – the impact on mental health.
Oddly enough, in a blog post I wrote back in 2008, I discussed the notion that the significant (and widespread) physical, emotional, and sexual abuse experienced by the generations of indigenous kids exposed to the residential school system would readily explain much of the rampant psychological problems (addictions, depression, PTSD, etc.) present in the indigenous populations across Canada today.
The following is an excerpt from this previous post:
This disastrous and cruel [residential school] policy resulted in much pain and despair in the First Nations’, Inuit and Metis people that lasts to this day (known as the “generational effect”). Sexual, physical and mental abuse was widespread; students were broken in heart and spirit; culture and identities were destroyed.
Much (if not all) of what ails the Aboriginal peoples of Canada can be traced back to this policy – including possibly issues that affect Aboriginal health to this day.
It is no secret that obesity and its consequences (e.g. diabetes) are rampant amongst the Aboriginal peoples of Canada. While poverty, breakdown of traditional lifestyle and culture and even genetic factors (thrifty genotype) have all been implicated in this, I wonder how much the misery caused by the residential school program had to contribute.
Early traumatic life experiences including sexual, mental and physical abuse as well as neglect and grief have all been implicated in binge eating disorder (BED) – in its purest form – the uncontrollable urge to devour large quantities of highly palatable high-caloric foods in response to emotional hunger. This behaviour has been interpreted as an emotional coping strategy, “filling the inner void”, building a physical protective barrier, etc., the ultimate result being excessive weight gain with all its consequences (the typical binger does not compensate by purging or excessive exercise).
In “treatment-seeking” patients with obesity, the prevalence of BED is estimated at 20-40%. Although I was unable to find a study that has applied the DSM-IV criteria for BED to an Aboriginal population – my guess is: the rates are probably high!
Given its distinct psychopathology, BED is highly responsive to psychotherapeutic approaches. In contrast, educational initiatives based on simply providing information on healthy lifestyles are useless.
Obesity is never an issue of “choice”. I have yet to meet anyone who “chooses” to be obese. This is most certainly also true for Canada’s Aboriginal population.”
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
Modelled on “Humans of New York”, WoL presents images and stories of Canadians living with obesity in all their diversity and variation.
After all, nothing is more effective in breaking down stereotypes and barriers than realizing that people living with obesity are no different from everyone else, in their hopes, their dreams, their challenges, their aspirations – doing their best to cope and overcome what life throws at them.
Rather than promoting a culture of fat-shaming and blaming, the Canadian Obesity Network seeks to destigmatise those living with obesity by encouraging them to share their real stories in their own words.
Thus, this project seeks to dismantle the stereotypes that surround the lives of people who live with obesity, including the notion that everyone who has overweight or obesity wants to lose weight because they are unhappy with themselves.
Many of the stories you will see in the upcoming weeks do not reflect this. The Canadian Obesity Network hopes that, by sharing these experiences, we all will realize that people who have overweight or obese have goals, dreams, and aspirations just like everyone else, and that their weight is not necessarily a barrier to achieving these, nor is it something that needs to be a source of fear and shame.
In contrast to many other “weight-loss” sites, the Canadian Obesity Network will not publish stories that glorify weight loss journeys, commercial programs or products, or extreme weight loss attempts.
“While we respect the importance and validity of each story we receive, publishing stories like these only serve to reinforce the idea that people who are overweight or obese are living unhappy, unfulfilling lives – and we know you are worth so much more than that.”
For more information on how to participate in this project click here or send an e-mail to email@example.com.
Continuing in my miniseries on reasons why obesity should be considered a disease, I turn to the idea that obesity is largely driven by biology (in which I include psychology, which is also ultimately biology).
This is something people dealing with mental illness discovered a long time ago – depression is “molecules in your brain” – well, so is obesity!
Let me explain.
Humans throughout evolutionary history, like all living creatures, were faced with a dilemma, namely to deal with wide variations in food availability over time (feast vs. famine).
Biologically, this means that they were driven in times of plenty to take up and store as many calories as they could in preparation for bad times – this is how our ancestors survived to this day.
While finding and eating food during times of plenty does not require much work or motivation, finding food during times of famine requires us to go to almost any length and risks to find food. This risk-taking behaviour is biologically ensured by tightly linking food intake to the hedonic reward system, which provides the strong intrinsic motivator to put in the work required to find foods and consume them beyond our immediate needs.
Indeed, it is this link between food and pleasure that explains why we would go to such lengths to further enhance the reward from food by converting raw ingredients into often complex dishes involving hours of toiling in the kitchen. Human culinary creativity knows no limits – all in the service of enhancing pleasure.
Thus, our bodies are perfectly geared towards these activities. When we don’t eat, a complex and powerful neurohormonal response takes over (aka hunger), till the urge becomes overwhelming and forces us to still our appetites by seeking, preparing and consuming foods – the hungrier we get, the more we seek and prepare foods to deliver even greater hedonic reward (fat, sugar, salt, spices).
The tight biological link between eating and the reward system also explains why we so often eat in response to emotions – anxiety, depression, boredom, happiness, fear, loneliness, stress, can all make us eat.
But eating is also engrained into our social behaviour (again largely driven by biology) – as we bond to our mothers through food, we bond to others through eating. Thus, eating has been part of virtually every celebration and social gathering for as long as anyone can remember. Food is celebration, bonding, culture, and identity – all features, the capacity for which, is deeply engrained into our biology.
In fact, our own biology perfectly explains why we have gone to such lengths to create the very environment that we currently live in. Our biology (paired with our species’ limitless creativity and ingenuity) has driven us to conquer famine (at least in most parts of the world) by creating an environment awash in highly palatable foods, nutrient content (and health) be damned!
Thus, even without delving any deeper into the complex genetics, epigenetics, or neuroendocrine biology of eating behaviours, it is not hard to understand why much of today’s obesity epidemic is simply the result of our natural behaviours (biology) acting in an unnatural environment.
So if most of obesity is the result of “normal” biology, how does obesity become a disease?
Because, even “normal” biology becomes a disease, when it affects health.
There are many instances of this.
For example, in the same manner that the biological system responsible for our eating behaviour and energy balance responds to an “abnormal” food environment by promoting excessive weight gain to the point that it can negatively affect our health, other biological systems respond to abnormal environmental cues to affect their respective organ systems to produce illnesses.
Our immune systems designed to differentiate between “good” and “bad”, when underexposed to “good” at critical times in our development (thanks to our modern environments), treat it as “bad”, thereby creating debilitating and even fatal allergic responses to otherwise “harmless” substances like peanuts or strawberries.
Our “normal” glucose homeostasis system, when faced with insulin resistance (resulting from increasingly sedentary life circumstances), provoke hyperinsulinemia with ultimate failure of the beta-cell, resulting in diabetes.
Similarly, our “normal” biological responses to lack of sleep or constant stress, result in a wide range of mental and physical illnesses.
Our “normal” biological responses to drugs and alcohol can result in chronic drug and alcohol addiction.
Our “normal” biological response to cancerogenous substances (including sunlight) can result in cancers.
The list goes on.
Obviously, not everyone responds to the same environment in the same manner – thanks to biological variability (another important reason why our ancestors have made it through the ages).
But, you may argue, if obesity is largely the result of “normal” biology responding to an “abnormal” environment, then isn’t it really the environment that is causing the disease?
That may well be the case, but it doesn’t matter for the definition of disease. Many diseases are the result for the environment interacting with biology and yes, changing the environment could indeed be the best treatment (or even cure) for that disease.
Thus, even if pollution causes asthma and the ultimate “cure” for asthma is to rid the air of pollutants, asthma, while it exists, is still a disease for the person who has it.
All that counts is whether or not the biological condition at hand is affecting your health or not.
The only reason I bring up biology at all, is to counter the argument that obesity is simply stupid people making poor “choices” – one you consider the biology, nothing about obesity is “simple”.