Wednesday, April 16, 2014

Shame And Blame Has No Role In Addressing Obesity

Balancing the scales Kirk et alAs a regular reader you will be well aware of my recent excursions into the use of comedy to promote a better public understanding of obesity.

A very different (and I dare say more scientific) approach to harnessing the performing arts to promote a discourse on obesity is that taken by Sara Kirk and colleagues, Balancing The Scales, now described in a paper published in Qualitative Health Research.

Their approach is based on the recognition that,

“…individuals living with obesity are caught in the middle, facing judgment by society if they fail to manage their weight successfully and exposing themselves to health professionals who are unable to fully support them…if an individual is unable to make the changes prescribed for weight loss, resentment builds on both sides of the therapeutic relationship.”

This led Kirk and colleagues to extensively explore the issue of obesity from a variety of perspectives resulting in rather unique insights into similarities, differences, points of consensus, and tension associated with values, beliefs, perceptions, and practices among key stakeholders.

The 42 semistructured interviews were conducted in 22 individuals living with obesity, 4 policy makers, and 16 health professionals (8 dietitians, 4 family physicians, and 4 nurses).

Three major themes emerged from the analysis of the interviews:

Blame as a Devastating Relation of Power

“Individuals living with obesity shared feelings of shame and embarrassment with their inability to control their weight on their own. This blaming discourse can easily be seen in messages of “eat less, move more” promoted by health professionals, the health system, and wider society.”

“Individuals living with obesity spoke about the complexities of trying to lose weight, inclusive of cultural, social, and organizational barriers. Despite this insight, however, they placed the final explanation for their weight status on themselves and expressed immense feelings of guilt and shame.”

“All of the individuals living with obesity had tried multiple methods to manage their weight, with limited or no success. This was extremely frustrating for them and compounded their tendency, wholly or at least partially, to blame themselves for this perceived failure.”

“Similar to individuals living with obesity, health professionals struggled to understand the complexity of the issue, which often led to blaming the individual. Health professionals commented on the unrealistic expectations of people who wanted to lose weight quickly and how their role as a health professional could not possibly be supportive of this.”

“The health professionals we interviewed also blamed themselves for not having the answers, and described feeling ill-equipped to assist individuals to make successful changes.”

Tensions in Obesity Management and Prevention

“Both the individuals living with obesity and the health professionals did not feel supported by the health care system. Health professionals [and policy makers] also struggled to know how to approach the issue.”

“Individuals living with obesity also experienced exclusion when attempting to find appropriate support within the health care system. Most individuals in the study began to access this system when they believed they could no longer manage their weight by themselves.”

The Prevailing Medical Management Discourse

“Health professionals experienced many frustrations and contradictions in their experiences with obesity management, and at times questioned the notion of obesity as a disease. Being obese was often in itself not enough to receive health care. Health professionals in this study found it easier to work with individuals living with obesity when they also had another diagnosed chronic condition, such as diabetes or cardiovascular disease. They could then more confidently prescribe a specific treatment regime.”

As for policy makers,

“[One] policy maker questioned whether medical treatment for individuals living with obesity is necessary…. As an alternative to medicalizing obesity, the policy maker suggested addressing the issue of population health and using health promotion to support the majority of people who are not morbidly obese but are still struggling with weight problems.”

“Overall, individuals living with obesity sought validation for requiring support in a system that currently does not provide the support they need.”

Based on these findings, the authors note that,

“…our findings highlight the need to reframe the public debate on obesity. However, we suggest that rather than choosing one discourse over another (management vs. prevention; system vs. individual), we should engage aspects of both. This requires not only consideration of socioecological perspectives, but also a greater awareness among health professionals of the need to offer support, not advice.”

“Furthermore, relationships between patients and health care providers should be supportive (not blaming), recognizing the widespread prevalence of weight bias in society and working hard to challenge the stereotypes that dominate the discourse on body weight”

“It was also evident in the language and experiences provided by health care providers that training, resources, and support for weight management were a substantive part neither of their professional training nor of the health care system.”

To facilitate improved training of health professionals, the authors have developed the rich narratives obtained in this study into a dramatic presentation, depicting the relationship between a health professional and an individual living with obesity.

This narrative can be viewed here.

For interviews with the researchers – click here.

Clearly, it is work like this that is essential to understanding the current discourse (or rather lack of it) about obesity and finding strategies that do justice to those living with obesity.

There is simply no room for “shame and blame” in such a discourse.

@DrSharma
Edmonton, AB

ResearchBlogging.orgKirk SF, Price SL, Penney TL, Rehman L, Lyons RF, Piccinini-Vallis H, Vallis TM, Curran J, & Aston M (2014). Blame, Shame, and Lack of Support: A Multilevel Study on Obesity Management. Qualitative health research PMID: 24728109

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Thursday, April 3, 2014

Why Coverage Of Anti-Obesity Medications For Federal Employees Is Only Fair

OPM-logo

One of the rather explicit biases that has hindered greater investment into finding more effective obesity medications, has been the unwillingness of many health care plans to cover the cost of such medications for their members.

Indeed, many private and public health plans around the world explicitly exclude obesity medications (and other obesity treatments) from coverage.

This is clearly a double standard, given that the very same plans have no problem covering medications for other “lifestyle” diseases such as type 2 diabetes, hypertension, or high-cholesterol.

Now, in a rather dramatic move last month, the US Office of Personnel Management (OPM), responsible for health insurance coverage for  over 2.7 million Federal Employees, ruled in support of health coverage for FDA-approved weight-loss treatments stating that obesity exclusions are no longer permissible in health plans for federal employees.

This move should set an important precedent for other health plans to follow.

In the March 20th letter to all FEHB carriers, John O’Brien, the Director of Healthcare and Insurance at OPM, agrees that while

“diet and exercise are the preferred methods for losing weight, …drug therapy can assist [those] who do not achieve weight loss through diet and exercise alone.”

In the letter, O’Brien provides further clarification:

“It has come to our attention that many FEHB carriers exclude coverage of weight-loss medications. Accordingly, we want to clarify that excluding weight loss drugs from FEHB coverage on the basis that obesity is a “lifestyle” condition and not a medical one or that obesity treatment is “cosmetic”- is not permissible. In addition, there is no prohibition for carriers to extend coverage to this class of prescription drugs, provided that appropriate safeguards are implemented concurrently to ensure safe and effective use.”

This ruling should end the long-standing practice of discrimination against people with obesity who require and are willing to take medications for their condition.

Obviously, medications for obesity need to always be used as an “adjunct” to diet and exercise, in the same manner that medications for diabetes, hypertension or high-cholesterol should always be used as an adjunct to diet and exercise.

It goes without stating that prescription medications for obesity, diabetes, hypertension or high-cholesterol should only be made available to those who fail to control their weight, blood sugar, blood pressure, or cholesterol levels with diet and exercise alone. (there is no “special case” for the role of diet and exercise in obesity management that does not also apply to these other conditions).

And of course, as for any prescription drug, means and measures must be in place to avoid misuse and monitor safety of such treatments.

That said, recognizing that prescription obesity drugs, deemed both effective and safe by the FDA should be made available to patients in the same manner as drugs for other chronic conditions, is only fair to patients and represents a major step towards decreasing bias and discrimination against those suffering the health consequences of excess weight.

@DrSharma
Edmonton, AB

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Wednesday, April 2, 2014

Trotting Out STAMPEDE

sharma-obesity-blood-sugar-testing2In the obesity world, this week’s big news is the publication of the three year results of the STAMPEDE trial in the New England Journal of Medicine.

As a regular reader, you may recall my previous post on this randomised controlled trial of bariatric surgery for the treatment of type 2 diabetes.

STAMPEDE involved the randomisation of 150 obese patients with uncontrolled type 2 diabetes to either intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy.

Rather than weight loss, the primary end point of STAMPEDE was a glycated hemoglobin (HbA1C) level of 6.0% or less (from a mean baseline of 9.3%).

For the 91% of the patients who completed 36 months of follow-up at three years, 5% of the patients in the medical-therapy group achieved an HbA1c of 6.0% compared to 38% of those in the gastric-bypass group and 24% of those in the sleeve-gastrectomy group.

In addition, surgically treated subjects overall had far lesser need for glucose-lowering medications, including insulin than those receiving medical treatment.

Weight was reduced by 20-25% in the surgical groups compared to a 4% weight loss in the medical arm of the study.

Quality-of-life was also significantly better in the two surgical groups than in the medical-therapy group.

There were no major late surgical complications.

By any reasonable standard, there cannot be any remaining doubt in anyone’s mind that surgical treatment for type 2 diabetes is vastly superior to anything that medical treatment has to offer.

Diabetologists and, in fact, all physicians, diabetes educators, dietitians and other health professionals, who fail to inform and counsel their type 2 patients with regard to surgical treatment options for their condition, risk being accused of malpractice.

Whether patients want surgery for diabetes or not is ultimately their choice – being informed of the potential benefits of surgery should not be a matter of choice – it should be good clinical practice.

@DrSharma
Edmonton, AB

Disclaimer: I am NOT a surgeon!

ResearchBlogging.orgSchauer PR, Bhatt DL, Kirwan JP, Wolski K, Brethauer SA, Navaneethan SD, Aminian A, Pothier CE, Kim ES, Nissen SE, Kashyap SR, & the STAMPEDE Investigators (2014). Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 3-Year Outcomes. The New England journal of medicine PMID: 24679060

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Friday, March 28, 2014

Why Watching Your Kid’s Media Use May Affect Their Weight

sharma-obesity-family-watching-tvElectronic media consumption has been linked to childhood obesity – but does monitoring your kid’s media use affect their body weight?

This question was now addressed by Tiberio and colleagues in a paper published in JAMA Pediatrics.

The researchers examined longitudinal data from a community sample in the US Pacific Northwest that indluced 112 mothers, 103 fathers and their 213 kids aged five to nine years old.

The data included what parents reported on their general monitoring of their children (whereabouts and activities), specific monitoring of child media exposure, children’s participation in sports and recreational activities, children’s media time (hours per week), household annual income, and educational level as well as parental BMI was recorded.

It turns out that maternal (but not paternal) reports of monitoring their kid’s media exposure was associated with lower BMI z scores at age seven as well as less weight gain between five and seven years of age.

These findings remained significant even after adjustment for several other variables including total media time as well as sports and recreational activities.

From these findings, the authors conclude that,

Parental behaviors related to children’s media consumption may have long-term effects on children’s BMI in middle childhood.

And that these finding,

“…underscore the importance of targeting parental media monitoring in efforts to prevent childhood obesity.”

I would not go quite that far for several reasons.

Firstly, associations do not prove causation. In addition, we don’t know much about other aspects of parenting style from this study that may well also have impacted body weight.

Thus, we could well speculate that moms who monitor their kid’s media consumption may also be more adamant about bed times, healthy eating, or even just spending more time talking to or listening to their kids – all of which may well have positive effects on their kid’s weight.

This is why simply getting parents to be stricter about monitoring their kid’s media consumption may not result in better weights at all.

As always, I  find it disconcerting when epidemiological data is used to predict what may or may not happen when interventions target a proposed “cause”.

Nevertheless, for anyone interested in this topic, the following event may be of interest:

Details:

On May 1, 2014 the Alberta Teachers’ Association, in partnership with the Alberta Centre for Child, Family and Community Research, is pleased to invite Dr. Michael Rich and Dr. Valerie Steeves to Edmonton for a discussion on how technology is impacting children, youth and society. This is a continuation of our series of evening public lectures with world renowned and distinguished speakers that has included Sir Ken Robinson, Sherry Turkle, Yong Zhao, Jean Twenge, and Carl Honore.

Dr. Valerie Steeves, Associate Professor, University of Ottawa, and principal investigator of the largest Canadian research study on children & teens’ online habits.

Young Canadians in a Wired World (2013) – Explore the highlights of Dr. Steeves’ pioneering Canadian research on children & teens’ online habits.

Ø  Cyberbullying: Dealing with Online Meanness, Cruelty and Threats

Ø  Online Privacy, Online Publicity 

Ø  Life Online

Dr. Michael Rich, Associate Professor of Pediatrics at Harvard Medical School and Associate Professor of Society, Human Development, and Health at Harvard School of Public Health, Boston, United States.

Ø Centre on Media and Child Health – Explore Dr. Rich’s extensive work on behalf of Children’s Hospital Boston, Harvard Medical School and the Harvard School of Public Health:

Ø CBC national panel discussion on Youth and Technology (February 2014):

Ø Ask the “Mediatrician” a question

There will also be a public lecture on Thursday evening May 1, 2014 entitled “Connected or Disconnected? Technology and Canadian Youth”.

Who: Dr. Michael Rich (Harvard University) and Dr. Valerie Steeves (University of Ottawa)

When: Thursday Evening, May 1, 2014

Where: Barnett House, Alberta Teachers’ Association, 11010 – 142 street NW Edmonton, Alberta

•6:00 pm Registration and reception (hors d’oeuvre and no host bar)

•7:00 pm to 9:30 pm Public lectures and discussions

Order Tickets ($10) Online at http://www.event-wizard.com/promiseperil2014/0/register/

For further information or any questions about this event please email karin.champion@ata.ab.ca or call 1-800-232-7208.

@DrSharma
Edmonton, AB

ResearchBlogging.orgTiberio SS, Kerr DC, Capaldi DM, Pears KC, Kim HK, & Nowicka P (2014). Parental Monitoring of Children’s Media Consumption: The Long-term Influences on Body Mass Index in Children. JAMA pediatrics PMID: 24638968

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Thursday, March 13, 2014

Is Weight Stigma Making Us Fat?

sharma-obesity-weight-bias-conduit1Regular readers will be well aware of my concerns around the issues of weight stigma and anti-fat messaging and policies that blame, shame and otherwise bully those of us, who happen to be larger.

Apart from the emotional and economical toll, we are now seeing more and more evidence to support that notion that weight bias and discrimination have significant biological effects on metabolism.

Thus, a study by Natasha Schvey and colleagues from Yale University, published in Psychosomatic Medicine, shows that exposure to weight stigma can significantly increase cortisol secretion.

A 123 lean and overweight adult women were randomized to watching either a 10-minutes of a stigmatizing or neutral video.

The stigmatizing video consisted of a compilation of 24 brief clips from recent popular television shows and movies in which overweight and obese women were depicted in a pejorative manner, or portrayed in stereotypical ways (e.g., overeating, wearing ill-fitting clothing, struggling to exercise, dancing in a comical manner, etc). These clips were primarily taken from comedic films, situation comedies, or reality television shows, (e.g., The Biggest Loser, Drop Dead Diva, Say Yes to the Dress, Friends, etc) and are strongly representative of how obese individuals are depicted in film, television, and news media.

The neutral video depicted 20 emotionally neutral scenes such as clips about the invention of the radio, commercials for household products, car insurance, and so on.

Exposure to the stigmatizing video resulted in a marked increase in salivary cortisol levels (a marker of stress) compared to watching the neutral video.

Interestingly, the increase in cortisol was seen in both normal and overweight women.

Similarly, viewers of the stigmatizing video were more likely to feel upset, anxious, angry, and dislike the way that obese characters were portrayed and would prefer not to view media that depicts obese characters in this way.

Thus, as the authors report,

“…not only do women of all weight strata object to stigmatizing depictions of overweight and obese individuals, but also these negative depictions result in increased neuroendocrine stress as measured by salivary cortisol.”

“Given the high levels of media consumption among Americans, it is likely that millions of individuals are frequently exposed to weight-stigmatizing content that may promote neuroendocrine stress and subjective distress, signaling a public health concern. Finally, this study directly challenges recently proposed strategies to combat obesity with the use of stigma and negative social pressure. In fact, the present findings suggest that weight stigma may induce physiological stress and contribute to adverse health, thereby underscoring the importance of removing stigmatizing content from public health efforts to address obesity.”

As stress and negative emotional states are well-recognised risk factors for weight gain, the prevalence of stigmatizing messages about obesity should concern us all.

@DrSharma
Copenhagen, DK

ResearchBlogging.orgSchvey NA, Puhl RM, & Brownell KD (2014). The stress of stigma: exploring the effect of weight stigma on cortisol reactivity. Psychosomatic medicine, 76 (2), 156-62 PMID: 24434951

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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