Dr. Sharma's Obesity Notes

Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Apr 19, 2010:

As blogged previously, health-care professionals including physicians, nurses, psychologists, dietitians, fitness professionals, medical students, and even health professionals who specialise in obesity are often biased against obese people.

This anti-fat prejudice has direct implications for the health of those struggling with excess weight as it can increase vulnerability for depression, low self-esteem, anxiety, suicidality, maladaptive eating behaviors, avoidance of physical activity, poorer outcomes in behavioral weight loss programs, and hesitation to seeking preventive health-care services.

Perhaps one reason why health professionals are particularly prone to anti-fat prejudice, may be because conventional health education curricula tend to focus primarily on the importance of “controllable” lifestyle reasons for obesity, with health promotion/public health programs typically emphasizing dieting and physical activity as the cornerstones of obesity treatment and prevention. (see my previous posting: Does the Focus on Prevention Promote Weight Bias?)

Thus, the predominant focus on personal control may well increase the notion that people with excess weight simply lack willpower or are gluttonous and lazy.

This hypothesis was now tested by Kerry O’Brien (Manchester, UK) and colleagues in a paper just published online in OBESITY.

University students (n = 159; 85% females) enrolled in a health promotion/public health bachelors degree program were randomised to take part in one of three 12-week tutorials:

1) A discussion of research on common causes and treatments for obesity emphasizing personal responsibility and control (e.g., overeating and lack of exercise).

2) A discussion of genetics (biological predispositions/heritability) and socioenvironmental (e.g., the calorie-dense food environment) reasons for obesity providing research evidence and discussion on uncontrollable causes of obesity.

3) A discussion of research on rates of hazardous drinking in young people (16–24 years), its consequences, drivers, and reduction approaches. (this was the control group).

Before and after tutorials, participants were examined both for explicit bias (e.g. “I don’t like fat people much”, “Fat people tend to be fat pretty much through their own fault”) and implicit bias (using a test that examines participants tendencies to associate negative attributes (e.g., “bad,” “lazy”) with “obese/fat people,” or positive attributes (e.g., “good,” “motivated”) with “thin/slim people”).

The researchers hypothesised that those receiving training about the controllable causes of obesity (e.g., diet and exercise) will display increased anti-fat prejudice relative to the control participants.

Conversely, the researchers expected that those receiving information on the uncontrollable causes of overweight and obesity (i.e., genetics, environment) will show reduced anti-fat prejudice.

And this is pretty much exactly what the researchers found: While, the diet/exercise condition (traditional obesity-related health curriculum) showed a 27% increase in motivated/lazy implicit anti-fat prejudice, the genes/environment condition exhibited a 27% decrease in implicit “good/bad” anti-fat prejudice and a decrease of 12% in implicit “motivated/lazy” anti-fat prejudice (there was no change in the alcohol education group).

Given this evidence that emphasising the importance of “controllable” risk factors for obesity in the education of health professionals can increase their anti-fat bias, it is perhaps time to rethink health professional educations.

As the authors point out:

“…health educators should ensure that information on genetic, social and environmental causes of obesity, and their interactions, is delivered in a convincing manner along side traditional information on causes and treatments of obesity, such as diet and exercise.“

This study not only has implications for professional education but also for public health campaigns that tend to focus exclusively on diet and exercise while avoiding placing as much attention on genetic and non-controllable risk factors.

My own experience in presenting our recently published aetiological framework for obesity assessment to health professional audiences is consistently met with an often palpable change in attitude amongst my colleagues, many of whom have explicitly thanked me for opening their eyes to the complexity of this condition.

As long as we as health professionals do not address anti-fat bias amongst our peers, those struggling with excess weight will continue to suffer the consequences.

AMS
Edmonton, Alberta

O’Brien KS, Puhl RM, Latner JD, Mir AS, & Hunter JA (2010). Reducing Anti-Fat Prejudice in Preservice Health Students: A Randomized Trial. Obesity (Silver Spring, Md.) PMID: 20395952

Breast feeding has been rather consistently associated with a lower risk of childhood obesity (and better post-partum weight loss in mothers).

Unfortunately, what was well intended by mother nature has long been widely abandoned (or shortened) to suit our rather unnatural lifestyles.

Is this a trend that can be reversed?

A paper by Sara Kirk and colleagues from the University of Dalhousie, Halifax, now examine the lessons learned from the implementation of a provincial breastfeeding policy in Nova Scotia and the possible implications for childhood obesity prevention, in the International Journal of Environmental and Public Health.

In recognition of breastfeeding as the optimal mode for infant feeding and a critical factor in promoting infant health, in 2005, the Canadian province of Nova Scotia introduced a provincial breastfeeding policy.

The policy applies to the provincial government Department of Health and Wellness, District Health Authorities and all health system funded providers. The policy comprises ten directives designed to promote breastfeeding initiation and duration in Nova Scotia and to provide supportive environments for breastfeeding mothers. These directives include the need for leadership and support for breastfeeding throughout the province, along with monitoring and evaluation of the policy.

For their study, the researchers conducted focus groups with members of provincial and district level breastfeeding committees who were tasked with promoting, protecting and supporting breastfeeding in their districts.

These discussions revealed five comon themes that posed barriers to the full implementation of this policy: an unsupportive culture of breastfeeding; the need for strong leadership; the challenges in engaging physicians in dialogue around breastfeeding; lack of understanding around the International Code of Marketing of Breast-milk Substitutes; and breastfeeding as a way to address childhood obesity.

Of these, the most pervasive and consistent barrier was that faced by mothers in a culture that is generally unsupportive of breast feeding. As the authors note:

“This unsupportive culture of breastfeeding was viewed as a barrier to breastfeeding across the continuum of care, but most especially beyond six months, or when women returned to work. Specifically, the perceived lack of a supportive environment was reflected in participants’ anecdotal accounts of breastfeeding, both in the workplace and in the broader community. While participants felt that breastfeeding mothers were philosophically supported to breastfeed when they returned to work, the practical reality of needing to pump or breastfeed at work was not seen as particularly well supported.”

This unsupportive culture was clearly evident from some of the quotes in the article:

“I tried with my first [baby] pumping when I came back and it did not work because…when there’s work to be done, people don’t look real friendly at you if you’re running off with a pump and you’re doubling up work for somebody else while you’re gone, so if you actually get a break you could run and do it…”

“…and this isn’t being judgmental either but there’s not one staff member in our facility that smokes that does not get three or four extra smoke breaks during the day and they don’t take those on their lunch breaks and their coffee breaks, they’re never questioned when they want to go out for a smoke…but granted, it doesn’t take as long to have your cigarette as it does to nurse a baby, but it’s just the whole thought process around it, like people don’t view that as a hindrance to your working life as much as they would to sneak off and feed baby”

“We’ve got to change the minds, the culture has to change because even nursing at 22 months I was getting to the point, and I know I shouldn’t have been, but to the point where I felt I had to hide it. I had to hide it from my mother because she’d say ‘oh my god you’re too old to be breastfeeding this child’, or ‘she’s too old to be breastfeeding’, but you get to the point where you feel you have to hide it because it’s not normal, it’s not considered normal to others”

This is not to say that the other themes were likewise relevant.

However, cultural acceptance of breast feeding (in public) is something that appears to be completely lacking in North America. While back in Europe, no mother would think twice about laying bare her breast to feed her infant in public (and no one would consider this anything but completely normal), it is almost hilarious to note the ridiculous fuss that people here in Canada seem to make about this.

In Europe, where parents are slightly embarrassed to be seen offering their kids a bottle in public, the opposite is true. But things are changing there too – and not for the better.

Thus, although the authors note that

“…promotion of breastfeeding offers a population-based strategy for addressing the childhood obesity epidemic and should form a core component of any broader strategies or policies for childhood obesity prevention.”,

I am less than optimistic that we will see widespread movements to breast feed infants for as long as nature intended. Unfortunately, policies cannot change culture – rather, changes in culture change policies.

I’d certainly like to hear my readers’ views on this issue. What are the perceived barriers to breast feeding and how do you think they could be addressed?

AMS
Edmonton, Alberta

Kirk SF, Sim SM, Hemmens E, & Price SL (2012). Lessons learned from the implementation of a provincial breastfeeding policy in nova scotia, Canada and the implications for childhood obesity prevention. International journal of environmental research and public health, 9 (4), 1308-18 PMID: 22690194

.

New Brunswick, one of Canada’s three Maritime provinces, home to about 800,000 (with a large Francophone minority), certainly has an obesity problem of its own – 34% of its children and youth (ages 2-17) are overweight or obese, much higher than the Canadian average of 26%.

So, not surprisingly, obesity is high on the list of reasons why this province has an official wellness strategy – interestingly, however, it is a strategy that does not focus on nor, for that matter, even makes ‘losing weight’ or ‘reducing obesity rates’ part of its objective.

Rather, this strategy takes about as ‘holistic’ an approach as I have yet seen in a policy document.

Thus, the public document with the title “Live Well – Be Well“, which outlines the 2009-1013 wellness strategy for the province – is exactly that – a wellness strategy – for all New Brunswickers – irrespective of body weight or size!

In case any one is wondering, the document speaks to seven dimensions of wellness:

Emotional: The ability to understand ourselves and cope with the challenges life can bring.

Mental/Intellectual: The ability to open our minds to new ideas and experiences that can be applied to personal decisions, group interaction and community betterment.

Physical:The ability to maintain a healthy quality of life that allows us to get through our daily activities without undue fatigue or physical stress.

Social: The ability to relate to and connect with other people in our world.

Spiritual: The ability to establish peace and harmony in our lives.

Occupational: The ability to get personal fulfillment from our jobs or our chosen career fields while still maintaining balance in our lives.

Environmental: The ability to recognize our own responsibility for the quality of the air, the water and the land that surrounds us.

Central to the strategy are four pillars, the first of which (mental fitness and resilience) is seen as being fundamental to the other three pillars, namely improving healthy eating, physical activity and tobacco-free living.

In this context, the document explains the term ‘mental fitness’ Mental fitness as follows

“…a state of psychosocial well being that goes beyond the absence of disease or sickness. It means having a positive sense of how we feel, think and act which improves our ability to enjoy life. It also implies the ability to efficiently respond to life’s challenges, and effectively restore and sustain a state of balance (e.g., through stress reduction practices, investing in friendships and healthy relationships, learning to become one’s own best friend, building new skills, seeking out support and information to take control over one’s health).

Having a higher level of mental fitness enables us to more fully enjoy and appreciate our environment and the people in it. When mental fitness needs are sufficiently met, people become more self-determined. They adopt behaviours that contribute to their own personal wellness and that of others, and they make healthier choices. Mental fitness is also reinforced by the messages we receive within our environments regarding the potential to make positive changes.“

Resilience, on the other hand, means

“…the “ability to persevere and adapt when things go awry” (Reivich, K. & Shatté, A. 2002). It is a person’s style of thinking that determines resilience, more than genetics, intelligence, or any other single factor (Shatté, A. J. 2002). Resilience is influenced by the number of positive assets we have in our lives such as positive relationships, experiences, and inner strengths such as values, skills, commitments, etc. Thirty years of research tells us that resilient people are healthier, live longer, are more successful in school and jobs, are happier in relationships and are less prone to depression (Reivich, K. & Shatté, A. 2002).”

The plan seeks to promote this virtuous goal of improving mental fitness and resilience by addressing the needs of autonomy, relatedness and competency, which, according to the plan requires

“Addressing such need areas requires heightening a sense of belonging in the workplace, schools, communities and homes or setting (relatedness), building on existing strengths and capacity (competence) and involving individuals directly in determining the actions that will ultimately contribute to their own health and well-being (autonomy).”

(Faithful readers may recall my previous post on self-determination)

In case anyone is wondering about how NB plans to measure the success of these measures:

The key indicators are pro-social behaviours, oppositional behaviours, susceptibility to tobacco and connection to school – all of which will be measured through the NB Student Wellness Survey.

Readers may also be interested to note that even in the pillars healthy eating and physical activity, in fact nowhere in this document, are any of the indicators or measures related to reducing obesity or worrying about body weights.

This is probably as close a strategy aligned with the notion of ‘health at every size’ as I have ever seen in an official policy document (if there are others, I’d sure like to hear about them).

Will this plan also reduce obesity rates? This probably remains to be seen, but, no matter what happens to body weights, if this strategy works, New Brunswickers should turn out to be a rather healthy, happy, and resilient lot.

AMS
Edmonton, Alberta

Hat tip to Isabel Savoie for pointing me to this plan.

Conventional wisdom of public health ‘gurus’ dictates that the solution to the obesity epidemic is to start early – particularly to target ‘prevention’ measures at kids – the younger the better.

A thoughtful and provocative commentary by Robert C. Whitaker, from the Departments of Public Health and Pediatrics, Temple University, Philadelphia, published in the latest issue of Archives of Pediatric and Adolescent Medicine, suggests that it may be time to focus on societal norms and the values underlying those norms rather than focusing on the ‘symptom’ (childhood obesity).

Thus, Whitaker reminds us that:

“The childhood obesity epidemic is just one symptom of our way of living. Reversing the epidemic may require that we apply a new approach to improving child health in the 21st century. One approach is to make societal changes to enhance human well-being rather than to prevent a particular symptom, such as childhood obesity. In the process, we may address obesity and other socially determined health conditions while preventing new ones from emerging.”

The discussion about ‘diet and exercise’ recommendations or targeting advertising to children is ‘misguided’ because it distracts from the broader societal discussion of how much value we place on creating a healthy and nurturing environment for our children.

As I have pointed out before – the questions (and answers) should focus on the ‘whys’ and not the ‘whats’ that determine our childrens’ health and well-being – in fact, obesity is only one of many problems attributable to the same ‘whys’.

Or, in Whitaker’s words:

“Many of the other “new morbidities,” such as depression, substance use, attention-deficit disorder, and bullying, are likely to share causes rooted in our way of living. To address those root causes, we must ask not only how our way of living has changed but why.”

Ignoring the ‘why’, Whitaker warns, may actually make things worse – not better:

“It is plausible that we could reverse the obesity epidemic by changing children’s environments in ways that make children less well than they are now, especially if we do not recognize that obesity may reflect how children are coping with multiple stresses induced by our current way of living.

For example, protecting children from food marketing or removing televisions from their bedrooms may leave children lean, but not well, if we fail to address the questions of whether we should market anything to young children or have more than 1 working television in a household.”

It is these decisions (that adults have made) that shape the environment for our kids.

“The decisions that led to changes in our way of living reflected the values of adults—what was important to us. Although these changes may have been disproportionately influenced by the values of those with the most political and economic power, the changes also reflected the values that parents brought to parenting, consumers brought to the marketplace, and voters brought to the polls.”

In fact, Whitacker suggests, the underlying ‘root causes’ of both the adult and childhood obesity (and other) epidemics likely share the same shift in values (consumerism, time pressure, etc.). Recognising these common roots should shift societal norms and values to benefit all – young and old, and not just their body weights.

“For example, addressing the problems of food insecurity and neighborhood safety can improve the well-being of both adults and children, involves questions of societal values, and can affect problems beyond the symptom of obesity. The need for a shared framework is also suggested by the fact that reversing the childhood obesity epidemic requires reversing the adult obesity epidemic, which should not necessarily require different approaches.”

Thus, both children and adults

“… need to find purpose and meaning in life, which requires lifelong growth and development… autonomy, competence, mastery, self-acceptance, positive relations with others, and transcending self through commitment or connection to something or someone else.”

“An emphasis on relationships might also clarify the tradeoffs in connecting to others through face-to-face vs electronic communication. The importance of helping children identify their natural gifts and find meaning and purpose in their lives might highlight the trade-offs in education between children’s cognitive development and their social, emotional, and spiritual development. Such trade-offs, while not about obesity per se, could also affect energy balance.”

I, for one, certainly concur with Whitaker that it will take a major and open public dialogue about the norms and values that underlie the way we run our societies to address these health issues of our times.

As I have said before, blaming, shaming and punishing will not solve the problem – this is simply shooting the messenger.

Nor will calls for laws and bans or other measures that target the symptoms (e.g. fast food) without addressing the real problem (e.g. lack of time) really solve the obesity issue (should we perhaps be learning something from the hopelessly lost ‘war on drugs’ here?)

No one said this would be easy.

AMS
San Francisco, CA

p.s. Hat Tip to Geoff Ball for alerting me to this article

Whitaker RC (2011). The childhood obesity epidemic: lessons for preventing socially determined health conditions. Archives of pediatrics & adolescent medicine, 165 (11), 973-5 PMID: 22065178

Who, in the light of the obesity epidemic and its myriad consequences, could possibly object to public health messages and other measures that would target obesity?

Aren’t messages to increase physical activity and eat healthier, even if provided with a ‘nudge’ (fat tax, BMI report cards, etc.), a reasonable and necessary step in the interest of promoting public health and tackling obesity?

It turns out that things are less clear than you may think, especially if you consider the ‘ethics’ of such measures and their implications for those, who these measures seek to educate and change for the better.

Thus, a comprehensive analysis of the surprisingly problematic ethics of some of the public health approaches to obesity prevention, by the medical ethicist Inez de Beaufort and colleagues, from the University of Rotterdam, published in the latest issue of OBESITY REVIEWS, makes a most enlightening and thought-provoking read.

In their paper, the researchers look at 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluate their ethically relevant aspects.

As the authors point out, while efforts to counter the rise in overweight and obesity, such as taxes on certain foods and beverages, limits to commercial advertising, a ban on chocolate drink at schools or compulsory physical exercise for obese employees, may appear ‘ethical’ as they are aimed at improving individual and public health, enabling informed choice and diminishing societal costs, they also raise potential ethical objections against such efforts.

The long list of potentially ethically problematic aspects identified include:

• Effects on physical health (of proposed interventions) are uncertain or unfavourable;
• There are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination;
• Inequalities are aggravated;
• Inadequate information is distributed;
• The social and cultural value of eating is disregarded;
• People’s privacy is disrespected;
• The complexity of responsibilities regarding overweight is disregarded;
• Interventions infringe upon personal freedom regarding lifestyle choices and raising children, regarding Freedom of private enterprise or regarding policy choices by schools and other organizations.

Whether or not the ‘ethical’ incentives to combat the obesity epidemic should ‘automatically’ override the potential ethical constraints, is less than clear.

The complexity of some of these ‘well meant’ initiatives can have unintended ethically problematic consequences: e.g. ‘demonizing’ candy, fast food, or chocolate milk can ostracize the child, who consumes these foods because of socioeconomic or other constraints. Oversimplistic and unrealistic messages about the benefits of diet and exercise can not only reenforce obesity bias and stigma but also lead to disengagement by the very individuals, for whom these messages are intended.

Blame, shame, and punish (tax) approaches to combatting obesity (implicit in many public health interventions) are ethically problematic not only because of lack of evidence of their effectiveness but also because such measures are unlikely to lead to positive and constructive solutions for the targeted individuals.

Thus, the authors recognise an urgent need to develop an ethical framework to support decision makers in balancing potential ethical problems against the need to do something.

Clearly, the need to kicking tires around the ethics of programmes to target obesity, is not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a program may hamper its effectiveness.

As I have noted before, the principle of First Do No Harm, should apply as much to public health interventions as to individual care.

AMS
Edmonton, Alberta

ten Have M, de Beaufort ID, Teixeira PJ, Mackenbach JP, & van der Heide A (2011). Ethics and prevention of overweight and obesity: an inventory. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 (9), 669-79 PMID: 21545391