The speaker series was hosted by the principal of the college,the Right Honourable Kim Campbell, who served as Canada’s 19th prime minister in 1993.
While I spoke about the particular challenges and barriers faced by Canadians living with obesity and how these can be accommodated and supported in the workplace and society in general, other speakers spoke on the accommodation of individuals living with other challenges.
Thus, Kelly Falardeau, herself a victim and advocate for burn survivors and Deryk Beal, one of Canada’s leading clinician scientists on stuttering and other speech impediments, joined me in speaking on the importance of diversity and the need to identify obstacles to social inclusion that keep individuals from reaching their full potential.
In my presentation I did my best to portray the biological, physical, emotional and societal challenges that Canadians living with obesity face everyday.
Here is what I asked the students to think about:
“So how can we help people living with such barriers?
For one, let us educate ourselves on the real issues – if there was an easy solution that actually worked, believe me my clinic would be empty.
Secondly, let us show some respect for people who wake up with this barrier every single morning and go through their day – for the most part doing everything everyone else does.
Thirdly, let us acknowledge that once you have obesity there is no easy way back. I have patients who have lost their entire weight over on diet after diet after diet only to put the weight back again. Diet and exercise is simply not enough for most people – surgery works but is not available and not scalable – we cannot do surgery on 120,000 Albertans. So let us not pretend that there is an easy solution to the problem – we simply don’t have enough treatments that work.
Fourthly, till we do come up with more treatments that actually work or maybe even get our act together on prevention, let us not make life harder for people living with this barrier than it has to be. We can do many things to accommodate people living with obesity – we accommodate people with all kinds of “special needs” at home, in society in the workplace – just not for people living with obesity.
Fifth, let us show our support for people who struggle with their weight by the way we treat them, the way we talk about them, the way we engage with them – they are people like all of us. Just because they carry extra weight does not mean they are second class citizens or people we can simply make fun of or ignore – we are after all talking about 7 million Canadians – men, women and children.
Let us not be the barrier that makes their life even more difficult than it already is.”
Our presentations were followed by an enthusiastic ‘master class’ with students in the inaugural leadership class of the Peter Lougheed Leadership College.
I’d like to thank the organizers for giving me the opportunity to advocate on behalf of Canadians living with obesity.
Listening to (or reading the bestsellers written by) pundits, one may easily think that the entire obesity problem can be brought down to a couple of factors – sugar-sweetened beverages, fast food, sedentariness, screen-time, – take your pick.
Now, Morgan Downey, former CEO of the Obesity Society on his blog – the Downey Obesity Report – provides an update of previous lists of putative causes of obesity – a list that now included 104 items.
As he is careful to point out,
“The links are not meant to be definitive or best study but merely a demonstration of the interest in the particular cause.”
Given that many of these factors are implicated based largely on observational studies, which by their very nature cannot prove causality, some scepticism is in order.
However, for many factors on this list there is biological plausibility, often backed by findings from animal or experimental studies.
Here is Downey’s list of putative causes of obesity:
1. agricultural policies 2. air conditioning, 3. air pollution, 4. antibiotic usage at early age, 5. arcea nut chewing, 6. artificial sweeteners, 7. Asian tiger mosquitos, 8. assortative mating, 9. being a single mother, 10. birth by C-section, 11. built environment, 12. celebrity chefs, 13. chemical toxins, (endocrine disruptors) 14. child maltreatment, 15. compulsive buying, 16. competitive food sales in schools, 17. consuming skim milk in preschool children, 18. consumption of pastries and chocolate (in Burkina Faso), 19. decline in occupational physical activity, 20. delayed prenatal care, 21. delayed satiety, 22. depression 23. driving children to school 24. eating away from home 25. economic development (nutrition transition) 26. entering into a romantic relationship, 27. epigenetic factors, 28. eradication of Helicobacter pylori, 29. family conflict, 30. family divorce, 31. first-born in family, 32. food addiction, 33. food deserts, 34. food insecurity, 35. food marketing to children, 36. food overproduction, 37. friends, 38. genetics, 39. gestational diabetes, 40. global food system,(international trade policies) 41. grilled foods, 42. gut microbioata, 43. having children, for women, 44. heavy alcohol consumption, 45. home labor saving devices, 46. hormones (insulin,glucagon,ghrelin), 47. hunger-response to food cues, 48. high fructose corn syrup, 49. interpersonal violence, 50. lack of family meals, 51. lack of nutritional education, 52. lack of self-control, 53. large portion sizes, 54. living in crime-prone areas, 55. low educational levels for women, 56. low levels of physical activity, 57. low Vitamin D levels, 58. low socioeconomic status, 59. market economy, 60. marrying in later life 61. maternal employment, 62. maternal obesity, 63. maternal over-nutrition during pregnancy, 64. maternal smoking, 65. meat consumption, 66. menopause, 67. mental disabilities, 68. no or short term breastfeeding, 69. non-parental childcare 70. outdoor advertising, 71. overeating, 72. participation in Supplemental Nutrition Assistance Program (formerly Food Stamp Program) 73. perceived weight discrimination, 74. perception of neighborhood safety, 75. physical disabilities, 76. prenatal maternal exposure to natural disasters, 77. poor emotional coping 78. sleep deficits, 79. skipping breakfast, 80. snacking, 81. smoking cessation, 82. spanking children, 83. stair design 84. stress, artificial lighting, air conditioning, 85. sugar-sweetened beverages, 86. taste for fat, 87. trans fats, 88. transportation by car, 89. television set in bedrooms, 90. television viewing, 91. thyroid dysfunction, 92. vending machines, 93. virus, 94. weight gain inducing drugs, 95. working long hours, 96. NEW too much homework, 97. NEW insufficient body heat, 98. NEW imagining the smell of food, 99. NEW dust components, 100. NEW living with grandparents in China, 101. NEW estrogens, 102. NEW thermogenic adipocytes, 103. NEW prenatal exposure to cigarette smoke, 104. NEW starting college.
For links to references for each of these putative causes, visit the Downey Obesity Report here.
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Now, an interesting paper by Charles Spence and colleagues from Oxford University, published in Brain and Cognition, makes a strong case for how exposure to images of desirable foods (which they label ‘food porn’, or ‘gastroporn’) via digital interfaces might be inadvertently exacerbating our desire for food (what they call ‘visual hunger’).
In their paper, the authors review the growing body of cognitive neuroscience research demonstrating the profound effect that viewing such images can have on neural activity, physiological and psychological responses, and visual attention, especially in the ‘hungry’ brain.
Beginning with a brief discussion of evolutionary aspects of vision and food, the authors remind us that,
“Foraging – the search for nutritious foods – is one of the brain’s most important functions. In humans, this activity relies primarily on vision, especially when it comes to finding those foods that we are already familiar with. In fact, it has been suggested that trichromatic colour vision may originally have developed in primates as an adaptation that facilitated the selection of more energy-rich (and likely red) fruits from in-amongst the dark green forest canopy.”
“The brain is the body’s most energy-consuming organ, accounting for somewhere in the region of 25% of blood flow, or rather, 25% of the available consumed energy. Note that this figure is even higher in the newborn human, where the brain absorbs up to two thirds of the energy that is consumed by the developing organism. As Brown notes: “In embryos, the first part of the neocortex to develop is the part which will represent the mouth and tongue…” As the brain grew in size over the course of human evolution, the demands on the visual system to efficiently locate nutrients in the environment would likely also have increased.”
This notion is not trivial given our current environmental exposure to a multitude of food images:
“Our brains learnt to enjoy seeing food, since it would likely precede consumption. The automatic reward associated with the sight of food likely meant another day of sufficient nutrients for survival, and at the same time, the physiological responses would prepare our bodies to receive that food. Our suggestion here is that the regular exposure to virtual foods nowadays, and the array of neural, physiological, and behavioural responses linked to it, might be exacerbating our physiological hunger way too often. Such visual hunger is presumably also part of the reason why various food media have become increasingly successful in this, the digital age.”
And the influence of food media is widespread:
“Every day, it feels as though we are being exposed to ever more appetizing (and typically high calorie) images of food, what some (perhaps pejoratively) call ‘gastroporn’ or ‘food porn’. Moreover, the shelves of the bookstores are increasingly sagging under the weight of all those cookbooks filled with high-definition and digitally-enhanced food images. It has been suggested that those of us currently living in the Western world are watching more cookery shows on TV than ever before. Such food shows often glamorize food without necessarily telling a balanced story when it comes to the societal, health, and environmental consequences of excess consumption.”
And let’s not forget facebook and Instagram:
“At the same time, the last few years have seen a dramatic rise in the dining public’s obsession with taking images of the foods that they are about to eat, often sharing those images via their social media networks. The situation has reached the point now that some chefs are considering whether to limit, or even, on occasion, to ban their customers from taking photographs of the dishes when they emerge from the kitchen. However, one restaurant consultant and publisher has recently suggested that the way food looks is perhaps more important than ever: “I’m sure some restaurants are preparing food now that is going to look good on Instagram”.
The paper goes on to discuss at length the evidence that exposure to images of foods can alter cognitive responses and create the need for constant dietary restraint, which may be more difficult for some than others.
But not all images of food have these effects:
“These results support the view that people rapidly process (i.e. within a few hundred milliseconds) the fat/carbohydrate/energy value or, perhaps more generally, the pleasantness of food. Potentially as a result of high fat/high carbohydrate food items being more pleasant and thus having a higher incentive value, it seems as though seeing these foods results in a response readiness, or an overall alerting effect, in the human brain.”
As for the parts of the brain that are stimulated by exposure to food images – pretty much all of it. Thus, in one study:
“…the results revealed that obese individuals exhibited a greater increase in neural activation in response to food as compared to non-food images, especially for high-calorie foods, in those brain regions that are associated with reward processing (e.g., the insula and OFC), reinforcement and adaptive learning (the amygdala, putamen, and OFC), emotional processing (the insula, amygdala, and cingulate gyrus), recollective and working memory (the amygdala, hippocampus, thalamus, posterior cingulate cortex, and caudate), executive functioning (the prefrontal cortex (PFC), caudate, and cingulate gyrus), decision making (the OFC, PFC, and thalamus), visual processing (the thalamus and fusiform gyrus), and motor learning and coordination, such as hand-to-mouth movements and swallowing (the insula, putamen, thalamus, and caudate).”
But this knowledge is not all bad. There is also some evidence that digital manipulation of images of vegetables and other healthy foods can make them more attractive and thus hopefully increase their consumption. Whether or not this would actually work in practice remains to be seen.
“Given the essential role that food plays in helping us to live long and healthy lives, one of the key challenges outlined here concerns the extent to which our food-seeking sensory systems/biology, which evolved in pre-technological and food-scarce environments, are capable of adapting to a rapidly-changing (sometimes abundant) food landscape, in which technology plays a crucial role in informing our (conscious and automatic) decisions.”
Are you affected by exposure to foodporn? Is this really a problem?
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In the context of severe obesity, this includes providing access to care in a setting that accommodates bariatric patients – larger blood pressure cuffs, larger gowns, larger scales and larger furniture.
But how is this viewed by the very people that these measures are meant to accommodate?
This is the topic of a thoughtful opinion piece by CON bootcamper Nicole Glenn and Marianne Clark, published in JAMA.
The paper describes comments of patients with severe obesity interviewed in a bariatric centre that tries its best to accommodate:
“Incredibly considerate and incredibly insulting at the same time.” This is how a woman describes the expanded chairs in the waiting room of the bariatric clinic….This woman is not describing the hospital administrators who purchased the chairs nor the designers from whose imaginations they sprung. Instead, she refers to the chairs directly, as if it were they doling out insults and praises in turn.
That these chairs were designed for the unique needs of these patients is obvious: they offer comfort and accommodation by way of sturdy metal arms and extended seats and backs. Nevertheless, these chairs are experienced in multiple ways; not all patients who encounter them find their welcome welcoming.
A woman waiting for her appointment at the bariatric clinic explains, “This giant chair makes me feel so very fat, and so very skinny at the same time…‘You are not normal,’ it seems to say to me.”
As the authors note,
By considering the experience of such ordinary things as enlarged chairs in the bariatric clinic waiting room, we must acknowledge how extraordinary these things actually are: how they have meaning and shape and are shaped by people’s lives. Listening to patients’ experiences allows us to see the world, if only momentarily, from their perspective, enabling deeper understanding of their lives, and ultimately leaving us better equipped to address their needs as they seek treatment and care.
At least it may be useful to consider that objects may be have unintended meanings and consequences:
Rather than finding chairs that accommodate larger bodies, these patients often seek a body that accommodates the world, one that slips easily and unthinkingly into “regular” chairs. Instead of providing rest and reprieve, the temporary comfort and accommodation afforded by the altered chairs in the bariatric clinic waiting room may act as a reminder of the shrunken world that exists outside these walls, ultimately marking a journey far from complete.
What are your thoughts on accommodation – what is the alternative?
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As Canada’s national representative in the World Obesity Federation (formerly IASO), the Canadian Obesity Network is proud to co-host the 13th International Congress on Obesity in Vancouver, 1-4 May 2016.
The comprehensive scientific program will span 6 topic areas:
Track 1: From genes to cells
- For example: genetics, metagenomics, epigenetics, regulation of mRNA and non–coding RNA, inflammation, lipids, mitochondria and cellular organelles, stem cells, signal transduction, white, brite and brown adipocytes
Track 2: From cells to integrative biology
- For example: neurobiology, appetite and feeding, energy balance, thermogenesis, inflammation and immunity, adipokines, hormones, circadian rhythms, crosstalk, nutrient sensing, signal transduction, tissue plasticity, fetal programming, metabolism, gut microbiome
Track 3: Determinants, assessments and consequences
- For example: assessment and measurement issues, nutrition, physical activity, modifiable risk behaviours, sleep, DoHAD, gut microbiome, Healthy obese, gender differences, biomarkers, body composition, fat distribution, diabetes, cancer, NAFLD, OSA, cardiovascular disease, osteoarthritis, mental health, stigma
Track 4: Clinical management
- For example: diet, exercise, behaviour therapies, psychology, sleep, VLEDs, pharmacotherapy, multidisciplinary therapy, bariatric surgery, new devices, e-technology, biomarkers, cost effectiveness, health services delivery, equity, personalised medicine
Track 5: Populations and population health
- For example: equity, pre natal and early nutrition, epidemiology, inequalities, marketing, workplace, school, role of industry, social determinants, population assessments, regional and ethnic differences, built environment, food environment, economics
Track 6: Actions, interventions and policies
- For example: health promotion, primary prevention, interventions in different settings, health systems and services, e-technology, marketing, economics (pricing, taxation, distribution, subsidy), environmental issues, government actions, stakeholder and industry issues, ethical issues
Early-bird registration is now open – click here
Abstract submission deadline is November 30, 2015 – click here
For more information including sponsorship and exhibiting at ICO 2016 – click here
I look forward to welcoming you to Vancouver next year.