Dr. Sharma's Obesity Notes

Continuing my discussion of the paper by Julia Temple Newhook, Deborah Gregory and Laurie Twells from the Memorial University of Newfoundland, St. John’s, published in the Journal of Social, Behavioral, and Health Sciences, on what causes some people to gain weight, we turn to what the authors describe as, “Gradual Processes”.

Thus, in their extensive interviews with individuals seeking bariatric surgery, although most interviewees focused on explanations with a considerable sense of self-blame, many did report social structural factors as playing an important role in their weight gain, without using these as “excuses”.

“Zoë pointed out that outdoor exercise was too difficult for her in winter conditions, and indoor exercise in a gym was out of her reach financially, and gave specific policy recommendations: “They’re always telling people to lose weight, that we’re an overweight province. Well, help out a bit. Make gym memberships a little more cheaper, make it a little more accessible to people.”

Other barriers included occupational and domestic work schedules:

“When you’re sitting at a desk 40, 45, or 50 hours a week, you’re trying to establish yourself so that people are looking to you, so you get promotions as opposed to someone else, so you’re putting in those extra hours and you’re coming home tired. You’re sitting down for supper, and then it’s 7:00 at night.Okay, when do I do anything now?”

“Wanda explained, “I got the two kids. I have a gym membership, a family gym membership; it’s just that we never get there. I work all day. When I get home I’m tired. … Just finding the time is hard.”

As the authors note, leisure time distribution is a social inequality that particularly affects those with less income as well as mothers of young children.

Furthermore, social inequality related to the risk for occupational injuries with subsequent weight gain are likewise often not seen as related to the social determinants of health.

Finally, built environments and the cost of weight-loss programs were seen as contributing factors that made weight management efforts difficult or unsustainable.

I am sure that readers will have their own social determinants to contribute to this list.

AMS
Berlin, Germany

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 Feb 2, 2008:

With the “sensational” results of obesity surgery being publicized in the media, it is not surprising that expansion of bariatric surgery is receiving increasing support. In every province, health plans are carefully looking at expanding access for their populations.

In light of these development it may be time for a word of caution.

Obesity surgery is not just about surgery. In fact, even the most enterprising bariatric surgeons will readily agree that the actual surgery is just a small (but important) technical piece in the overall treatment plan.

No doubt, good surgical outcomes require well-trained experienced surgical teams but we know that much of the long-term outcome depends on what happens before and after surgery.

Done in the wrong patients with no or little long-term follow up, what could be a life saving operation can become a disaster – and weight regain is perhaps the least that can go wrong. Much more severe and potentially devastating are the nutritional deficiencies and the psychological and social consequences that are not seldom after surgery.

For surgery to produce good long-term results it is absolutely essential that as access to surgery expands, so does the pre-surgical selection and education process as well as the access to life-long post-surgical monitoring.

Expansion of surgical programs does not just need more surgeons and OR time – it needs dietitians, psychologists, physicians, occupational therapists, social workers and other health professionals who are trained and qualified to prepare and follow-up surgical patients.

In the end it will be family doctors who have to look after the 1000s of patients who will be asking for and undergoing surgery. Given the numbers of eligible patients and the geographic distances in Canada, this task of preparing and following patients for life cannot be performed by a handful of Centres of Excellence. This is particularly true for the adjustable gastric band, which while offering a simpler and safer surgical procedure, does require regular and ongoing adjustments to be fully effective.

If we hope to see the spectacular results from the published studies on bariatric surgery replicated in daily practice, we must start bringing primary care providers up to speed on counseling, preparing and following their patients.

Ignoring this task will leave 1000s of Canadians stranded post-surgery with nowhere to go when things go wrong.

Obesity surgery is NOT just about surgery.

AMS

At the 1st National Summit on Weight Bias and Discrimination organized by the Canadian Obesity Network in Toronto almost exactly a year ago, I learnt that weight-based bullying is one of the most common and pervasive forms of bullying experience by children and youth.

This topic is further examined by Obesity Network Bootcamper Atif Kukaswadia and colleagues from Queens University, Kingston, Ontario in a paper just published in OBESITY FACTS.

The researchers report on their findings in a longitudinal analysis of the Health Behaviour in School-Age Children Survey conducted in 2006 and then again in 2007, which included 1,738 youths from 17 Ontario high schools.

Based on self-reports, excess adiposity preceded bullying involvement and obese and overweight males reported 2-fold increases in both physical and relational victimization, while obese females reported 3-fold increases in perpetration of relational bullying over the observation period.

In addition, among those free of bullying at baseline (2006), significant increases in perpetration of relational bullying were reported by obese females in 2007 relative to normal-weight females (14.8 vs. 3.8% among normal-weight girls).

These findings support previous findings on the increased risk for bullying faced by overweight and obese youth and certainly suggest that this problem, if anything, is getting worse.

Given the many deleterious (and often lasting) effects of bullying on mental and physical health, this issue is certainly something that should concern us all.

Thus, it is certainly not surprising that one of the strategic priorities identified at CON’s Weight-Bias Summit was to “address weight-bias and discrimination in education settings”.

A full report of the Summit is available here.

AMS
Edmonton, Alberta

Kukaswadia A, Craig W, Janssen I, & Pickett W (2011). Obesity as a determinant of two forms of bullying in ontario youth: a short report. Obesity facts, 4 (6), 469-72 PMID: 22248998

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In a follow up to yesterday’s post on why parents are often reluctant to seek professional help to deal with their kid’s excess weight, I want to draw my readers’ attention to an article by Jillon Vander Wal and Elisha Mitchell from Saint Louis University, MO, just published in Pediatric Clinics of North America.

The paper gives a succinct overview of the many psychological and behavioural problems that can be associated with excess weight (or weight gain) in kids and adolescents: body dissatisfaction, symptoms of depression, loss-of-control eating, unhealthy and extreme weight control behaviors, impaired social relationships, obesity stigma, and decreased health-related quality of life.

The authors note the importance of recognizing and addressing psychosocial issues in overweight kids – they point out that:

“ecological models that take into consideration individual, psychosocial, physical, and macrolevel environments are best suited for understanding the associations between child obesity and psychosocial difficulties”

They discuss how such approaches can be important determinants of successful interventions:

“Consistent with the bioecological theory, these interventions addressed the more immediate family social context, but also the broader peer environment. These findings highlight the importance of addressing these issues before the initiation of weight loss treatment or, at the very least, concurrently. The addition of social facilitation and skills building may prove to be a core improvement to lifestyle intervention programs.”

While noting that:

“The topics of weight and mental health issues must be approached with care and consideration.”

the authors also point out that:

“Physicians must objectively evaluate psychological complications among overweight youth and not assume maladjustment.”

A number of non-threatening and non-judgemental ‘conversation starters’ for assessing mental health concerns are suggested (e.g. Does your child express concerns regarding appearance?, Does your child worry a lot?).

The paper also provides practitioners with a list of standardized and validated assessment tools that can help explore a wide range of important dimensions like emotional functioning, physical functioning, teasing/marginalization, positive social attributes, mealtime challenges, and school functioning (e.g. Sizing Me Up).

As the authors point out:

“More comprehensive screenings for high-risk populations are also available and should be used by appropriately trained professionals, preferably in multidisciplinary treatment settings. These tools are most applicable for high-risk children, such as children with BMIs of 40 or greater or for youth presenting for professional weight loss services.“

Ideally, if significant psychosocial concerns are identified, the family can be referred to an experienced psychologist for further consultation and management:

“Pediatricians may consider referral to psychologists who can assess for a broad range of physical and mental health conditions and aid in their treatment, as well as associated psychosocial difficulties.Further, psychologists can intervene from a systems-level approach to promote the individual, family, and social-level change needed to promote and maintain weight loss. A psychologist intervening at a systemic level works not only with the child, but with the child’s family to promote healthy eating practices, engage in opportunities for physical activity, and establish positive peer interactions at home, with external caretakers, in the child’s school, and in the surrounding community. “

As the authors conclude:

“Addressing psychological complications associated with pediatric obesity is an important component of treatment success.”

I would certainly like to hear from any of my readers, who have had positive and helpful interactions with health professionals regarding their kids’ excess weight.

AMS
Edmonton, Alberta

Vander Wal JS, & Mitchell ER (2011). Psychological complications of pediatric obesity. Pediatric clinics of North America, 58 (6), 1393-401 PMID: 22093858

I always thought that the three most important determinants of food choices for most people are taste, cost and convenience. (interestingly, health benefits feature much further down this list than most people think).

Now a fascinating article by Matthew Ruby and Steven Heine from the University of British Columbia, just published in APPETITE, suggests food choices also have to do with factors like virtue and masculinity.

In Western societies, people who chose to be vegetarian most often do so for reasons that are widely perceived as virtuous: concern for animal welfare, concern for the environment, and concern for health ( a fourth reason is disgust at the sensory qualities of meat – but this often develops after people have been vegetarian for a while). This raises the issue of whether or not vegetarians themselves are less tolerant of omnivorous diets.

But choosing to eat meat or go vegetarian may not just be about perceived morality or virtue. As the authors point out, in many societies, meat consumption is associated with manhood, power, and virility:

“In contemporary North American society, meat is often viewed as an archetypal food for men, with many men not considering a meal without meat to be a “real” meal, and the concept of the strong and hearty “meat and potatoes man” abounds.”

In their paper, the authors report the results of two studies that looked at people’s perceptions of others who follow omnivorous and vegetarian diets, controlling for the perceived healthiness of the diets in question.

In both studies, subjects were asked to rate targets who were presented in brief identical vignettes – the only differences being the targets’ reported dietary preferences, omnivorous or vegetarian – with regard to three scales: virtue, masculinity and health.

In both studies, omnivorous participants rated the vegetarian targets as significantly more virtuous and rated vegetarian men as less masculine. Ratings of female targets’ masculinity did not differ according to their dietary status.

Thus, the authors conclude:

“Taken together, the two studies support the notion that, above and beyond the previously found effects of diet healthiness, people infer a stronger sense of virtue and morality in those who abstain from eating meat. Especially for male targets, participants perceived vegetarians as less masculine than omnivores….Through purposefully abstaining from meat, a widely established symbol of power, status, and masculinity, it seems that the vegetarian man is perceived as more principled, but less manly, than his omnivorous counterpart.”

These findings may have important implications for dietary counseling. Thus, recommendations to reduce meat consumption (or even to just eat more vegetables) may be less likely to appeal to men, who may perceive this (or fear that others may perceive this) as a loss of masculinity and therefore socially unacceptable.

Indeed, I can easily picture the men, who would happily forgo taste, cost and convenience just to prove to themselves (and whoever else may care) that ‘real’ men eat meat.

On the other hand I can also see why the well-meaning dietary advise from the ‘holier-than-thou’ vegetarian may be ill received by individuals (not just men), who resent the moral and judgmental undertones implied in such advise (especially if it is unsolicited).

Suddenly, the title of Carol Adams’ seminal work, “The Sexual Politics of Meat”, makes so much more sense.

AMS
Edmonton, Alberta

Ruby MB, & Heine SJ (2011). Meat, morals, and masculinity. Appetite, 56 (2), 447-50 PMID: 21256169