Does the Focus on Obesity Prevention Promote Bias and Discrimination?Saturday, February 2, 2008
Imagine walking into an emergency room with chest pain and simply being sent away with a leaflet advising you to quit smoking.
Imagine arriving at a hospital with signs of stroke and simply being referred to a lecture on reducing sodium intake.
Imagine being diagnosed of colon cancer and just receiving well-meanining advise on the virtue of eating more fibre.
What is fundamentally wrong with the above scenarios? The simple fact that they are confusing prevention with treatment.
While giving up smoking, excessive salt and eating more fibre may be valuable in preventing heart disease, stroke and cancer, as treatments (at least in the short term) they are near to useless.
Once patients present with the disease, they need treatment.
This is not to say that lifestyle changes are not as important for secondary prevention – but they are rarely enough.
While many may agree with the above, they seem to have a hard time applying this knowledge to obesity.
While every politician, non-government organization and legions of health workers are campaigning for more efforts on preventing obesity, rarely do I hear the cry for more treatments – this is blatant discrimination!
When a quarter of the population or around 11,000,000 Canadians already have the “disease” focussing all available resources solely on prevention is a joke.
Not that efforts at prevention are not important – of course they are. Yet, even the most optimistic experts do not think that the current epidemic can be reversed in the forseeable future. It will take time to rebuild our cities, force people to abandon their cars, regulate our food chain, focus on calories and change our culture of overconsumption and sedentariness.
Even if any of these measures worked, no one expects them to have an immediate impact on those struggling with obesity today.
A 200 lb 17 year-old does not have 10 years to wait for “prevention” to kick in – he/she needs help today.
Even if treatment focussed only on providing minimal obesity treatments to those who most need them, i.e. those already experiencing the complications of diabetes, knee pain, sleep apnea, fatty livers, infertility – we would still need to provide obesity treatments for millions of Canadians.
Ignoring their plight and focussing all resources on “prevention” is not only demeaning and in-human, it also perpetuates the wide-held notion that obesity is entirely preventable and that anyone who has obesity has obviously “failed” at doing the right thing and therefore simply deserves no better.
The more we promote the idea that all it takes to prevent obesity is simply for individuals to eat less and move more – the more we can rest in our armchairs and blame people with obesity for just eating too much and not moving enough.
What message could be more powerful in cementing the already widespread bias and discrimination against individuals struggling with this condition?
Perhaps only worse is the message that anyone can become masters of their own weight if they only tried hard enough (as in Biggest Loser?). This idea is even more discriminating, because it implies that anyone who is too heavy is simply not making the effort.
All of this flies in the face of the fact that recidivism of obesity in our current obesogenic environment is almost 100%.
No matter how much weight people lose and irrespective of the weight-loss method (perhaps short of surgery) weight sooner or later comes back. In the exceptional few who do manage to keep the weight off, it remains nothing short of a daily obsession, where the slightest slip-up is punished with immediate weight re-gain.
Simply losing weight is not treatment for obesity – keeping it off is!
Continuing to channel all our efforts solely into prevention and ignoring the plight of the millions who have no where to turn for help except to commercial weight-loss scams is a direct reflection of and only promotes the bias and discrimination against people with obesity.
Fortunately, treating obesity is not more difficult or even more expensive than dealing with other chronic conditions – but it does require at least the same attention and commitment of resources as we devote to other chronic diseases. Not providing treatment is perhaps only a reflection of the bias and discrimination towards people struggling with this condition (they deserve no better!).
We cannot afford to simply write off a quarter of all Canadians. Health ministers, health authorities, NGOs and health professionals now have to step up to the plate!
Tuesday, February 5, 2008
I agree with Dr. Sharma that patients suffering from obesity face tremendous stigma. In many peoples’ minds (including health professionals), obesity is seen as a self-inflicted disease. This idea has been and continues to be reinforced by politicians, researchers, and health professionals advocating for prevention programs focused on lifestyle changes. This narrow perspective of health is convenient for politicians as the can commit very little money to “prevention” programs that put most of the responsibility on individuals. Obesity prevention, in politicians’ minds, is about lifestyle modification (i.e. trying to change peoples’ behaviours). But, many of these prevention programs have not been successful because the fail to consider peoples’ day-to-day contexts or environments (physical and social).
Obesity is a complex disease that can be linked to many determining factors, not just lifestyle. Dr. Sharma has discussed this in his blog before and has even made the link between obesity and globalization. I believe we need both prevention and treatment programs. However, we need prevention programs that are situated within a person’s or community’s reality and go beyond individual behavior modification theory. Yes, it will take time, as Dr. Sharma, points out to make systemic changes. But, governments and non-government organizations have only recently begun to invest in more long term and ecological prevention programs.
In a study comparing spending priorities for health care in six middle-income countries, researchers found that the strongest and most consistently shared value across countries was a general preference for prevention over treatment (Alkeld G, Henry D, Hill S, Lang D, Freemantle N, et al., 2007). This finding, is at odds with the actual spending priorities in most OECD countries, where on average only 2.8% of total health expenditure is spent on organized public and private prevention programs.
I agree with Dr. Sharma that we need to develop treatment programs for patients suffering from obesity. But, we also need more prevention programs that are situated in real life. Surely, spending a bit more than 2.8% of the total health care budget on prevention (not lifestyle programs) is not too much to ask.
Monday, December 22, 2008
Unfortunately (at least in Australia) prevention programs for overweight and obesity are having the opposite effect to that which they were designed for. Apparently they merely make people feel guilty for not being more healthy, or for being overweight, and, particularly in school populations where the messages flow thickest and fastest, are associated with a strong rise in childhood eating disorders, which most clinicians working in the area know to have a +64% mortality rate.
This data has been available for over 2 years now, but the government-funded health messages and programs run on regardless.
I don’t think that those well-meaning but misguided folk who are planning and executing these programs are going to deliver us from the obesity epidemic. So I don’t see the wisdom in giving them a bigger budget. I think we’d be better off stripping them of 100% of their funding, and redirecting it as refunds to families who play sport or regularly engage in socialised physical activity.
In the absence of effective non-drug, non-surgical treatment, I’d be inclined to agree with Dr Sharma that weight loss is a medical issue. But the fact is that there are at least some programs out there that are effective when it comes to creating intrinsic behavioural change that leads to weight normalisation. I know at least 2, myself being one of them, and Tapas Fleming in the US (sponsored by the Kaiser Foundation) and I have no reason to believe there are not a lot more.
What I do vehemently protest are cases such as gastric banding in children, when this could be viewed as medicalising a child instead of treating the parental abuse/neglect, and/or removing the child from an environment which is killing him/her.
I believe we can reverse rates of overweight and obesity, but that it would be counter-productive and dangerous to move too quickly to prescribe medical treatments for people suffering these conditions.