Embracing Diversity of Opinion
Tuesday, May 10, 2011
After a short week of recovering from the National Obesity Summit, I very much enjoyed the many passionate and provocative comments to yesterday’s tongue-in-cheek post – I am grateful for all responses and there’s nothing like passion and discourse to keep things interesting.
As far as diversity of opinions is concerned, there was certainly no shortage of that at the Summit. Whether this was in the ‘building trust’ workshop where participants vehemently and decidedly agreed to completely disagree (I recall the odd shouting match or two), to the full-day workshop of the Québec Charter for a Healthy and Diverse Body Image, that featured speakers like Gail McVey, one of Canada’s leading researchers on the negative impact of unhealthy size obsession on body image and eating behaviours, which certainly provided a very different view of the obesity problem and possible solutions to Summit attendees.
It is also the only obesity conference that I have ever been to, where the booths of the Public Health Agency of Canada and Québec’s Coalition Poids were right besides booths displaying the latest in bariatric surgical technology.
But if that is not enough evidence of diversity, I strongly recommend reading this TweetReach Report, which summarizes the almost 500 tweets that reached almost 80,000 people for a total of 350,000 impressions.
This is what I call fostering diversity and dialogue.
I am with Edward de Bono on this one: “Argument is meant to reveal the truth, not to create it.”
Or, as a management pundit once told me – if two members on your team completely agree on everything, it’s time to fire one of them!
AMS
Edmonton, Alberta
Tuesday, May 10, 2011
I remember on the playground a little girl saying, “you’re fat! Just kidding.” (So, that made it okay to say it, right?) My nicknames were Sappo and Sappopotamus. But, hey, they were just kidding, so it was okay, right?
Were you “just kidding” on “obesity deniers”? Did you see how many people jumped on the bandwagon to support that kind of bigotry? What part of your post, exactly, was tongue in cheek? I think we need a little more explanation.
Tuesday, May 10, 2011
Ok, I’m just catching up on the posts and comments from last week. I definitely feel like I’m not a black and white person…I am a continuous learner and proponent of critical thinking and always try to see things from another person’s perspective. As a dietitian I was educated on the traditional medical model of obesity/weight loss but have been learning about HAES for the past few years and am trying to sort out where I stand on all of this…I don’t like to think that I have to be firmly in one camp or another…I hate the “we’re right and you’re wrong” mentality…I typically dislike ‘fundamentalists’ of any topic.
The biggest thing that stood out for me in the discourse between L. Bacon and Dr. Sharma was Dr. Sharma’s comments about his patients that ‘cannot breathe, move, put on their shoes, clean themselves…” and that this is true of “1000’s of Canadians”. First, if this is the typical patient you see every day, your view point will be much different than the ‘catagorized as obese by BMI’ person who is still healthy and lives a good life in a large body. Obviously, this ‘extreme’ patient is suffering and their weight is decreasing their quality of life.
The fact that Dr. Sharma refers to 1000’s of patients says to me that he recognizes that the number of people suffering from this extreme situation is a tiny fraction of the Canadian population (which the first hit on google tells me that in 2009 was over 33 million…do the math, my calculator doesn’t have enough digits to even calculate the tiny fraction of the population that this represents) much different than the “50% of the Canadian population suffering from the obesity epidemic” that is reported in the media and by other mainstream health care professionals.
From the discourse I’ve read here, it seems that some of the HAES proponents need to be a bit more open minded about the treatment of these extreme patients who’s weight really seems to be causing them to suffer. I also think that Dr. Sharma needs to focus more on the fact that this sort of suffering is only seen in a tiny fraction of Canadians and that for most of us, a weight neutral approach to health care needs to be advocated for strongly. It is not clear if his 10 points in the original blog post last week were meant for these extreme patients, or for the generally defined ‘obese BMI’ population…clarifying this would help us all understand his intentions better. I also think he needs to understand the HAES approach a bit better…as I am sure no one having this debate thinks that a diabetic should ignore their diabetes/HgA1C numbers…if you have a disease/medical condition, you need to address it…I think this is a source of common ground for everyone here!
Semantics, implied connotations, and passionate feelings in the heat of the moment aside, I think the views of everyone here are more alike than not and certainly far from being on opposite sides of the spectrum.
Tuesday, May 10, 2011
I recently read a book by Carol Tavris and Elliott Aronson entitled “Mistakes Were Made, But Not By Me: Why we justify fooish beliefs, bad decisions and hurtful acts”. This fascinating book is about cognitive dissonance and it chronicles how once we have made a decision and acted in a particular way, we become more attached to the rightness of that decision or way of thinking. In fact, we tend to become more polarized in our opinions over time, even in the face of mounting evidence that our opinion may be wrong. When I listened to the viewpoints of various people at the obesity summit, or even when I listen to my colleagues, I am struck by how hard it is to let go of entrenched beliefs. This of course is no easier for me than others just because I have read the book, by the way.
I think the biggest hurdle we currently face in addressing what needs to be done is the belief that obesity is caused by individuals choosing the wrong food or action (inactivity). While it isn’t untrue that we make choices everyday about what we will eat or what we will do with our bodies, there are many factors that dictate what those choices can be in the context of our lives. As an example, I could say I would like to eat 14 varieties of broccoli this month, but the reality if that there really is only 1 variety in the grocery stores to choose from and that has been dictated by a retailer who wants a certain specification for colour, size, shipping capability, etc. My choice, therefore, is limited to what is available, as is the farmers’ choice about what to grow. This only makes sense but what about thinking about the ways the system might need to change so that my choices and the farmers can be different.
In the motivational interviewing model of working with patients, one of the strategies is actually to foster dissonance and challenge a person’s many conflicting truths. How do we do this on a larger scale? How do we take obesity out of the realm of “blame the victim” and recontextualize it as ‘in what ways is it difficult for all of us, not just the obese, to eat healthy food and live healthy lives”. I would like to see a reframing of obesity as a self inflicted lack of “choosing well” to seeing it as a red flag being waved by the most vulnerable in our society about how difficult it is for most of us and them to live a healthy life because of how various systems are structured. These systems include how we farm, how we compensate farmers, the role of trade, the role of subsidies, how retailers specify what will be sold to end users, how food is wasted (see the movie Taste the Waste), what we pay for food, how we reward people in daily life, how we celebrate, what normal eating is, what acceptable levels of advertising (if any) are, etc., etc.
Tuesday, May 10, 2011
In 1991, I travelled through much of Canada with a federally appointed panel on violence against women. By the time I got home from the first leg of the trip, which lasted ten days and took us on a whirlwind tour from Manitoba to B.C., I felt like all men were violent and abusive, and as a woman, I was constantly at risk and could never trust a man–any man–again. Even though, thank goodness, I myself had never suffered abuse at the hands of a man, I think that hearing horror stories, day after day, gave me a little window into what it means to suffer from post-traumatic stress disorder.
Might I humbly venture, Dr. Sharma, that that is how you view obesity: a never-ending stream of people literally crushed under the weight of their fat, risking amputation from hard-to-control diabetes, cardiac arrest from an overtaxed heart, death in the night from sleep apnea. I do not deny what you see, just as I could not deny what I saw and heard from women whose stories of horrific abuse remain with me still twenty years later.
However, your view of obesity is, as Pat points out, only one part of the truth. Much more of the truth is infinitely harder to deal with. And with our society-wide witch hunt against those whose BMI does not sit comfortably below 24.9, we are adding to the problem, not solving it.
I am appalled at your facile treatment of HAES. You mention a patient in her twenties who is gaining 40 pounds a year. No sane person, and certainly not someone who has given any thought and reflection to the principles of HAES, would send her off with a “prescription” for fruit and veg, a walk around the block, and listening to her hunger signals. Why did you not tell us what kind of investigation you did to determine the cause of this significant weight gain? Is she suffering from PCOS? Was she sexually abused as a child (an oft-cited reason for morbid obesity in women)? Does she go on drastic, starvation diets and then fall off the wagon (as any normal human being would do.)?
It’s so hard for doctors–who must be absolutely sure of their abilities and beliefs in order to practice their profession (I certainly wouldn’t want a surgeon who’s not sure of her abilities cutting into me!)–to admit how little they actually know about effective treatments for certain conditions–especially if the treatment might actually be exacerbating what was originally not really a problem or medical condition in the first place.
While I would not presume to advise you on how to treat a full-blown case of diabetes, I will presume to say that if more medical practitioners used HAES principles as their first line of attack (though I don’t like this bellicose imagery), you would have a lot fewer cases to treat. “Unfortunately”, we would probably also see a lot more body diversity among healthy people in society as a whole.
Tuesday, May 10, 2011
Actually, my BMI is 57, and I don’t have any trouble wiping my ass, taking a shower and washing all parts of my body, or any other thing that needs to be done to keep myself clean – and I don’t need any help to do this, I do it by myself. I’m in that minuscule percentage of super-morbidly obese people who would be recommended to have WLS simply because I have mobility issues. Guess what? I’ve already had WLS and it failed, spectacularly. It made me fatter than I was before I had it, just like every diet I ever went on did, and just like every diet drug I ever tried did (phen-fen anyone?). I would have been much better off if all those doctors/NPs had recommended HAES instead, since the only problems I had were mobility issues – I’ve never had a problem with my blood pressure, blood sugar, or cholesterol. But being fat caused all my mobility issues according to them and they’ve refused to look for any other reasons, it’s my fat, pure and simple. The older I get, the worse the mobility issues get, and now, on top of those issues, I have all the complications from WLS, and those are no picnic, I can tell you. I wish to heaven I had told my NP to get stuffed when she recommended WLS and that I had never had it, and that I had fired her and looked for a fat-friendly doctor. Because right now, I don’t have a doctor, my last one was another “your fat is the only problem you have, it’s calories in/out, visit the Nightmare on ELMM Street and you too can be thin for life” and I fired her for refusing to look beyond my fat for the root of my problems. This is why fat people have bad outcomes – we get fed up with being told our fat is the problem and doctors refusing to treat us as anything other than our fat. We don’t see a doctor until we’re so sick that we don’t have a choice, it’s see a doctor or a die – and it’s the fault of fat-phobic doctors, who are in the majority.
Your piece yesterday didn’t come off as in tongue-in-cheek, it came off as holier-than-thou and paternalistic, and to tell you the truth, I’ve heard enough of that in the last 30 years to last me the rest of my life. I’m sick and tired of having my issues blamed on my fat and being given no options other than lose weight. I’ve done everything I can to lose weight, and I’ve lost hundreds of pounds over the course of 30 years, but it keeps coming back and bring friends with it. There’s a time to say “enough is enough, I’m done with the insanity of this” and there has to be a better way. You sure as hell don’t seem to have it, not from what I’ve seen on here, pardon my bitterness.
Wednesday, May 11, 2011
NewMe, you raise a good point, and one that’s been on my mind as well. Dr. Sharma and his colleagues are constantly exposed to fat people who have thrown themselves onto the mercy of the medical establish, often for decades. These people will have gained weight with every weight loss attempt. They will have a low muscle percentage from all the weight cycling. They’ll have lost track of hunger and satiety cues, and they’ll be so used to starving that physical activity will always feel like a punishment. They’ll be desperate for help, and they’ll be blaming the way they feel on their weight.
This is all the more reason why Dr. Sharma and his colleagues should listen to us. We’re speaking for a lot of people who have been categorized as “obese” (perhaps even the majority) – people who Dr. Sharma and his colleagues normally do not get a chance to interact with. Many of us avoid doctors unless we absolutely need to see one, due to weight bias in the medical profession. Others go in for regular checkups. For the most part, we lead normal, happy lives. Some of us are perfectly healthy, and others have health issues that require a bit of management (just as anyone might).
For the most part, I suspect that we’re better off than the people who have thrown themselves at the mercy of the medical profession. And, that’s got to be a tough thing to hear if you’re a bariatric doctor; that you may be doing more harm than good, even though you have the best intentions. But, I think that the anti-obesity establishment should listen to us, because what we have to say is important. We’re the people who don’t seek them out; who manage our own health, and they could learn a lot from us.
Thursday, May 12, 2011
For the people who put a “thumbs down” on my comment: I wore a size 20 when I was 11 and was one of the three fattest kids in my high school graduating class of 400; I weighed between 180 and 215 pounds as a teenager at 5′-4″.
At 41 years old, I’m still the same size I was in high school, that is, I wear a US 16W or a British size 20. I don’t have diabetes or high blood pressure, and my HDL/LDL ratio is good. My body fat percentage tracks my BMI pretty closely. That is, I’m not a body builder-type, but I’m in reasonable shape. I’ve been physically active all my life and haven’t allowed my weight to be a barrier to anything I’ve wanted to do.
Do you have a patient (or know of anyone) who was as heavy as I was as a teenager who isn’t any bigger as a middle-aged adult? All I did was ignore my weight and live my life the same way I would have if I’d been thin. Refusing to regard my weight as a problem has been both psychologically and physically advantageous for me. It wasn’t a decision that I made without a lot of consideration. I’d seen people in my parent’s generation yo-yoing upward in weight over the years and I consciously decided that I’d rather not risk that. It worked out exactly as I’d expected.
DebraSY has kept 60 pounds off for 8 years (I believe – it could be longer) through being hyper-vigilant about what she eats and how much she exercises. How many people do you know who have kept off that much weight for that long?
How many of your patients have been as successful at weight loss maintenance as DebraSY? How many of your patients have been as successful at weight management as I’ve been (even though I don’t call it that)? Do you really think that we’re not worth listening to?