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Is Obesity the Worst “Choice” a Person Can Make?
I am guessing that by now, everyone on this planet has probably watched the video of US TV anchor Jennifer Livingston, who delivered a sincere and well thought trough ‘comeback’ to an e-mail taunter, who declared that she was a bad model for viewers because, “Obesity is one of the worst choices a person can make and one of the most dangerous habits to maintain“. While the public discourse and the world-wide media coverage of this issue has gone off on some interesting tangents (like for e.g. whether or not this e-mail actually constituted ‘bullying’ or was merely stating the facts), the immense outpouring of support that Livingston received may be a first indication that the tide on what is acceptable behaviour towards larger people may indeed be turning. Interestingly enough, the statement that obesity is a ‘choice’, implying that the opposite is also true and that anyone can ‘choose’ not to be fat, remains a widely held notion. Irrespective of the fact, that the vast majority of people who ‘choose’ to lose some weight, actually end up putting it back on (and more), the belief that anyone can lose weight and keep it off if only they ‘choose’ to do so is prevalent even among people who have been battling their weight all their lives. Thus, many of my patients blame themselves for their excess weight and blame themselves for not trying hard enough or failing again. It is one thing for the non-obese public to think of obesity as a self-inflicted matter of choice, It is something else entirely, for someone, who has already spent enormous time and effort on losing weight (over and over again?) to blame themselves for failing to make the right ‘choice’. As health professionals, the one thing we can certainly acknowledge to our patients is that managing weight is anything but easy. Any health professional, who still tells their clients that managing weight is as simple as eating less and moving more (ELMM), has not yet grasped the very fundamentals of human biology. Take someone with a genetic predisposition (i.e. the majority of us) and throw them into an environment of stress, sleep deprivation, sedentary jobs, hour-long commutes, abundant and omnipresent energy dense foods, unhealthy body-image promoting media, and obesogenic medications and I’d be surprised if they did NOT gain weight! And remember, weight has never been a good measure of health or… Read More »
How To Discuss Weight With Your Patient
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 Sep 16, 2011: One of the reasons that many health professionals do not bring up the issue or weight, is simply because they feel uncomfortable doing it. So what is the best strategy and what does the research on this issue actually show? This topic is a significant part of a new Scientific Statement From the American Heart Association, endorsed by the Society of Behavioral Medicine, published in the latest issue of Circulation. Based on a systematic search of the literature on this topic (published between 2002 and 201), it is clear that patients describe a need for empathy, nonjudgmental interactions, and specific personalized recommendations. As regular readers will recall, this is actually rule 1 of my 10 tips for family docs, and if nothing else, this is the only rule that all health professionals should adhere to – always! While some patients associate even the word “obese” with discrimination, patients rate “‘weight” as the most desirable term, and “fatness” as the most undesirable term. In my practice, I often also use the terms ‘large’, ‘size’, or ‘big’ and have never had a negative response – much of how you use the language is determined by the general ‘non-judgemental’ manner in which the words are used. When I do use the term ‘obese’, I generally explain that I am using this ‘clinically’ as the ‘medical’ definition. “Patients also express a preference for clinicians taking time to deliver weight loss counseling, rather than offering weight loss advice as an afterthought as they leave the room.” “The importance of verbally recognizing patients’ small weight losses as well as their unsuccessful weight management efforts was also noted, because nonrecognition by providers was seen as a judgment that the patient did not care or was not making an effort toward weight loss.” I generally do acknowledge changes in weight, but do not make them the topic of discussion unless I am specifically asked. Any comment would always be objective, non-judgemental and generally encouraging, no matter what – even a small weight gain could be worse! When the patient brings up and insists on discussing the weight – this is always a good opportunity to explain (once again) that obesity management is not about… Read More »
Does Not ‘Medicalizing’ Obesity Promote Weight Bias and Discrimination?
Yesterday, in Ottawa, I participated in a Café Scientifique discussion about whether or not obesity is a disease, which naturally also touched on the issue of whether or not obesity needs to be medicalised. My co-discussant was Jacqui Gingras, Associate Professor at Ryerson University’s School of Nutrition in Toronto. The discussion was elegantly moderated by Mark Tremblay, Director of the Active Healthy Living and Obesity Research Group, at the Children’s Hospital of Eastern Ontario. While there was no disagreement that excess body fat can indeed pose a health problem as well as no disagreement that the current definition of obesity, based on simple measures of height and weight, is clinically meaningless (as it does not discriminate between those for whom ‘excess’ body fat is indeed a health problem from those for whom it is not), there were nevertheless differences of opinion on whether or not ‘medicalising’ obesity would be helpful. Although I am the first to agree that health cannot be determined by simply stepping on a scale, it is exactly because things are not that simple, that it does take a trained and knowledgeable health professional to determine for whom excess body fat is a disease and for whom it is not. Indeed, I am fully aware that it often takes extensive medical knowledge and understanding of the rather complex socio-psycho-biology of weight gain as well as clinical skills, experience, and judgement in its assessment, to decide, when the accumulation of body fat poses a health risk and when it does not. This, interestingly, is no different from the many clinical decisions that health professionals deal with every day. Indeed, figuring out exactly in which cases a symptom, a clinical sign, or the result of a diagnostic test is an indicator of ill-health and in which cases it is merely a harmless ‘norm-variant’, is what makes the practice of medicine so interesting (and complicated). If diagnosing a ‘disease’ was as easy as taking out a measuring tape or ticking off lab values, then anyone could do it. Indeed, to take specific examples, deciding when a wave on your ECG is a sign of underlying heart disease and when it is not, or when a mole on your skin is a precancerous growth and when it is not, is exactly what doctors go to medical school to learn. It is exactly because we do not exclusively leave the diagnosis of… Read More »
Will Losing Weight Make You Sick?
One of the intriguing (some would say frustrating) aspects of analysing large datasets is that this often raises more questions than it answers. This is certainly the case with one of the studies on the Edmonton Obesity Staging System, published in Applied Physiology, Nutrition and Metabolism this week. The paper looked at data from the Aerobics Center Longitudinal Study, a cohort of over 29,000 participants who attended the Cooper Clinic (Dallas, TX) for periodic self- or physician referred medical examinations between 1987 and 2001. Of these, 5,453 men and 771 women both the met the BMI criteria for obesity and had enough information available to allow EOSS grading. As reported before, irrespective of BMI, EOSS stage 0 and 1 participants had no significant impact on their risk of mortality over 16 years, which, however, was higher in EOSS stage 2 and stage 3 participants. So, if not body weight (or BMI), what exactly were some of the characteristics of individuals with higher EOSS stages? It turns out that apart from (as one may expect) the fact that individuals with lower EOSS stages reported eating more fruit and vegetables and had higher cardiorespiratory fitness (as an indicator that they were clearly more physically active), they were also less likely to have a history of weight cycling. Indeed, lower EOSS stages were associated both with less lifetime weight loss as well as fewer (or no) episodes of prior weight loss. This certainly poses the question, whether dieting or losing weight in fact increases the long-term risk of health problems and one can only wonder if the folks with higher EOSS scores would be better off had they never lost weight before. Now, obviously, this association (as all associations) does not prove causality. It could well be that people who already have health problems may be more likely to engage in (or remember) previous weight loss attempts. It may also be that worth noting that people who tend to engage in weight loss are the ones who often have significant body image and body dissatisfaction issues, as well as a generally higher prevalence of psychiatric illnesses than people who do not diet or lose weight. As psychiatric and mental health are part of the EOSS criteria, it may well be that this alone accounts for the association of yo-yo dieting and elevated EOSS stages. Or, as we discuss in the paper: “…for the… Read More »
Will Losing Weight Make You Less Depressed?
Regular readers will appreciate the importance of mood as a driver of ingestive behaviour. While typically depression is associated with a loss of appetite, atypical depression can lead to increased cravings for “comfort” foods, especially those high in sugar and fat. Depression is also well recognized as a major barrier to weight loss in that individuals with depression will appear less motivated, report lower energy levels, and have poor sleep patterns, all of which can in turn affect diet and physical activity. So while depression can clearly drive weight gain and make weight management more challenging, a question often asked is whether weight loss will actually improve mood. This question was now addressed by Anthony Fabricatore and colleagues from the University of Pennsylvania in a paper just published in the International Journal of Obesity. The authors conducted a comprehensive meta-analyses of over 5971 articles, including 394 randomized controlled trials, regarding the relationship between weight loss and depression. Thirty-one studies, in almost 8000 participants were included in the final analysis. Comprehensive lifestyle modification was found to be superior for reducing symptoms of depression than control and non-dieting interventions. Lifestyle modification was also marginally better in improving mood than dietary counseling or exercise-alone programs. Of particular note (given my recent post on the nutritive benefits of exercise), exercise-alone programs were superior to control interventsions in reducing symptoms of depression. Nearly all active interventions improved depression but there was no relationship between the amount of weight lost and the reduction in depression symptoms. Health at every size (HAES) enthusiasts will likely argue that the improvement in mood has more to do with the active interventions (which include eating healthier and increasing physical activity) than with the actual weight lost – something that would be hard to argue with given that the amount of weight lost appears to have little impact on the actual improvement in mood. Thus, rather than concluding that weight loss leads to an improvement in mood, it would perhaps be more accurate to conclude that lifestyle modifications AIMED at weight loss ALSO, on average, tend to improve mood. This of course would not be hard to believe given the evidence that both dietary intake of certain (unhealthy) nutrients as well as increased physical activity can significantly decrease symptoms of depression. Certainly, this study does not change my opinion that in many patients mood disorders need to be identified and addressed… Read More »
