body image · equality · fitness · inclusiveness · Martha's Musings · stereotypes · training · weight stigma

Weight bias and obesity interventions: no easy answers

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A person wearing a black swim dress and pink flip flops gets ready to swim.

By MarthaFitat55

A while ago I had reason to consult with an anaesthetist. We went through the risk assessment and had a chat. The clinic nurse had told me the team might have some questions because of my weight.

Fair enough. I could hardly fault them given what’s involved in going under, so to speak. But I was cautious because context is so often missing when numbers are thrown around, especially numbers relating to the Body Mass Index (BMI).

According to that scale, one originally developed by insurance companies, I am obese. Anaesthetists aren’t fond of having to deal with obese people. So we had a chat and it was actually quite good.

Here’s the thing: I eat reasonably well, with almost all the required fruits and veggies, high fibre foods, lower fat choices, more fish and legumes, and less red meat and alcohol, our health system deems the better diet to follow.

I’m also pretty active. At the time of the chat, I was weight training twice a week, swimming two to three times a week, taking a trail walk lasting more than an hour weekly, and looking to get my steps in on a daily basis.

The doctor asked me about the weight training, and I ran through the numbers: bench was around 48kg, deadlift was around 105kg, and squat was 97.5 kg. So those numbers tipped the deal. If I could do all that, then I wouldn’t have any trouble, they concluded.

It made me think though. For the past ten years, I have acted on the guideline about eating less junk and focusing more on whole foods while being more more mindful about how active I am.

Truth is, I’m not prepared to starve nor am I prepared to add any more hours of activity (in fact I am at or past the threshold for the recommended 150 to 300 minutes of moderate to vigorous activity per week already).

At the back of my mind, I always believe I should be able to do more, and yet I can’t. It bugs me when I hear facile comments repeated in every weight loss inspiration story shared by the media. We all make choices, but some times even the good choices don’t make that much difference.

When SamB shared an article about how such tag lines like “Eat less, move more” contribute to weight bias, I was intrigued.

And I felt vindicated. Despite all my efforts in the gym, in the kitchen and yes, in my own mind, when I ran up against health professionals, who looked at numbers like BMI as reliable indicators of health, I felt my work was not enough, nor good enough, to make the difference society expected in my body shape.

Nor am I the only one. Canadian Obesity Network researcher Ximena Ramos Salas looked at obesity prevention policies and messages. She tested the messages with people living with obesity and what she heard was illuminating.

The short form is those messages don’t work. They are neither helpful nor accurate.

“Saying obesity is simply an issue of diet and exercise trivializes the disease. It makes those living with obesity feel like it is a lifestyle or behavioural choice, and therefore their fault. This causes them to feel judged and shamed, and to internalize the stigma of weight bias.”

Ramos Salas also reported “People told me that the public health messages were not relevant to their experiences. They didn’t relate to the messaging, they felt it didn’t consider other factors that contribute to their obesity that are unique to them, like genetics, mental health, medications and so on. It did not reflect the challenges that they faced while trying to manage their weight on a daily basis.”

I think these are two useful insights that should get more attention. But the best message arising from the research Ramos Salas is engaged in is this: “Not everyone who is big has obesity. People come in different shapes and sizes, so the idea that we categorize people based on their size as ‘healthy’ or ‘unhealthy’ is not accurate.”

I was fortunate I met with a health professional who was open to hearing about my numbers intead of relying on a flawed indicator to make a decision about my health status. Too many people though do not and some actually close that door themselves because they are not confident they will get the care they need.

For me, my conversation with the anaesthetist helped validate my choices about the fitness path I am on even though assumptions about weight and health by others may have forced the issue. I may never meet the biased image for health and fitness such weight stigma imposes, but I know I am doing the best I can given my circumstances. To suggest otherwise is limiting and dismissive.

— Martha is a writer and powerlifter in St. John’s.

health · stereotypes · weight loss · weight stigma

6 things Sam hates about seeing doctors, as a larger person

None of this is true about my current set of health practitioners. But they took awhile to find. Right now I’m halfway between jobs and cities and I’m looking for a new family doctor to start. It’s tough. And here’s why!

1. They believe ridiculous things about me. See this article about doctors and bias against larger patient. “Much research has shown that clinicians have biases related to overweight and obesity, conditions that affect more than two-thirds of U.S. adults, Dr. Gudzune said. “[With] the magnitude of the effect of obesity in our country, a substantial number of people are experiencing health care disparities as a result,” she said. Studies have consistently shown that physicians associate obesity with such negative attributes as poor hygiene, nonadherence, hostility, and dishonesty, Dr. Gudzune said. “These types of attitudes are pervasive. It’s not just in the U.S. … [but] physicians across the world as well: Australian, Israeli, European physicians. … These attitudes have been documented as far back as 1969, and they continue to persist up until today,” she said. In surveys of primary care physicians, more than 50% view patients with obesity as awkward, unattractive, and ugly, Dr. Gudzune said. “They have less respect for patients with obesity. They also believe that heavier patients are less likely to follow medical advice, benefit from counseling, or adhere to medications, which are some of the things that are really critical in thinking about managing obesity,” she said. She added that these attitudes may extend to other health professionals, such as medical students, nurses, and nutritionists.” Not fun.

2. They prescribe weight loss for everything. The evidence bar is very low. If there’s even a small chance that weight makes a difference, they mention it.

3. They don’t believe my attempts at trying to lose weight. I just haven’t tried hard enough apparently. It’s as if once a have a serious medical reason, like putting off knee replacement surgery, I’ll snap to it, get down to business, and the pounds will just melt away.

4. They don’t have anything useful to say about how to lose weight. See this post on unwanted weight loss advice. “Why do doctors weigh patients and offer weight loss advice? Other than “eat less and move more” which is kind of like the weight loss equivalent of “buy low and sell high,” what recommendations do they make and why?”

5. But they recommend diets anyway even though the most likely outcome is that the patient weighs more at the end. In this post I wonder if doctors would do that with any other “likely to fail spectacularly” treatment. See Well intentioned lies, doctors, and the diet industry: If weight loss is impossible, ctors-and-the-diet-industry-if-weight-loss-impossible-then-what/

6. They never believe my blood pressure readings or my cholesterol levels. I’ve had a complete work up with a endocrinologist who gave me a clean bill of fat health but still, it’s an uphill battle being seen. See this post and this one.

I know Catherine and Nat have blogged here about issues with doctors. I often think, hey we’re all strong feminists with serious amounts of post secondary education and some good attitudes, we’re white, English speaking, able bodied, if we have problems with doctors what’s it like for other women who don’t share our bundle of privileges? If you’re a larger person, what’s the medical world like for you. We want to know.

fitness · weight stigma

Obese people? People with obesity? How about this: People.

Language matters. What words people use for us have lots of effects– they contribute to the way we see ourselves and also how others see us. In school, I was known as “that smart girl” in a way that was definitely not complimentary. It was as if that was the box I had to occupy, never to stray into other territory. Luckily, I got over this once I arrived at university, where being hailed as “smart” was definitely considered praise.

For people who are living with illness or disability, language does additional harm by burdening them with labels that identify them with the illness or disability they are dealing with in their lives. Calling someone sick, disabled, or other terms simplifies them by identifying them with one feature of their lives to the exclusion of all the complexity and richness of personhood.

Luckily, there’s a solution to this problem: we can use what’s called people-first language (see here for a good handout on how to shift from harmful to more accurate language).  Here’s what the organization The Arc has to say about it:

People-First Language emphasizes the person, not the disability. By placing the person first, the disability is no longer the primary, defining characteristic of an individual, but one of several aspects of the whole person. People-First Language is an objective way of acknowledging, communicating, and reporting on disabilities. It eliminates generalizations and stereotypes, by focusing on the person rather than the disability.

Disability is not the “problem.” For example, a person who wears glasses doesn’t say, “I have a problem seeing,” they say, “I wear/need glasses.” Similarly, a person who uses a wheelchair doesn’t say, “I have a problem walking,” they say, “I use/need a wheelchair.”

So what does this have to do with obesity? In a blogpost this week, James Fell reported that Obesity 2018 Canada has shifted to using people-first language when talking about people’s weight.  He says:

From a post by endocrinologist Dr. Sue Pedersen: “Obesity is a diagnosis, and not a way to describe a person. Thus, instead of the terminology ‘overweight or obese people’, the correct terminology is ‘people with overweight or obesity’. This is a critical step in breaking down the stigma against obesity!”

I thought “people with overweight” sounded a bit weird, but Yoni [Freedhof, obesity medicine physician and writer of this blog ]told me, “people with excess weight” could be an easier way to address that.

I have a bunch of responses to these developments. First, let me say that people-first language strikes me as respectful and indeed a necessary step in the direction of destigmatizing lots of diseases, conditions and modes in which people make their way through their lives.

That said, let me turn to its application to the terms “overweight” and “obese”. It’s true that both  the Canadian Medical Association and the American Medical Association having a BMI >30 as a disease (even though scientific and other subcommittees of the AMA recommended against this classification; see here for one such report). However, announcing that people with BMI >30 (the standard medical definition for obesity) have  a disease is both massively stigmatizing and arguably incorrect. Announcing that people with BMI >25 (the standard medical definition for overweight) have a disease is arguably absurd and definitely flies in the face of loads of evidence to the contrary.

I’m aware that what I’m saying is controversial.  I’m questioning whether all or most people with BMI>30 have a disease/are unhealthy. I think I’m on safer ground questioning whether all or most people with BMI>25 have a disease/are unhealthy.

So, if I’m right (which of course I think I am, and I have a gigantic bibliography of evidence available), then maybe the language we need is not people-first, but people-only.  Do we need these terms  “overweight” and “obesity” at all? If medicine needs precision, there are actual body weights and dimensions available for help in assessing someone’s health. And BMI can be calculated easily from those measurements using tables (I’m not linking to one, but you can find them anywhere). I don’t think these terms are helpful in medical contexts (I’m working on an article with a colleague– Hi Dan!–  on this now), and as general descriptors they are stigmatizing and shaming (and often an inaccurate way to convey information about a person).

If we want to describe someone’s dimensions, there are lots of words to use, including large, big,  fat, heavy, etc. These are descriptive words, and many people in fat acceptance movements embrace them. I just happen to think that obese and overweight aren’t helpful as descriptors. And I think that using the terms “people with obesity” or people with excess/over weight” is terrible– its strangeness calls attention to the person’s size, maybe also invites stigma, and presupposes something that I argue elsewhere is false. For more on this, you can look at this blog post. And when the article comes out, I’ll blog about it too.

So what do y’all think? Do you prefer “obese people”? “People with obesity”? Or maybe just using their names?

 

 

fitness · weight loss · weight stigma

Weight watchers is not kid stuff; what about other programs?

Since Weight Watches announced its program targeting teenagers, there’s been a flurry of posts here, chock-full of information and perspective.

One of Sam’s recent posts has (among other things) pointed to research on fat shaming. There are severely harmful physical and psychological effects of identifying children as fat (calling them fat or overweight, treating them as fat, subjecting them to dieting, etc.)   Enrolling a child in Weight Watchers is a guaranteed way to label them as fat.

While we’re talking about studies, the data on the long-term effectiveness of Weight Watchers (or any commercial diet program) is not promising.  A 2015 systematic review  of commercial diet programs suggests that, in the very short term (3-12 months, mostly 3—6 months), Weight Watchers might produce a slightly higher incidence of >5% body weight loss in some populations (all adult) than self-directed dieting, but in the longer term (>12 months), we either have no data, or the data show weight regains (and then some).

Tracy’s post on dieting and magical thinking really gets at the psychological pitfalls of yearning for some way to transform our and our children’s bodies into shapes and sizes that conform to medical guidelines and BMI charts.  It’s an illusion, one that does us and our children much harm.

So, taking Sam’s challenge to heart—if not weight watchers for children, then what?—I decided to look around town to see what programs were on offer.

As some of you know, I live in Boston, which is a very good place to be sick; we have highly-rated hospitals to treat whatever ails you.  I found out from my friend Janet, who’s a health care provider, about the Optimal Weight for Life program at Children’s Hospital.  It’s associated with (and I assume partly funded by) New Balance  (the athletic shoe manufacturer), which has a named Obesity Prevention Center and also sponsors the OWL program at Boston area community health centers.

The OWL program is for families who are worried about their children’s weight and risks for type 2 diabetes, or who have children with type 2 diabetes.  After doing a bunch of medical tests, the treatment services focus on nutritional counseling and individual behavior modification.  Some group therapy is offered, and follow up is required for at least 6 months.  They tend to favor a low-glycemic index diet (one of their directors is David Ludwig, who leads research investigating and has written popular books promoting low-glycemic index diets; look here  for research and here for popular books).

I have to say, I really like the approach they use in the OWL programs at community health centers.  Here’s what they do:

10-week comprehensive program that introduces families to healthful eating and supports them in making changes to benefit their entire family.  The program offers group and individual counseling and is led by a dietitian and psychologist from the OWL clinic.  Group discussions and interactive activities allow for peer support, skill building and knowledge sharing. 

The first six weeks are spent in a group format.  For the groups, parents and youth are separated and both groups discuss the same educational topic.  Following the educational intervention, the groups unite for a healthy meal and a question and answer session.  Each class concludes with a hands-on activity to reinforce the main messages.  Upon completion of the groups participants attend 2-4 weeks of individual counseling with the dietitian and psychologist to develop behavior change strategies to support individual goals. 

Through the program, patients learn:

  • How to shop for and prepare balanced meals and snacks
  • How sleep and screen time impact health
  • How small changes can be implemented to benefit the entire family
  • How to address body image and bullying

All of this sounds reasonable, comprehensive and evidence-based.  By the way, what’s good for the goslings is also good for those of us on the spectrum from geese to ganders—that is, adults can also use support around shopping, screens, sleep, small changes, body images and fat shaming/bullying/harassment.

But I don’t like the name of the program—Optimal Weight for Life.  Yeah, it’s cool to have OWL as your acronym.  You could give away T-shirts with owls on them, or maybe even have an owl-petting room at the hospital.  It’s already been done in Japan at this café, and I hear it’s popular.

Here are my three problems with the name OWL– Optimal Weight for Life:

1.Optimal.  Why do we have to be optimal? That’s a pretty high bar to set.  There are lots of reasons and causes for a child to be of non-optimal weight.  Maybe it’s not an optimal time in a kid’s development to be optimal.  I’m not a parent, but I have observed my niece’s and nephews’ growth patterns over time, and their sizes and shapes and heights don’t increase in perfect synchrony. It’s just not the way human growth works (as Sam pointed out about her own kids). Sometimes they are shorter and wider, and sometimes longer and narrower, and this varies over time and across people.

Also, who says that optimality should be the goal?  We know from epidemiological studies (and by looking around in the world) that there’s a range of body weights, shapes, sizes, influenced by a host of factors, many of which we have no control over.  What makes “optimal” optimal is presumably association of a class of body weights with lowered risk factors for disease; otherwise, this is just a matter of aesthetics/conventions, right?  When we dive deep into that data vortex, I argue that, given both the intractability of long-term weight loss and the small or nonexistent shifts in relative risk profiles that come with some weight changes, setting “optimal” weight as a general patient goal is both unrealistic and unnecessary.

2. Weight. Why do we have to focus on weight? Why not health? There are lots of metrics that track health quite well, and weight is arguably not one of them. Yes, this is a contested position, but it’s held by lots of medical and public health experts.  Physical activity happens to be one of those metrics.  See here for results of a very large European study showing strong association between even small increases in physical activity and lowered all-cause mortality risk.

3. For Life. That sounds scary to me. Why?  Because it seems controlling, demanding, and not understanding about the ups and downs of our experiences through the life trajectory.  There are going to be times in every child’s life when their physical state will be non-optimal.  This is not a cause for panic, and it may not even indicate that anything is wrong. So, setting people up with this humongous and unrealistic (yes, I said that before—it’s still true) goal is not very nice and not, uh, well, realistic.

We’ve got a lot to learn about how to help people identify, move toward and find some stability around health-according-to-them.  Owls are a great symbol, but how about we go with more variation, in keeping with our own glorious variation?  I have something like this in mind, but need help with names/acronyms.  Any thoughts?

Animated brightly colored animals of all types, shapes and sizes.

 

body image · diets · eating · fat · fitness · weight loss · weight stigma

The new health target of the century: kids

The news made the rounds of the health at every size (HAES) contacts I have in my social networks. I shouldn’t have been surprised to learn that Weight Watchers was offering free six-week memberships to 13 year olds, and yet I was.

Shortly after that, I learned the makers of FitBit were launching a fitness tracker for children. According to TechCrunch, the makers of FitBit are targetting the eight- to 13-year-old market because as the Telegraph noted, we need to do something about getting “couch potato kids” off the couch and into the gym.

Because child obesity y’all. (Insert eye roll here.)

I’ll admit I’ve been on diets, and I also have used a FitBit (see this post for how I use mine). I went on my first diet with WW when I was 14 and I needed my mom to sign for me. I can’t say it was a success because despite an endless variety of diet plans, I have continued to be my own fun-sized self and not the one society said I should be.

I stopped dieting when I reached my 40s. I read the literature, I looked at the research, and I considered the methodology of the studies. These days I try to eat most of my fruits and veggies every day, be moderate about my meat consumption, and add more whole grains, beans, pulses, and fish to my plate.

I still eat chocolate, potato chips and ice cream treats on occasion, but I am more mindful about my daily choices. And when I really, really want the chocolate bar, I go for the good stuff and thoroughly enjoy it.

Diets are all about deprivation, regardless of how they are marketed. And they don’t work. The problem with marketing to teens, especially teen girls, is they already have a decade of misdirection on what a female body is supposed to look like behind them. All those messages have been accumulating and Weight Watchers is stepping up to take advantage of the anxiety-fertilized soil to grow their market.

Ultimately, the only thing the plan will do is teach girls deprivation is the norm, their bodies at 13 are unacceptable, and it is on them to change their bodies rather than society change its expectations for the form expected for women.

At first blush, there shouldn’t really be an issue with creating a tool for kids. However, there are many people who see the number of steps reached as tacit permission to indulge. Weight Watchers for awhile had an exercise component that allowed users to collect food points through exercise and then spend them on either more, or fun type foods.

Many of these exercise tools track not only steps or other types of activities but also calories and weight. If you want off the diet train and onto the gym track, it can be very hard to find a gadget or tool that doesn’t link weight and fitness. In fact, it is one of the reasons I and my trainer make a point to track personal records that are strength based instead of scale based.

Whatever your size, age and body type, we are, at least in North America, a more sedentary society. Television, junk foods and in house gaming systems are factors in the higher weights we are seeing. But the problem with marketing fitness gadgets to kids is that after awhile the appeal is going to fade. While gamification of anything works effectively in the short term for setting goals, once kids and youth get where they want to be, there isn’t a point to doing it anymore and it stops being fun.

A co-blogger on this site shared with me some thoughts she and her sister had about the Fitbit and they echo mine: “My experience with fitbits with grown ups is they don’t understand the correlation between steps and food so it almost gives them more ‘permission’ to eat that piece of cake or whatever. I only know two people who use it in the way it was designed (make sure I get in my steps to stay fit) and they are both people who would be fit anyway. For kids, it’s a good awareness raiser and a ‘game’ but if it becomes the gadget it kind of loses its function.”

My co-blogger’s sister also made an important point that links to unpacking, resisting, or creating a new culture around fitness: “Fitness especially in kids comes from values, habits, home discussions, role modelling, fun activities, and doing things that don’t seem like fitness to the kid.”

Doing things that don’t seem like fitness are often more fun when you don’t have the “must” factor. Even I think it is more useful to say to myself: “It’s a gorgeous day out — let’s go for a walk!” instead of “I need to get 2500 more steps in to meet my time for today’s fitness.”

While I think the offer from WW for 13-year-olds is more problematic than FitBit’s plan to extend its market share by focusing on kids, I do believe we need to think carefully about how we look to change the behaviour of children when it comes to eating and moving.

Because in some respects is not how we change the behaviour, but why we feel it is necessary in the first place.

— Martha enjoys getting her fit on with powerlifting, swimming, and trail walking.

fitness · weight stigma

Is the end in sight for headless fatty photos? Here’s a glimmer of hope

We see them all the time:  media depictions of fat people minus their heads, commonly called the “headless fatty” photo.  I won’t post any, but you can see a google images collection of them here.

What’s the problem with these pictures?  They portray fat people not as people, but as objects– objects of ridicule, disgust, pity and contempt.  These are strong words, but apt.

And, it turns out, a recent article from the Lancet agrees with me (thanks, Sam, for sending it).   The authors call out popular media outlets for publishing articles with derogatory and inaccurate content about body weight and those with larger bodies:

The media portrayal of obesity—often stigmatising and inaccurate… is influential, and insidious to popular belief. Yet publishers and editors rarely challenge this media content, and so a stream of derogatory articles floods into mainstream media.

They cite a number of articles as examples of what they consider irresponsible journalism, some with mocking and hate-mongering tones.  We’ve all seen these sorts of stories– again, I won’t link to or quote any, but they engage in criticism of larger bodies and also make judgments about what the responsibilities of larger-bodied persons are (namely to lose weight as fast as possible to ease the burdens they create for society).

Yes, yes, we know all this.  But what can be done about it?  Here are their suggestions:

  • Adhere to the national journalism societies such as the Society of Professional Journalists code of ethics,10 which states that journalists should avoid stereotyping and examine the ways in which their values might shape their reporting, and the National Union of Journalists code of conduct,11 which emphasises that journalists should not produce material likely to lead to hatred or discrimination;
  • Accurately portray obesity;
  • Refrain from publishing articles that stigmatise and discriminate against people with obesity;
  • Use non-stigmatising images when reporting on obesity;
  • Take the opportunity—where stigma and discrimination are reported—to condemn such behaviour, as has been done for other topics (eg, mental health).

These proposed guidelines do a very good job of making this clear: many stories and articles about health, illness and body weight are written in ways that do the following:

  • they stigmatize larger bodies (I no longer use the o-word if I can avoid it);
  • they are used to perpetuate discrimination against and condescension towards those with larger bodies;
  • they use images of parts of bodies, disconnected from people or contexts in which they live, for shock and amusement;
  • this type of reporting promotes hatred of fat people.

Hatred– this is a very strong word, too.  I’ve been thinking lately about fat-shaming and fat-stigmatizing and its connections to hate speech.  Hate speech is not an area I know much about academically, but I’m starting work on a project with a friend investigating the relationships between the forms of weight stigmatizing speech and more traditional forms of hate speech.  I’ll be reporting on our progress here, and will welcome your responses, as always.

I’m heartened by this article, which calls weight stigmatizing articles as they see them:  discriminatory, inaccurate, and hateful.  Thanks, authors.  Thanks, Lancet, for publishing it.  And thanks, readers, for reading.