fitness · weight stigma

It’s dessert week in nutrition science!

CW: discussion of research related to body weight, BMI, and weight gain.

While the rest of us have been busy baking bread at home, nutrition researchers have been hard at work keeping dessert science going strong. They’ve been thinking and plotting and measuring and parceling out various amounts of dessert items to various sizes of people, then watching them closely to see what happens.

A group of busy-bee food science professionals released their results this week in an article investigating associations between body weight and milkshake liking. No, that’s not me rephrasing it– it’s the actual title of the article (using the word “ob*sity”, which I strongly dislike for scientific and ethical reasons).

First, they the formed their hypothesis:

Milkshake hypothesis: Make milkshakes, they said. Boys will come to your yard, they said.
Milkshake hypothesis: Make milkshakes, they said. Boys will come to your yard, they said.

(side note: if you’re not familiar with the references in this meme, you’re in for a sweet treat! Start here, then go here. Important: this is not to be confused with the “mikshake duck” meme, which I just learned about one minute ago.)

Back to the meme at hand: that’s not their research question (better to leave it to the “directions for future studies” section). Here’s what they wanted to know:

Prevailing models of obesity posit that hedonic signals override homeostatic mechanisms to promote overeating in today’s food environment.,,Here we define hedonic as orosensory pleasure experienced during eating and set out to test whether there is a relationship between adiposity and the perceived pleasure of a palatable and energy-dense milkshake.

non-science-journal version: they want to know if people’s body weights have an effect on how yummy milkshake consumption seems to them. What they are actually looking for is whether larger people report yummier milkshake drinking experiences (which they think might partly explain their larger sizes). That’s what these scientists are really up to.

What’s next? The researchers set up their test group: 110 people with BMI 19.3–51.2. They asked them to arrive neither hungry nor full, and to have not eaten for at least one hour. The participants came, and waited.

Please note that this study took place before pandemic social distancing protocols were instituted. Otherwise, group size would be strictly limited.

Safety first: milkshakes are allowed to bring at most 9 boys to the yard. A meme with Kelis.
Safety first: milkshakes are allowed to bring at most 9 boys to the yard.

Back to the study: I can’t tell you about the exact methods because even with my awesome library access I can’t get the full article yet. But: the researchers measured hunger before milkshake consumption and also recorded how much the participants said they liked and wanted the milkshake (during consumption).

Finally, we get the results! Here’s what the article says:

We identified a significant association between ratings of hunger and milkshake liking and wanting. By contrast, we found no evidence for a relationship between any measure of adiposity and ratings of milkshake liking, wanting, or intensity.

We conclude that adiposity is not associated with the pleasure experienced during consumption of our energy-dense and palatable milkshakes. Our results provide further evidence against the hypothesis that heightened hedonic signals drive weight gain.

Uh oh! The nutrition scientists got a negative result! They found that body weight had no effect at all on how pleasurable people said their milkshakes were. Keanu pretty much sums it up:

What if the boys were already on their way to the yard, and my milkshake had nothing to do with it-- meme with Keanu.
Keanu reports test’s failure to find association between two variables. It happens.

Yes, the study did find a correlation between hunger levels pre-consumption and reported pleasure during consumption. But no one doubted that. And yes, it’s a good thing when scientists get and publish a report on failure to find correlations.

This study gives us a glimpse of something very interesting and a bit worrisome to me, as a fat woman and a health ethics researcher: medical research spends a lot of time and effort searching for causal factors involved in body weight and weight gain that are located in individual persons’ actions, psychological makeups and personal habits. Are fatter people fatter because of something they are doing or feeling or attracted to?

These scientific questions make me uneasy about what may be underlying speculations (or assumptions) by researchers, clinicians and even the general public about what fatter people are doing differently or feeling and acting differently that accounts for their increased fatness. These views are likely yet another source for deep-seated fat-biased beliefs and weight-stigmatizing judgments.

Should we stop doing this kind of research? Even as a public health ethics professional, this is not in my lane, so I can’t say. I think we should remain careful about uptake and reliance on nutrition research, lest it leave a bad taste in our mouths.

fitness · weight stigma

Does COVID-19 care what you weigh?

CW: discussion of body weight and fat shaming in news and medical writing.

Even in the midst of a global pandemic, some folks manage to carve time out of their busy schedules for fat-shaming, patient-blaming and promoting all-purpose weight hysteria. On April 16, the NY Times wrote this story:

NYT headline: Obesity linked to severe Coronavirus disease, especially for younger patients.

Okay, but what are those “studies”, and what do they “show”?

Here’s the lede, which is rather unpromising:

The research is preliminary, and not peer reviewed, but it buttresses anecdotal reports from doctors who say they have been struck by how many seriously ill younger patients of theirs with obesity are otherwise healthy.

No one knows why obesity makes Covid-19 worse, but hypotheses abound.

It’s worth noting a few key points here: There are no studies. There are preliminary reports, based on gathering some information about some patients in some places. These reports sound similar to anecdotes from medical workers about particular patients who were 1) young; 2) severely ill with COVID-10; and 3) had BMIs>30.

I looked at the report the NYT was going on about. It’s here, and is accompanied by a serious disclaimer:

This article is a pre-print and has not been peer-reviewed [what does this mean?] It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.
This article is a pre-print and has not been peer-reviewed [what does this mean?] It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.

Good to know. But, just out of curiosity, what’s in there?

The upshot is this: the biggest relative risk (by a factor of 10) for being hospitalized for COVID-19 is age (75 and over for huge relative risk, 65-74 for smaller risk). Smaller relative risk factors were BMI>40 and heart failure. BUT: they didn’t control for race, socioeconomic status or quality of care (according to this article in Wired, and also according to me from looking at the original article).

We do know that it’s not always true that people with higher body weights automatically have higher risks of complications or death when they’re hospitalized for respiratory diseases. Here’s what one study on pneumonia found:

The cohort [of veterans who were pneumonia patients] comprised of 18,746 subjects. Three percent [had BMI <18.5], 30% [had BMI 18.5–25], 35% [had BMI 25–30], 26% [had BMI 30–40], and 4% [had BMI>40]. In the regression models, after adjusting for potential confounders, [BMI>40] was not associated with mortality (odds ratio 0.96, 95% confidence interval 0.72-1.28), but BMI 30-40 was associated with decreased mortality (0.86, 95% 0.74-0.99). Neither [BMI 30-40] nor [BMI>40] were associated with ICU admission, use of mechanical ventilation or vasopressor utilization. BMI <18.5 patients had increased 90-day mortality (1.40, 1.14-1.73).

The only group with increased mortality risk was the BMI<18.5 group. The other BMI groups either had a lowered risk or a non-increased risk.

Of course, this is only one study, but there are a lot of studies that fail to show a connection between higher body weights and risks of complications and death during hospitalization for some respiratory illness.

Other investigations are at ongoing and at various stages of revision and peer-review. This is important, as one thing we know for sure is that trying to tease out the influence of one feature of patients on particular health outcomes is very very hard. Small sample size, lack of representativeness, potential confounders and methodological flaws all get in the way of reliable results. Wired gives a good and detailed analysis of ways that some claims about the relationship between BMI and COVID-19-related health outcomes are unwarranted. And they offer a possible explanation:

The fact that researchers have been pointing to body size as a risk factor for weeks now, even in the absence of much evidence, is a clear example of how weight stigma gets enacted in science.

I don’t work in medicine, but I do know that there is a humongous evidence gap between what’s happening clinically in a particular hospital and its patients (each with their own complex medical and other histories), and what is true about everyone with higher BMIs in the US (not to mention other countries) with respect to risks related to COVID-19. Right now we can’t say much of anything. So maybe we shouldn’t. Which means the answer to my blog title question is, “we don’t have evidence right now to answer this question”. It doesn’t make for exciting news copy, but it’s the closest thing to the truth right now.

body image · covid19 · diets · fat · normative bodies · weight loss · weight stigma

The “covid 19” isn’t funny, it’s fat shaming and fat phobic

I wasn’t going to blog about this because when I mentioned it on my FB timeline, more than one person commented something along the lines of “people have different senses of humour and we all need outlets in these difficult times.” But if there is one thing that I can’t stand, it’s “jokes” about self-isolation weight gain. Isolation / shelter-in-place weight gain (“the covid 19,” riffing off of the “freshman 15”) has become a hot topic, as people are confined to their homes, possibly moving less and eating more, routines thrown off. There are articles about how to prevent it (with the usual advice, like all the usual advice). There are even quarantine diets.

That’s all fat phobic, fat-shaming, perpetuating harmful diet culture, and triggering for people recovering or recovered from or in the throes of eating disorders. They buy into harmful social ideologies that vilify fat and weight gain.

Jokes and memes take it to another level. They take it seriously as a thing, even a thing to fear. And they make light at the same time. The “humourous” edge makes it more difficult to take issue.

If you don’t find them funny, you are dismissed yet again as a feminist killjoy. Sometimes reprimanded for wanting to deprive others of their sense of humour (the old “just scroll past” rejoinder).

This Allure article, “Can I Socially Distance Myself from These Terrible Jokes about Gaining Weight While in Quarantine?” does a great job of explaining the harm. The most obvious issue is that “gaining weight is framed as an inherently bad thing–an idea that steeped in fat phobia.” When we frame weight gain as a bad consequence of being in quarantine, self-isolation, or shelter-in-place, we add a further layer onto an already difficult situation that calls for kindness to ourselves, not judgment and self-flagellation.

That kind of thinking can drive people into diet mode, or trigger feelings of self-loathing that come up in chronic dieters or people with eating disorders. As if living in isolation during a global pandemic isn’t challenging enough, bringing with it all sorts of fears grounded in the rapid pace at which our lives have changed, coupled with uncertainty about what awaits us in the future, how long we are going to need to live this way, in this shrunken version of our previous lives.

We do not need another demon. We do not need to shame ourselves for wanting treats. And we do not need to shame ourselves for gaining weight. We are trying to survive an unprecedented global situation. Surely that is task enough right now?

I am well aware that people have different senses of humour. And that people need occasions to laugh in the midst of this pandemic. I am also well aware that some jokes perpetuate social harm. Racist and sexist jokes do that. And jokes about the covid 19 do too. They are fat phobic and shaming. I’m sure we can find other things to joke about and lift our spirits.

Image description: Pie chart of “Things I’ve Learned i the last few weeks,” with the 3/4 of the chart taken up with “I fucking love touching my face.”
Image description: White mug with black printing on it in bold, made to look like a broken mirror, and says “I don’t like this episode of Black Mirror.”
fitness · weight stigma

US report predicts 50% obesity rate by 2030: some takeaways

CW: talk about body weight, obesity, weight stigmatization.

While I was busy grading last December, a report came out in the New England Journal of Medicine that predicted an almost 50% obesity rate in the US by 2030. The report also predicted that almost 25% of Americans would, by that time, be “severely obese” (a term I’m not going to use again, but which means a BMI of at least 35).

This is certainly not good news. However, some people are more worried than others. Jane Brody of the New York Times calls it “dire” and compares it to global warming:

Climate change is not the only source of dire projections for the coming decade. Perhaps just as terrifying from both a health and an economic perspective is a predicted continued rise in obesity, including severe obesity, among American adults.

Brody interviews experts who point to increased snacking, consumption of sugar-sweetened beverages, eating out more, and increased portion sizes as contributing culprits of the trend.

They make the usual policy recommendations, including taxes on sweetened sodas and other sugary beverages (which, in this recent study, found a reduction in sales after being implemented, but may mean that people purchased them in other places); working to create policies to promote reduced meat consumption, reduced portion sizes, and lower-calorie foods. These are the standard responses, and I think old news.

Reading through the original article, though, a number of things struck me that Jane Brody didn’t mention at all. I’ll share them with you, and I’d love to hear what you think as well.

First takeaway: the projected distribution of increased average BMI is not uniform throughout the US. We see it graphically displayed below, with darker colors indicating higher percentages of BMI30+, and BM 35+, respectively.

Projections of BMI>30 (left), and BMI>35 (right) in states of the US, with darker colors indicating greater percentages in those states.
Projections of BMI 30+ (left), and BMI 35+ (right) in states of the US, with darker colors indicating greater percentages in those states.

And what do we see? As an American, I see poorer states, states whose citizens get less good healthcare, states whose legislatures refused to expand Medicaid under the Affordable Care Act. The US is a country with severe health care inequality, and that shows in these graphs and in the tables in the article.

Second takeaway: the NEJM article talks about increase in “severe obesity” (I promised I wouldn’t use it again, but this is really the last time) but that term just means BMI 35+. We know that not all BMIs 35+ carry the same medical risk profiles. The authors of the article mention the need for more information across the BMI spectrum, but their analysis represents a shift only from BMI 30+ to adding BMI 35+. It’s also important to know the distribution BMIs 35–40, 40–45, 45–50, and so on. Why? Because they represent different health needs, and mandate different approaches to health promotion. I’m talking not only with respect to medical conditions that often go along with say, BMIs 50–55, but also with respect to responses that help citizens of those sizes navigate life, work, medical, educational and other public spaces. Which gets me to my next point.

Third takeaway: if we expect many of our citizens to be much larger in the next 10 years and we want them to be healthier, we need for them to be able to be active and present in the community, not barred from participating in ordinary activities of life. Yes, I’m talking about literally making space for larger and heavier populations (from restaurant chairs to hospital gowns), but not just that. We need a variety of ways to make physical activity accessible, easier, and safer for larger people. This means exercise machines that obviously handle larger weights, wider yoga mats, bikes with higher max weights. This also means more outdoor spaces tailored to physically accessible and satisfying activities (e.g. shorter nature trails with benches, railings, surfaces with less steep grades, etc.).

Last takeaway: the NEJM article acknowledges that medical research hasn’t been successful in developing weight-loss methods that will be able to reverse this trend on a nationwide level. The authors suggest turning to prevention as the most important strategy for health. I disagree. I think the most pressing agenda item is reducing weight stigmatization, especially in health care. Health care workers are the second-most common source of weight stigmatization, and the effects on people are a real hazard to their health. We know that stigmatizing weight doesn’t motivate people to lose weight, but instead reduces self-esteem, increases depression and anxiety and social isolation, and often results in increased body weights among those stigmatized. The Lancet published a series in 2015 (I wrote about it here in the Conversation) in which they made a number of recommendations for reframing obesity. One of them was to treat obese patients better. Yes, that sounds right. Let’s do that.

What do you think about these takeaways? Do you have other thoughts about this news? I’d love to hear from you.

body image · competition · diets · fitness · weight loss · weight stigma

Can you watch the Biggest Loser ironically?

No. That’s my answer anyway.

I have some thin friends who say that they just watch it for a joke. They’re looking forward to new episodes. It’s so bad, it’s good they say. I’m not a “it’s so bad it’s good” kind of person.

I said, just stop. It’s not funny. It’s abusive. It doesn’t work. It hurts people. But also, it affects your attitudes towards fat people. Did you know that?

“A 2012 study published in the journal Obesity found that people who watched just one episode of the show exhibited higher levels of explicit bias against fat people. “Participants who had lower BMIs and were not trying to lose weight had significantly higher levels of dislike of overweight individuals following exposure to The Biggest Loser compared to similar participants in the control condition,”the researchers found. Just one hour of watching the show left thinner people with an even greater personal dislike of fat people.” From Jillian Michaels and the Alarming Legacy of the Biggest Loser.

What do you think? We know that my sense of humour about the treatment of large bodied people by the media is running low. You might have read my very very cranky review of Brittany Runs a Marathon.

You can’t miss the announcements: “The all-new Biggest Loser | Premieres January 28th‎.” But you don’t have to watch the show.

We’ve written about the show before. Lots. As you can guess we don’t much like it.

From the Olympics to the Biggest Loser? Say it ain’t so Holly

TV shows, fitness, and weight loss: Love and hate

I know the mistake they made: The biggest losers just stopped exercising

More on the mistakes the biggest losers make: But what about muscle?

The biggest losers just did it the wrong way! They lost the weight too quickly!

Extreme Dieting and Metabolic Adaptation: The “Biggest Loser” Dataset (Guest Post)

Imagine if size didn’t matter. Can you?

So has Caitlin at Fit and Feminist:

THE ‘SHOCKING’ OUTCOME OF THE BIGGEST LOSER IS NOT ALL THAT SHOCKING

Don’t watch the Biggest Loser. Watch this great ad instead!

alcohol · beauty · body image · eating · fat · fitness · habits · health · injury · movies · running · self care · sex · stereotypes · weight loss · weight stigma

Sam watched Brittany Runs a Marathon and recommends that you don’t

Catherine wrote a blog post about Brittany Runs a Marathon without watching it. That was definitely the wiser choice. See her commentary here.

She writes, “So why I am writing about a movie I haven’t seen? Because I think the movie/advertising/fashion/fitness industries have (sort of) taken in the message that it’s not okay to blatantly fat-shame people or overtly identify lower body weights with fitness, success and happiness in life. Notice, I said “overtly” and “blatantly”.”

Catherine goes on to identify “some strong fitspo messages buried (not too deeply) in this film:

  • Health problems should first be addressed by losing weight
  • Weight loss is possible to achieve through physical activity
  • Weight loss makes physical activity possible and easier and better and more fun
  • Some deep-seated emotional problems will resolve through weight loss and physical activity”

There’s a lot to dislike about the film that I knew before I hit play. It erases larger runners, it promotes weight loss fantasies, and it’s fat-shaming. All that I knew at the outset.

So why did I end up watching it? I sometimes watch “bad” TV or fluffy shows while cleaning. Easy to follow rom-coms? Sign me up! I hadn’t seen the floor of my room in weeks. There were Christmas gifts I still hadn’t put away, clean laundry, bags of gym clothes, yoga mats etc all over the floor, the bed needed making, the socks needed sorting and so on. I needed something longer than a regular half hour show to deal with all of the mess. I needed a movie length thing at least. I thought I could handle the fat shaming and enjoy BRAM for its redeeming features. The trailer looked, as a friend put it, cute. The Guardian called it a fluffy feel good flick. It is not that. By the end, I did not feel good at all.

Friends, it was not mostly cute with a side of fat shaming, which I expected. Instead it was a dumpster fire of stereotypes and it was also super sex shaming. All of this was lumped into criticism of Brittany’s self-destructive lifestyle. At one point in the movie someone opines–in a line that was supposed to save the movie, “Brittany, it was never about the weight.” Instead, “weight” is just a stand in for all of Brittany’s problems. Before fat-Brittany is taking drugs and giving men blow jobs in night clubs and by the end of the movie, thin Brittany isn’t just thin. She’s also turning down casual sex. The friends-with-benefits/boyfriend proposes. There was way too much moralizing about sex and drugs. And I say that as someone who is no fan of drugs or alcohol and is often accused of moralizing in this area.

This happens because Brittany isn’t just a fat girl. She’s a fat girl with low self -esteem. She could have just gotten some self-esteem. But no, she gets thin and then gets self-esteem. She could have gotten self-esteem and demanded equal pleasure in the casual sex. She could have started using drugs and alcohol in a responsible manner. Instead, no. She gets self-esteem, says no to drugs, and holds out for a real relationship.

Not surprisingly, it doesn’t manage the weight-loss plot line well at all.

The Guardian reviewer writes, “The film struggles to square its protagonist’s weight loss with the pressure to present a body-positive position and ensure it doesn’t alienate the very female audience it courts. One minute it’s wryly poking fun at the expense and inaccessibility of gyms, the next it’s fetishistically cataloguing the shrinking number on Brittany’s scales. Indeed, as her body transforms, so does her life. She finds a new job, and supportive friends in her running club; men begin to notice her. Yet Brittany still battles with her body issues, unable to shed her identity as “a fat girl”. There’s a note of truth in Bell’s finely tuned performance as a character whose insecurities have calcified over the years, hardening her to genuine goodwill, which she frequently misreads as pity.”

For the record, fat Brittany is smaller than me. She starts out weighing 197 pounds. Her goal weight is 167. And we can track it because never in movie history has a person stepped on a scale so often.

(A blog reader pointed out a more charitable interpretation of why we see her stepping on the scale so often: “She steps on the scale a lot because she trades in her addictions to drugs and alcohol for an addiction to scale weight loss, which the movie portrays as an unhealthy obsession. What starts out as a good “oh look, I lost this many pounds now!” thing quickly escalates into a dangerous “go for a run, jump on the scale, dislike the number displayed, so go back out to run in the mistaken belief that it will make the number change” cycle. That’s why she steps on a scale so often. Because it’s NOT good that she does it.)

Forget the weight loss and the sex, even the running themes aren’t handled well. Friends tease Brittany when she first starts running because she isn’t a real runner. The longest she’s run is 5 km. Rather than tackling the “real runner” thing head on instead the film has Brittany run a marathon and become a real runner by the friend’s standards. Even her triumphant marathon finish is marred by Brittany’s continuing to run on her (spoiler alert) injured and possibly still stress fractured leg. We don’t know that but we do know she’s holding her leg and crying, running and not able to put much weight on it, and her first attempt to run the marathon was derailed by a stress fracture.

There is nothing to love here. Nothing cute or funny or feel good or fluffy.

Friends, don’t watch it. Not even on an airplane.

diets · eating · eating disorders · weight loss · weight stigma

Losing My (Diet) Religion (Guest Post)

by Mavis Fenn

(This post discusses disordered eating. Please be aware it may be triggering for some.)

 Eating issues began when I was ten. There were two contributing factors. The first was that I was pre-puberty, a time when many children put on additional weight. The second was related to my mother’s health. She died at fifty-eight of early onset Alzheimer’s. It was when I was about ten that her behaviour began to change. Looking back on it now, I realize that this was also the time I began to binge-eat. I clearly remember ketchup and mustard sandwiches on white bread. Yuck!

My parents were older and came from a generation that had survived the depression of the thirties and the Second World War. Not wasting and will power were considered virtues; a lack of frugality or will power was a moral failing. Fat people were considered to be lazy, gluttons with no will power. My dad loved me and wanted the best for me. We were close until he died at ninety-four. He was a great role model and still is. Having said that, family and friends believed that teasing was a good way to correct behaviour. How well I remember, “Your eyes were bigger than your stomach,” when I didn’t finish the food on my plate. Unfortunately, that hurt my feelings; hurting my feelings makes me mad. Thinking, “I’ll show you,” I would eat everything up even if they said I didn’t have to. And the boys that called me names, I ran them to ground and sat on them until they apologized.

For a girl, being fat could be limiting. It didn’t matter how smart you were, how funny or caring you were, you weren’t going to get a good job or a husband who would take care of you if you were fat. So, at about twelve I got on the diet roller coaster. I stayed on it for well over fifty years. It eroded my confidence and sense of self-worth. I was never good enough, strong enough; I was not perfect and it was all my fault. When I was thin, I worried about getting fat; when I was fat, I was anxious and depressed because clearly I was lacking in will power. Eating compulsively was my punishment. It made things worse and I knew it.

I never had trouble losing weight, just keeping it off. I used food in times of stress, knowing that I could lose it when the latest crisis passed. I didn’t know that genetics determines most of your weight range, that only about two percent of people who lose weight are able to keep it off permanently, and that when you begin to gain weight again your body adds a bit more because dieting puts your body into starvation mode. In January 2015 I decided it was time to lose weight again. I struggled and struggled. I couldn’t; I just couldn’t. I was overwhelmed with defeat and shame. I sat down on the bench in the gym, put my face in my hands and cried.

My trainer asked me what I intended to “do” about my situation. I mumbled that I guessed I’d get a therapist to recommend something.  She said not to worry and the next morning my inbox had an email with the contact information for the CMHA Eating Disorders program. I called.

When I met with the nurse, she asked me if I could accept myself as I was if my body stayed the same. My response was, “Absolutely not!” Getting rid of the diet mentality wasn’t easy.

As the introductory workshop wore on, I realized that I had in the recesses of my mind the idea that I was still looking for weight loss. That was not going to work. So, I made the decision to go “all in.” I analysed how I used food, the mind traps I set for myself, and most importantly I examined why I was still allowing myself to be controlled by childhood beliefs about body size. Those were stereotypes of a past generation and they were wrong. I didn’t need to continue to judge and punish myself for not being someone else’s idea of perfect. I was not defined by my body; it is only a part of who I am.

Do I ever think of weight loss or body image? Occasionally, but dieting would cost me my freedom and mental health. I prefer to think about healthy eating and being fit. In the two years since I completed the program, my weight has stayed just above or below my last “set point” (where my body decided we were safe from famine).

The last day we were asked to reflect on completing the course, I wrote this: “I think I have come to peace with my body. Therefore, I am at peace with myself.”

Image description: A plaid pajama clad foot with bright blue toenails stepping on a bathroom scale.

Mavis Fenn is an independent scholar (retired). She loves lifting weights, Yin yoga, and Zumba Gold. She is mediocre at all of them.

fitness · weight stigma

Reducing anti-fat bias among doctors: will a little more knowledge help?

Here’s some good news: medical schools are (finally) paying attention to the fact that their students have a bunch of false beliefs about their fatter patients, which contributes to bad medical care. Johns Hopkins and NYU medical schools created some special 3-4 day courses devoted to better understanding obesity (a term I hate, but they use it, so I will use it here when I have to). Their goal is to help future doctors care better for their fatter patients.

For those who love references: you can read a news article about the NYU study here, and the actual NYU here. For the Hopkins study, there’s a JAMA article about it here, and the Hopkins study in more detail is found here.

Okay, now that the bibliography is done, here’s what the studies discovered about medical students’ beliefs and attitudes toward fat patients.

tl:dr version: lots of future doctors falsely believe that body weight is largely controllable. They also have negative feelings and attitudes toward fat people– a significant percentage think fat people are lazy or don’t make good decisions. Possibly as a result, they are less empathetic to their fat patients. This translates into bad medical care.

Here’s my deeper dive: from studies we know that a large percentage of 4th year medical students believe that lack of willower is an important contributor to obesity. The Hopkins study looked at 6 medical student cohorts who had taken a 4-day course on obesity. Before the course, here is what the students believed:

Across cohorts, 89% of students agreed or strongly agreed that obesity is a disease (range, 85% to 92%), and 89% of students believed it was behavioral (range, 82% to 92%). At the same time, over 90% of students agreed or strongly agreed that obesity results from poverty (range, 90% to 97%), and 57% believed that obesity is primarily genetic (range, 51% to 62%). Finally, 74% of students agreed or strongly agreed that ignorance contributes to obesity (range, 70% to 79%), and 28% had the opinion that people with obesity were lazy (range, 21% to 38%). 

This is appalling but not surprising. The NYU study found similar negative attitudes and false beliefs:

More than half of medical students rated unhealthy diet (62.0%), physical inactivity (56.3%), and overeating (52.1%) as very important contributors to obesity. Only 26.8% of students rated genetics or biological factors as very important. Lack of willpower was rated as less important than genetics or biological factors, but over 40% of students considered it [lack of willpower] to be at least a moderately important cause of obesity.

These disheartening results hold for practicing doctors as well. The NYU study cites this information:

In a survey of US primary care physicians, genetic factors ranked below physical inactivity, overeating, and high fat diet as important causes of obesity. More than 30% viewed patients with obesity as weak-willed, sloppy, or lazy, over 50% viewed them as awkward, unattractive, ugly, and noncompliant, and only 50% of physicians rated genetic factors as a very important cause of obesity.

So, we have a situation in which physicians and future physicians have false beliefs about human metabolism and controllability of body weight. Medical schools (and hospitals and medical associations and patient groups) are aware of this fact, and are trying to educate these populations to give them correct information and a solid knowledge base from which to view their patients more equitably and justly.

But the problem is: knowledge doesn’t seem like it’s going to make things better. In a followup survey, the Hopkins researchers asked the medical student cohorts how (if at all) the course changed their views about obesity. More than 50% of the respondents reported no change at all. 30% reported positive changes in their views. The rest reported either no change or more negative views over time.

As the NYU study authors put it in the last line of their article, “Research about the most effective methods for teaching the basis of obesity and reducing bias is sparse, however and more studies are needed to identify best practices.”

Yeah, I would say that’s right. So, what’s missing here? Some researchers say this: we don’t know how to teach people to be empathetic with others, especially about fatness. You might think that doctors or medical students who have struggled with body image and dieting yo-yo weight changes would be more empathetic toward their fat patients. But no– the data show otherwise.

So how do you teach people empathy? There are actually programs to teach physicians empathy for their patients. Knowing that how a primary care provider responds to us emotionally is a strong influence on how well they treat us (medically and personally) gives us a little more power in an area of life where people are relegated to the status of passive, silent patient. And if we’re up to the task, advocating for ourselves and others by calling out lack of empathy and calling for more empathy training might make going to the doctor less daunting and unpleasant. Here’s hoping…

Doctors walking down a hallway, rearview. Photo by Unsplash.
injury · Sat with Nat · weight stigma

Nat grapples with plantar fasciitis

It started as a dull ache in the summer around the rim of my left heel. It culminated in me limping home 2 weeks ago from work. Did I take the bus? Oh heck no!

So, first, this is a self diagnoses as I am actively avoiding my family doctor after my last visit. Why? I had gone in to talk about my hay fever and how it has aggravated my snoring.

The doctor recommended gastric bypass surgery. I’d never heard of that to treat hay fever before!

I spoke with my Gran, who weighs 80lbs, and she laughed. Apparently she, as her father before her, is a very loud snoring human. As is my dad (her son).

Anyway, no way am I going to see my family doctor about anything correlated to weight gain unless it’s drastic.

So after much research on the Internet and speaking with many friends I’m quite confident self-help options are going to help me recover.

I really liked the detail and approach in this article about stretching, yoga and things that help & aggravate symptoms.

https://yogainternational.com/article/view/yoga-for-plantar-fasciitis

  • Things that have definitely helped:
    • Over the counter insoles
      Calf stretches
      Rolling a hard ball on the bottom of my foot
      Ice
      Ibuprofen
      Rest
      Commuting in running shoes
      Yoga postures that flex & stretch my calves & feet
      Cycling inside on my trainer

    You can see Natalie’s legs stretched out in front of her. She has a yoga belt around the balls of her feet pulling her foot up to 90 degrees, stretching her calves and feet.
    Couch time is a great time to stretch those calves & get!

    It’s taken me a while to get in this much pain so I know it will be a while to recover. Thinking back over the past year I have had a few changes that would exacerbate plantar fasciitis:

    • started commuting with a full backpack
    • stopped doing other activities
    • wore older footwear even when my feet started bothering me
    • Ignored my early symptoms
    • Doubled my walking distances by canvassing
    • Gained some weight

    So, if you start to get that ring of fire around your heel, please, don’t be a Nat! Get checked out by a healthcare provider, try some self help options and talk to friends & family. You may not need to wince in agony for long.

    cycling · weight loss · weight stigma

    Not all cyclists are thin, not all drivers are fat

    This image is said to be from https://twitter.com/modacitylife

    I put it that way–“said to be from”–not because I like that feed, though I very much do, but because although a number of people have shared it and attributed it to them, I couldn’t find it there when I looked. (Update: Found. But they just retweeted it from someone else. I’m glad.) This contrast between fat drivers and thin cyclists drives me up the wall.

    Modacity life is about this: “In the summer of 2010, our family made the conscious decision to sell the family car, embarking on a new and enlightening adventure. Forced to move to a multi-modal commute, relying on public transit, walking and a great deal of cycling, we quickly realized the benefits of living a ‘car-lite’ lifestyle, not the least of which was the increased human interaction with the city we call home. Using writing, photography, film, and the power of social media, we used this revelation to communicate a more human image of multi-modal transportation. Together, we now strive to educate people and cities about the inherent benefits of moving away from a car-centric transportation model, to a more inclusive one that is accessible to people of all ages, abilities, and economic means.Promoting the public health, environmental, and social benefits of walking, cycling, and public transit, our goal is to improve on the great strides already made in many cities, creating a more open and welcoming environment for residents and visitors alike.”

    The Brunlett’s had a book launch in Guelph and I loved the launch. I’ve enjoyed reading the book. 

    Anyway, anyway, there are lots of wonderful reasons to ride bikes. It’s great for the environment. It’s great for your mood and for your physical health. Just so many reasons…

    But on behalf of larger cyclists everywhere, I just want to say IT WON’T NECESSARILY MAKE YOU THIN.

    Also, cycling is for everyone!

    See Big women on bikes.

    Want an example of how to talk about public policy and bike advocacy without false promises and fat shaming? Look here.

    From that interview, ““I got started working on transportation issues, which came about mostly because I love the fun and freedom that comes with being able to ride my bike and walk around my neighborhood.  But when I talk about bicycling from a public-health perspective, it’s easier to emphasize the health and financial benefits of obesity reduction. Which is just plain silly; I don’t want someone to take up bicycling just because it will help them lose weight. That’s a recipe for disappointment and frustration and doesn’t support sustainable healthy choices.”

    Just ride and enjoy!