Just how bad is obesity stigma?

So, yesterday a friend shared a story about the obesity stigma surrounding gay men. In it, he explains how the teasing he endured relentlessly, and the comments he continues to receive today are overwhelmingly about weight, not his sexuality.

This got me thinking--what's worse? What's the most painful? I've been through plenty of trauma in my life.* From severely ill children, abuse, loss of a sibling, depression, the one trauma makes the most impact on a daily basis, and always has, is that I am fat. As painful and difficult as everything else has been, I don't get blamed for them. On the contrary, people empathize--there is no expectation I can undo any of those. Even depression, in more recent years, is more widely understood. But obesity? That problem is one I should simply undo, that it is a trauma I deserve because I have brought on myself.

It's not that obesity stigma is worse than the pain of other losses and experiences, it's that obesity stigma is wholly different, not even comparable in it's effect. The umbrella of blame and the effect of the stigma has woven itself into every aspect of social culture. There is an "us" vs. "them" characteristic where the experiences rarely cross. If you've only ever been part of the "us" group, it's difficult to understand why anyone in the "them" group could say something like I did--that it's the worst thing I've experienced.

Let's be clear here--I'm a well-educated woman who understands obesity better than almost anyone in the country, and I understand obesity stigma nearly as well. I also understand myself better than most people understand themselves--years of therapy and many life experiences have given me insight many people don't have an opportunity for. But even for me, obesity stigma is something that hurts, not just that I see.

It culminated this week, soon after "Weight Stigma Awareness Week" with the birth of #FatShamingWeek. Of course, most people do not think this way. But enough do that when you put that on top of the "kind words" suggesting some weight loss "for your health", the constant images of beauty that involve only thinness, and an ever-growing array of diet products, and stir that up with the beliefs about being fat that fat people have about themselves. Well, it's a recipe for disaster.

How can fat be the worst thing I've ever experienced? Because I can reconcile all of the other things. I can understand what loss is, and I can recognize the things I've learned and gained from all my traumatic experiences. But it's a daily internal conversation with myself about what I'm supposed to look like and what I actually do, how I'm happy and comfortable with myself despite constant messages that I'm should change myself, that I'm an obesity researcher who wants treatment and acceptance simultaneously. The cognitive dissonance of being fat in this world is overwhelming. If someone like me can't figure out how to reconcile it, why should be surprised when others live a daily struggle--disguised as a struggle WITH their weight, but truly a struggle with the MEANING of their weight, and the meaning of their life.

This stigma is not bad--it's overwhelmingly, heartbreakingly,  inescapable.


*I think it's important to note that I've also had lots of wonderful things, great luck and blessings.

Ignore Obesity Research in the News, Please

Today there is yet another study demonstrating a decline in obesity in children. Here is the actual study and here is a news report.

This follows reports from several weeks ago that obesity among preschoolers was falling.

This on top of the most recent F as in Fat report, which emphasizes greater obesity in the South.

Let's get a few things straight:

Reporting obesity prevalence based on self-report is bad science.

Reporting obesity prevalence based on non-representative samples is bad science.

All reports of state comparisons are bad science.

In the United States, no matter what anyone tells you, we do NOT have any idea what the actual prevalence of obesity is by state. We have ONLY ONE survey that allows us to make good estimates of total prevalence of obesity, and it will not allow state-level estimates. Most states do not have good systems to estimate obesity prevalence within their own state.

Please, for the love of the Flying Spaghetti Monster, just stop reading news reports about obesity prevalence. We have no idea if it's improving or getting worse.

I have no idea why the journals don't send me THESE articles to review, but I would definitely have them temper their language. I've kept a few from getting out there, but I don't get to review everything. Even if I did, I can't control the press releases. There is lots of good obesity research. Unfortunately, the news seems to only pick up the small fraction that is bad science.

Low-Sugar Juice is Stupid

I've had multiple requests this week for donations to a local food pantry, which is great. But the featured request of the month is "low sugar juice boxes". I can't bring myself to donate anything because of this absurdity.

What is low-sugar juice?

I would think normal people would put these in that category:

Juicy Juice 100% juice “no sugar added”: 26g/8oz

Apple and Eve “1/3 less sugar”: 22g/8oz (Made with vegetable juice)

Let's compare to the evil drinks:

Hi-C Fruit Drink: 28g/8oz

Coke: 27g/8oz

Or we could (OMG!) poison them with chemicals and give them Splenda-sweetened drinks or (OMG even more!) diet soda.

Seriously? Can we just call a spade a fucking spade? Juice IS sugar. Deal with it. Argue that juice is fine, and serve juice. Argue that sugar is bad, and don’t. But don’t pretend like a “low-sugar” name makes things any better.

If you are worried about adequate nutrition in your population, give them 100% juice drinks. If you worried about obesity (probably a bigger deal for poor North Carolina), give them water or something with an artificial sweetener. 

There are plenty of reasons to argue for and against the juice box, and it's fine to want to get organic things (though I believe unnecessary). But you don't get to plop down "low sugar" and make things healthy. I'm not the only one who thinks juice and smoothies are as bad as other sugary drinks.

Even your organic, no-sugar added, hipster juice boxes are still just fucking sugar.

The Endless Stupidity of Wellness Programs

I could go on for hours about the ethical issues of "wellness programs" for employer-based health insurance. Most recently, Penn State began requiring employees to report a variety of health parameters in order to avoid a relatively large financial penalty.

Lost in that discussion was that North Carolina has just done a similar thing for their entire base of state employees (it does not require actually having a physical exam). The financial penalty is a bit smaller--on the order of $50--and requires completing a health assessment, attesting to being tobacco-free, and designating a primary care physician for everyone on the plan.

Let's set aside the fact that wellness programs don't work.

Obviously, I think requirements to report these things are wrong, but I thought I'd take out the "wellness plan" for a test drive.

I won't go into laborious details about the health assessment itself, because that's not what is most interesting. They asked my height and weight and waist circumference, the last of which I just guessed on because I don't typically keep a tape measure in my office. They asked about stress, drinking, tobacco, whether I take medications to sleep, details about my activity levels even I, an activity researcher, found difficult to interpret, and then a whole host of measures most people aren't going to know--blood pressure, cholesterol values, glucose values. Finally, they asked if I thought I would work on losing weight, eating better, and reducing stress.

So, I finish my assessment. Here's what I get:

First, take note of the little female icon. Just in case I forgot.

Okay, so I'm medium risk. Medium risk of what I'm not quite sure, but apparently something. Death? A cold?

Well, I don't want that! Surely they can help!

 


Well, if I scroll down, I get to learn the things I need to work on. "Work on"? Aren't I already working enough? And, hey, how do they know if I'm working on my depression or my "obesity"? Maybe I've worked my depression into submission and what I really need is to leave it alone.

Anyway, I'll bite. Let's find out how to cure my "obesity".

First, I suppose they need to tell me what obesity is.  Because that's never come up before.






Holy shit, I have SO MUCH FAT that my health is in danger. Okay, even if that WERE true, healthy diet and daily Jazzercise notwithstanding, is that the most appropriate way to tell me?

Well, let's find an action plan. Because I don't want my health in danger!


 


Oh, nothing. Darn. Let's click around and see if I can find a back door in. Well, no plan, but more details on my condition.





Are those really warning signs of obesity? Because I'm pretty sure I don't have any of those. I know, I know, they are warning signs of obesity-related disease. But I do believe all of those can happen to anyone. And who puts the "right before you die" symptoms of a disease?

Okay, back to the search for my action plan. Ooh, here are my action steps!


 


Disregarding that half of these are indecipherable, they are called HOMEWORK!! Not "good stuff to do", but actual fucking HOMEWORK. I've already sold my soul to you, and you give me homework--without directions, no less?

But we're trying to cure my obesity, no? Ah, I found it.




Are those really all my options?

Maybe the health action details will help.


 



My "educational tool" consists of three bullet points, the first of which is to remind me it looks like I have a weight management "issue". My response to it goes from was this helpful (um, no) to "how likely are you to have bariatric surgery?"

Let me just get this out there. My BMI puts me in the obese category, but my health is great and I'm in fabulous shape. I need a lot of things--more time, more sleep, more money, better fucking health insurance--but I do NOT need bariatric surgery.

These people still haven't told me what to do. Oh, look, I found something. Well, I sort of did, because I can't find it again. But I did get a lovely screen shot.






Who looked at that and thought it was a good idea? Besides telling me absolutely nothing I didn't already know (or that every fat person also doesn't already know), it's like painful, dense text. For the record, the depression action detail looks very similar. I don't want to read it now. I'm pretty sure if you showed it to me when I actually WAS depressed I probably would've just cried.

Speaking of depression, let's see what tools are available to help me "work" on that.

 

None of those are relevant to me, and they know that (because I had to tell them that I am not menopausal and currently not pregnant and presumably they are aware I am not a child). The only POSSIBLY relevant thing is that incredibly depressing sad face in the sand. I mean, that makes non-depressed me want to cry. But I sure as hell don't need to know if I have depression. I do. I have--with a diagnosis--for a decade, and the State Employee's Health Plan certainly knows that.

So, my sum experience with the NC Health Smart "Wellness Program"? Buggy. Insulting in its treatment of obesity. Naive in its effort to address depression. (I can only imagine how the other conditions get treated. I wonder how many times people who report hypertension get told to avoid salt.) Seriously offensive in its approach--making caring for my health "work", using thinsplaining, and potentially dangerous in implying that I need to "work" on things that are already under fabulous control. Worthwhile primarily as a great way for the state to collect private health data about me, under threat of punishment.

We can only hope this effort--and the enormous amounts of money I'm sure went into it--will fall apart as quickly as the last wellness effort in NC.

JAMA Pediatrics has posted an interview with me and Daniel Callahan, about our perspectives pieces in this month's issue.

You can listen here.

Love Song of the Headless Fatty

So, I got a paper published today, one I'm quite proud of. It's a viewpoint in JAMA Pediatrics, and is accompanied by a contrasting viewpoint from Daniel Callahan.

My basic premise is that we must stop stigmatizing children, even in small ways, because the thing that can be seen--the fat--is not what we should hope to change. Callahan, on the other hand, argues that "the main and simple message is that obesity is bad, not to be accepted or delicately evaded or minimized".

I would never argue that we should minimize the health effects of obesity, but we can not shame anyone into thinness. And we should never view obesity as solely the result of individual decisions, an (unstated) assumption that we know is faulty. 

I'll let everyone read them and make a decision for themselves. If you are at an academic institution, you likely have full access. If you are not (and are not on a mobile device), you will get to see a first-page preview, which is the majority of both articles. Shoot me an email at asheley@unc.edu, and I can share a full PDF if you like.

(The titles below link to the JAMA Pediatrics page.)

The Love Song of the Headless Fatty and Other Observations

Children, Stigma, and Obesity

The Stigma of Childhood Obesity

Some colleagues and I recently received a rejection of a letter to the editor of JAMA. When we saw this cover, we were immediately struck by the child in the middle, and decided a letter was needed. I guess I shouldn't be surprised by the rejection, given that JAMA recently rejected another piece of mine on how stigma pervades the medical and scientific communities that work on childhood obesity. (That piece, however, was accepted by another in the JAMA family, JAMA Pediatrics, and will be published July 1.)

The refusal to engage in the discussion is as informative as the original point we were trying to make. Below is the image on the cover, which should link you to Dr. Zylke's description--my apologies to those who can't access it freely. I think our letter was appropriate and true.
 



 

Dear Dr. Zylke,

It was with great excitement that child health researchers came across a special issue of JAMA focused on child health last week.  Unfortunately we found this issue’s cover alarming.  The illustration promotes the stigmatization of obesity that has not only pervaded popular culture, but, as so clearly demonstrated here, the research and medical communities, as well.
   
On the cover, we instantly saw a portrayal of an obese child with a large soda-an image that managed to meet all three criteria for defining pejorative images from the Yale Rudd Center for Food Policy and Obesity at Yale University media guidelines.¹  While you say this image tried to portray “problems stemming from social or environmental issues,” the use of a picture of an individual child with a large soda to reflect the high prevalence of obesity among children is stigmatizing in that it recognizes the individual behavior without also recognizing the larger environmental roots.  

Far more disturbing are the subtleties apparent in the image.  The fact that so many people in the scientific community must have looked at this obese girl—with an awkward facial expression, unflattering clothing, and avoiding the world—as an honest representation of childhood obesity is truly disheartening.  Social constructs of disease place responsibility on different individuals, assigning blame in ways that portray children as either victims or perpetrators.² On this cover, nearly all these children are either promoters of their own health or “victims” of their diseases, except this child, who is shown as a perpetrator of hers.  

In your description of the cover’s more idyllic images, you quote Norman Rockwell: “I paint life as I would like it to be.” We would like to offer up another of Mr. Rockwell’s quotes: “Right from the beginning, I always strived to capture everything I saw as completely as possible.” The narrow, incomplete and negative view of the obese child so painfully portrayed on the cover demonstrates the narrow, incomplete view that many people have of obese children and obesity itself. 

If we only focus on the doubt and difficulty of changing individual behaviors, we will not reduce the prevalence of obesity as significantly as if we address systemic factors.  Continual perpetuation of stigmatizing images of obese children reinforces beliefs that obesity is a problem driven only by individual behaviors. Such stigma serves to dehumanize obese people, and may even serve to perpetuate obesity itself.³





Asheley Cockrell Skinner, PhD

Stephanie E. Hasty, BA

Eliana M. Perrin, MD MPH 

References

1.         Yale Rudd Center for Food Policy and Obesity. Guidelines for the Portrayal of Obese Persons in the Media. 2012; http://www.yaleruddcenter.org/resources/upload/docs/what/bias/media/MediaGuidelines_PortrayalObese.pdf. Accessed May 9, 2013.

2.         Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology. Sep 2003;22(5):533-540.

3.         Puhl RM, Latner JD. Stigma, obesity, and the health of the nation's children. Psychological Bulletin. Jul 2007;133(4):557-580.

The Political Destruction of Health Research

The Washington Post has a fabulous interview with Elias Zerhouni, a former NIH Director, about the effect of the proposed NIH cuts in the federal budget.

The projected cuts are 8.2%. Zerhouni does a great job explaining why this is particularly devastating to an organization that functions on long-term research.

I hear lots of arguments about why this is really not so bad.

1) "Research should be in the purview of the private sector."

Rely on market forces for medical research, and you get research that produces all sorts of new hormone treatments, but not the research that shows how the hormone treatments harm women. What you will get is research that is profit-driven, not health-driven.

2) "Some of that research is so dumb anyway."

Hear about the study that used recovery funds that had people mail in toenail clippings and measure nicotine exposure? It might sound crazy, but it actually aims to determine people's risk for lung cancer--and understanding risk is critical to protecting health. Believe me, I've gone through the grant-funding process. I'm sure a few crazy things slip through the cracks, but I can assure you most things that sound crazy are probably actually pretty important.

3) "We need to spend money on 'real' jobs."

I'm a puny little researcher, with very little grant funding, in comparison to those around me. But even I have--in addition to what I like to pretend is some half-decent research, in the world of incremental findings--created two jobs. Created two jobs with (sort of) decent wages for bachelor's-level individuals--not "fancy scientists". Huge portions of grant funding goes to personnel--and much of that goes to creating jobs at many levels. Researchers, for sure, but also the assistants, administration workers, project managers... 8.2% cuts won't just be felt by "researchers" but by people who work in all sorts of jobs.

Cuts in medical research hurt everyone. And they will continue to hurt everyone even if funding is restored, because researchers like me won't be able to stay in research, and will have already left. If I'm not funded, I don't have a job. My "cushy faculty job" is entirely dependent upon my success with funding--which is largely government-based. I'm still fighting the fight, but it's not something I can do forever. Many of the bright minds--the person who could find the proverbial "cure for cancer"--will leave the field, and that gap in brainpower will be felt for generations to come.

Isolationist Science and the Failure of Obesity Research

I'm an "obesity researcher". I have to admit that I'm not 100% sure what that means. I'm interested in the health issues that affect people who are overweight or obese, but I'm also interested in those health problems when they affect "healthy weight" people. I'm interested in how weight has changed across the population over time, and I'm interested in understanding the huge, complex system that led to those changes.

Even though I'm an "obesity researcher", I'm becoming more and more disillusioned with obesity research with each passing day. In some ways, I can see how "curing" the obesity epidemic seems to us now much like early efforts to "cure" infectious diseases. Except that with obesity, it's not that there aren't any easy answers--rather, there appear to be virtually no answers at all.

One of the reasons I think obesity research has struggled to find a "cure" is that most of the work aims to determine how much some variable affects obesity. Oh, everyone acknowledges that obesity is a complex problem, with many influential factors. But when it comes time to actually do research, we fall back on the traditional "randomized trial as gold standard" method of research (and I am most assuredly guilty of this myself). For a problem like obesity, it really doesn't matter how much any particular variable affects the outcome. It matters how all the variables work together. It matters how all the variables feed back on each other. It's "the system". (Click the picture for a blog post and link to an interactive version.)


 

There is certainly a (relatively) small group of people trying to think about obesity from this perspective. And almost any obesity researcher would agree that the above chart is "true". But doing this well requires funding, and funders make their decisions based on the wisdom of seasoned researchers, and most of these researchers find it particularly difficult to break out of the clinical paradigm of isolating a single variable.

At the moment, though, I'm struggling to decide if I should continue to fight the paradigm, or perhaps just go work at Waffle House. (See how complex obesity is? My decision on whether or not to study the complexities of obesity will affect my obesity!)

Do we really know the best nutrition policy?

If it's possible to reblog from wordpress to here, I don't know how. But here's the link to an amazing blog post from Laura Schoenfeld, about nutrition policy in the US.

I'm not even going to try to write much more about it, because she does such a great job. All I can say is that we really take for granted that our nutrition recommendations are based on science and evidence.

A New Approach to Data?

We all know that new technologies are changing how we do research. One of the most interesting was first introduced to me several years ago by a student of mine, who was particularly interested in how social media spread information about health-related issues. The first goal was to see how accurate the information was, but I think it's becoming more and more obvious that social media can be used to identify things more quickly than traditional research methods.

A post by kottke shows a fascinating result of using Google to identify disease breakouts. This picture is the interesting point:

The Orange is US data, Blue is Google-based data.

The tracking of certain Google search terms is very, very close to CDC data. What appears to be happening, though, is that Google identifies the trends a couple of weeks before CDC data.

Potentially more interesting, though, is what this could mean for other types of disease outbreaks. The US has a good system for tracking certain infectious diseases, particularly flu. But what about for diseases or problems that are newly emerging? Can we use Google, or other social media, to identify problems before we even know there is a problem we should be looking for?

We haven't even begun to understand how we can make use of all of the data that are being generated by millions of individuals across the world. This is the true "new frontier" of research.

Inertia

A Forbes article from earlier this month tries to dispel the myth that doctors will only increase their (uncompensated) work burden if they are willing to communicate with patients via email. Personally, I communicate with my physicians via email--I actually go so far as to nearly use that as a criteria when choosing a physician. But I think this form of communication is important for a far greater reason.

The power differential in the doctor-patient relationship is a key factor in how a particular patient's care will proceed, as I've written about before. Email has the benefit of being a low-pressure method of communication, one that doesn't require confident, direct interaction. Many individuals, no matter their background, find it difficult to speak openly with their physician, to ask questions, to be sure they are sharing all of the information and history they should. But email provides an opportunity for the patient to carefully consider what they want to say, and to do outside the pressure of the exam room. Patients may share information--some which might be critical to providing the best care--that might otherwise be left out or simply overlooked.

As technology becomes more and more integrated into all aspects of life, including medicine, health care will have to embrace these changes. People are embracing them. We can't let inertia prevent improvements in care.

Dangerously Stubborn

I stumbled across this article in Slate today, where a leading environmental activist professes he was wrong about opposing genetically modified crops. In and of itself, it's an outstanding, and seemingly courageous thing to do.

I say "seemingly" because, in truth, this is how science should always be. The steadfast adherence to a particularly belief is one of the most dangerous things in science, and one that far too many scientists are guilty of. I understand, I really do. It's difficult to write something and then go back later and say that maybe you were wrong. But the point is, barring truly poor or fraudulent science, studies aren't ever wrong--they just all provide different results. The entire point of the scientific method is to replicate until the preponderance of the evidence suggests a particular hypothesis to be true.

Unfortunately, we live in a scientific world where novelty is valued over replication, regardless of what it means for a particular hypothesis. I do believe we are making some strides, particularly with the advent of journals whose purpose is publish either negative findings, or to publish other things that might not get much interest but are still scientifically sound.

As I have begun to pay more attention to this phenomenon, I've become more determined to not allow myself to fall prey to this pressure. I hope, throughout my career, that I will be able to recognize and admit when I am wrong, and that I will always work towards doing the right things, as a scientist. I probably won't have a very storied career, but at least I'll know I've done well.

No child left behind in recess?

Earlier this week, the American Academy of Pediatrics issued a new policy statement on the importance of recess during school for kids. Recess is NOT the same as physical education, the statement makes is clear that both are needed.

This certainly isn't the first time that we've been told that kids need more recess. As childhood obesity has become a mainstream issue, many parents and policymakers have argued that recess is critical for kids to ensure they are active during the day. However, many schools continued to focus on classroom instruction time, particularly with regard to the standardized testing required as part of No Child Left Behind. My personal experience has been one of frustration with the seemingly endless amount of class time and homework for my children, but I'm also sympathetic to the administrators and teachers who are so dependent on successful testing scores.

One thing the policy statement makes clear (and this is not new information, but it's always nice to see it in an actual policy statement) is that recess is not good just for children's bodies, but their social, emotional, and cognitive development. In short--if you replace class time with recess, you get kids who are more successful in class.

Will this make a difference? I just don't know. I think the culture of testing has become the axle around which all of public school instruction turns. A policy statement is a start, but schools have rarely heeded the advice from non-educational professionals. I don't think it's because they don't want to, but because the risk of poor test scores is too great. We've created a monster that, in its effort to hold teachers and schools accountable to children's educational success, is not held accountable for the damage it does to children's overall health and success.

Is obesity really a health issue?

I've long had concerns about how we measure and define overweight and obesity, and what it means for health. The entire reason to wage a "war" on the "epidemic" of obesity is because we want to improve the health of individuals and the population. Many studies have demonstrated previously that being overweight and (in some cases) obese is NOT a risk factor for mortality. Obesity only becomes an issue at levels of "Grade 2 Obesity". However, I've always found it difficult to reconcile the data with the message. These studies--and I've been involved in a few related to child obesity--are difficult to publish, precisely because they go against the paradigm, and when they are, they receive little attention.

Yesterday, a study was published that should have helped bring the matter to a close. In a meta-analysis of 97 studies, representing nearly 3 million people and 270,000 deaths, Flegal and her colleagues demonstrated that being in the overweight category (so, a BMI of 25-30, the lowest of the overweight groups) was associated with lower mortality than being "healthy weight". Grade 1 obesity (BMI 30-35) was associated with no difference in mortality.

This is not an inconsequential finding. Meta-analyses have their own set of critiques, but, at least in my opinion, this one addresses to the extent possible most of them. They appear to have a rigorous a clear protocol for selecting the included studies, and perform the analyses in several different ways (presenting all of the findings). Indeed, Dr. Flegal herself is a well-known obesity researcher at the National Center for Health Statistics and has played an important role in development of obesity-related research. If she has any subconscious bias, I would expect it to be in the direction of demonstrating overweight obesity are bigger problems.

The authors make very little comment on the meaning of these findings. They do, however, note that possible explanations include earlier presentation to health care for heavier patients (meaning more screening for risks), and higher metabolic reserves (a fancy way of saying that when you get cancer or other severe illness and lose a bunch of weight, heavier people can tolerate that better). An accompanying editorial (which, unfortunately, can not be accessed for free) extends the discussion a bit, but discuss whether BMI is a good measure of obesity (in terms of fat tissue) and that, of course, weight alone should not be the only factor a physician considers when estimating a patient's risk.

What no one is willing to come out and say is this: Maybe overweight and (moderate) obesity are just not a big deal? Maybe we defined these "diseases" all wrong, and maybe we're creating problems that don't really exist. Maybe we let social perceptions of what someone "should" look like effect these definitions? Maybe we have been unwilling to consider the possibility that overweight is not a health risk because we are so invested in the paradigm of obesity = really, really bad that we are unwilling, as a field, to step outside that paradigm.