Treat the Obesity First?

So, I've been struggling with an internal debate about the new guidelines from the Endocrine Society about treating obesity and comorbidities.That's why I'm late to this party.

On the one hand, I think recognition of obesity as something that can and should be treated is great. On the other, I worry that putting obesity--defined here solely by BMI--above actual health problems is a risky, dangerous proposition.

The Good

It's refreshing to see guidelines for obesity treatment that view medications as positive and not as last-resort efforts. Of course, these are the guidelines for "Pharmacological Management of Obesity".

There is a clear recognition of the array of factors that cause obesity. 

The Bad

The labeling of individuals with obesity is clear from the start. Throughout the document, individuals are referred to as "obese patients" while diabetes is "patients with diabetes", not diabetics. The first and most important step in treating obesity appropriately is recognizing it as a disease, not a characteristic of the person.

One of the only recommendations they make based on the highest-quality evidence is that lifestyle modifications be included in all obesity treatment. I'm not pretending for moment that lifestyle modification is NOT useful, but it doesn't work long-term. A wide variety of reasons exist for this, from an unsupportive environment to metabolic changes occurring as a result of weight loss. The evidence is just not that good.

Successful treatment is defined only as weight loss. If someone stays at exactly the same weight, but show clear improvements in health, have we failed?  If weight loss occurs and there are no improvements in comorbidities, have we succeeded?

Health, not weight

I suppose my greatest concerns are with the media reporting of the guidelines, more than the guidelines themselves. Most articles report, and the lead author comments, that the "new paradigm" is the "treat the obesity first, then the comorbidities". I think the message should be "treat the obesity along with the comorbidities" and that's actually closer to what's in the actual guidelines.

Treating obesity is something that we absolutely, 100% need to do, and do more effectively. However, I can't overstate my opinion that we must view everything through the lens of health. Obesity is not simply size.

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.

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.