Oh, Splenda, I can't even

This morning I ran across this little beauty. My initial reaction is that it’s just more of that unconscious weight bias inherent in our society. Today, though, I found that I didn’t like the negative connotation that implied. I think of all the things I’ve learned in my life, and I wouldn’t want people judging me on my actions about something before I knew better. We need a way to describe our society that captures the unique difficulties faced by people of size or with obesity while not demonizing those who are thin.

Some of this alteration to my thinking came from my 15 year old daughter, who has very passionate opinions about the social justice implications of the heteronormativity of our society. (Would anyone think less of me if I admitted I don’t think I’d heard the term “heteronormativity” until she taught me?) What I really like about the term is that it gives an explanation for the difficulties experienced by those who do not fit into traditional gender roles and heterosexuality. But while identifying heterosexuality as a societal norm, it does not imply that heterosexual individuals have done anything “wrong”.

I realized this matters a great deal in how we perceive weight bias. Underlying the terms we use—thin ideal, thin-obsessed, weight bias—is some level of assumption that thin is bad or that individuals are responsible for the things they say. Just like obesity, the truth is a much more complicated picture. It’s acceptable for Splenda to say “This packet has been approved for swimsuit season” not because Splenda wants to stigmatize people and we’ve simply allowed it to happen, but because our society just assumes that thin is what people are always striving for. 

In order to shift the view from “people with obesity are stigmatized” to “we need to recognize the societal roots of our beliefs”, we need a better term. Heteronormativity does not suggest that those of other sexual orientations aren’t stigmatized—of course they are. But it recognizes that stigma as rooted in a deep societal construct. By understanding what underlies stigma related to sexuality, we can consider how best to alter that stigma and lessen the strength of society’s heteronormativity.

We can do the same with obesity. If we better understand what underlies the stigma experienced by people with obesity, and accept it as a societal construct—let’s call it “thin-normativity”—then we can better isolate where stigma is rooted in individual prejudice and where it’s instead the unsurprising result of a thin-normative society.

After all, if we want people to understand that obesity is a complex issue and not simply the fault of individuals, don’t we also need to understand that weight bias is a complex issue and not simply the fault of individuals?

People-First Language

At the most recent meeting of the Obesity Society, the use of people first language was widely encouraged. "People first" means using obesity language in such a way that it is not part of the person's identity, rather that it's indicated as a condition. So, saying "people with obesity" rather than "obese people".

People first language stems from the perception that obesity is a disease, something I regularly debate with myself. As an obesity researcher, I'm a huge proponent of people-first language. But the reaction of others has been, well, mostly confused.

When trying to explain the concept--to highly educated PhDs, no less--most seem very confused. "People with obesity" works okay, but "people with overweight" just sounds strange, and that is apparent on the faces of those I try to explain this to. Some people also think the distinction is silly, that "obese people" is not offensive, that it's simply a descriptor.

But I think there is an important difference. "Obese person" makes obesity part of the identity of the person, makes it an attribute. "Person with obesity" makes obesity something that happens to a person. Using "obese person" perpetuates the concept of blame and responsibility. We haven't reached a point in the public perception that people with obesity are not blamed and held responsible, but I hope we have in the research arena. Our use of people-first language is most important in how it influences perceptions of a wider audience.

But we don't. A quick survey of the most recent issue of Obesity, fewer than 15% of articles demonstrated use of people-first language in their titles and abstracts. How do we encourage this use without seeming to either obsess over small details or scold those not using it? I don't have a brilliant answer. I think the most important thing we can do is model the behavior. I try to always use people-first language, and I bring up the concept with students, fellows, and colleagues when opportunities arise.

People first language has become the norm for most other health conditions and disabilities. However, there is plenty of reasonable criticism. One argument is that by forcing people-first language, especially in awkward ways (like "people with overweight") actually has the opposite effect of the goal to focus on the person first. Others argue that taking on the identity of a disease or disability is not inherently bad, as the condition is inseparable from the person.

Personally, I believe we should continue to promote people-first language with obesity. Individuals have the right to take on the identity of obese, or fat, or anything else for themselves. But the language we use shapes the perceptions of the world around us. People with obesity already feel like obesity is their defining characteristic, and most do not want it to be. Most just want to be seen as people. We can use other conditions (diabetes, for example) when explaining the purpose of people first language. But the most effective thing we can do is just use it. All the time.

Weight Stigma is not a Myth, or Why You Should Never Trust Headlines

Across my Twitter feed this morning, I kept seeing a link to this headline:

"Weight Discrimination is Surprisingly Rare, Study Finds"


I feel very strongly about stigma against people with obesity (and those with mental illness or lung cancer or any other stigmatized health condition). So, I was, of course, immediately drawn to the study. Despite substantial evidence that people with obesity ARE discriminated against and stigmatized, I try to keep an open mind. It's also important to allow my personal experiences and beliefs to change in the face of new evidence.

After some in-depth looking, I've decided this is a particularly egregious example of a headline that does not adequately represent the study. The logical interpretation of the headline is "people with obesity rarely experience weight discrimination." The study is in Obesity, and the reporting is from Discovery, so it shouldn't be too far off. Right?

Let's start with the obvious:

Weight Discrimination Is Surprisingly Rare, Study Finds

 

Yes, we have a statement that weight discrimination is rare directly above a photo representing weight discrimination.

The story reports that "only about 5 percent of people reported experiencing such discrimination." There are two important definitions here--people and discrimination.

People are all people, not just those with obesity. The people asked are actually pretty representative of the population. That's like asking a group representative of Americans if they experience racial discrimination and then reporting that bias against African Americans is actually not very prevalent. Of course healthy weight (and underweight) individuals can experience stigma, just as white individuals can experience stigma, and I don't want to pretend that never happens. But it's seems clear that if you want to understand discrimination, you ask those most likely to experience discrimination.

The authors of the study did indeed provide separate analyses for discrimination among individuals with obesity. What they found is that 35% of the "most obese" experienced discrimination. Over one-third.

And what is "discrimination," you ask? The study asked 5 questions, each representing pretty broad domains. Experiencing discrimination was defined as experiencing it for at least 3 of the 5 questions (as reported by the story). So, being stigmatized by your doctor is not enough. That's not "real" discrimination. You must also be given poorer service in stores and have people think you are stupid. Only then can you count it as "discrimination."

Oh, please.

[I'm going to make a note here that the news article and the actual study report different things. I can't determine for certain what the definition was of weight discrimination.]

In any case, that "rare" discrimination is actually that a third of people with class II or class III obesity experience discrimination. [For reference, take a look at my picture. I have class II obesity.] A THIRD of these people experience overt discrimination which they attribute to their weight more than they attribute it to their age, gender, or race.

What's perhaps most disheartening about the entire reporting of this study is that it completely overlooks the far more interesting finding: people who experience discrimination are more likely to gain weight and those who do not are more likely to lose weight. Not only does the headline incorrectly minimize the prevalence of stigma, the story completely overlooks the negative implications of weight bias.

This has to stop. Benjamin Radford, the author of the story, claims to want to understand why people believe things for which there is little or no evidence. Perhaps people believe in such things because most people do not have access to the real evidence, instead relying on stories with inaccurate representations of "evidence."

The reporting of this study is, in and of itself, a clear example of weight discrimination. It claims, despite widespread evidence to the contrary, that the perception that overweight people experience social discrimination and harassment is a "myth." Yes, he actually used the word myth. It neglects to note the significant harm that weight bias causes, not only on weight, but general well-being. The authors themselves end their study with: "Our findings underscore the need for effective interventions at the population level to combat weight stigma and discrimination."

Weight-stigma is not a myth. While we will never be able to control the media, we researchers need to work much harder in developing an accurate message and helping reporters present it.

Is Obesity a Disease?

Is obesity a disease? This is a question I ask myself regularly and have many internal debates in my efforts to answer.

On the one hand, I want the health consequences of obesity to be taken seriously. In the spirit of The Obesity Society's "I Treat Obesity Seriously" campaign, I want people needing treatment to have access to it. I want people to have access to evidence-based, sound treatments, with plenty of options between the extremes of "just eat less" and bariatric surgery.

On the other hand, obesity is currently defined as a size. As Dr. Sharma told us at this week's Your Weight Matters Convention, anatomical descriptions of obesity don't tell us anything. By using definitions--even if they can be calculated with numbers--that ultimately rely on visual cues, I worry we further stigmatize people who have obesity.

In order to think of something as a disease--and treat it seriously, we (1) need a definition that demonstrates health impact, (2) we need ways to screen and identify individuals with a disease, and (3) we need treatments to offer them.

The CDC, and pretty much everyone else, defines obesity based on BMI. Of course, BMI doesn't distinguish fat from muscle, subcutaneous fat from visceral fat, healthy people from unhealthy. There have been some good attempts to "score" obesity in terms of health, including the Edmonton Obesity Staging System. They are huge improvements, but we don't have enough evidence to define obesity using them alone. Does my BMI-defined obesity remain "obesity" because I think Prevacid is the best drug ever invented, or do I need to have actual GERD? Is a tight airplane seat enough functional limitation, or does it have to reach the point I buy velcro shoes?

For that matter, how we are we going to implement and screen any sort of health-based measure like this? Do I have to have a high BMI? I could have high percent body fat and a low BMI. What about all of the people who have a low BMI and conditions associated with obesity? If we use size as the fundamental requirement for defining obesity, how do we get past the stigma of the current societal perceptions of size? BMI is used because it's so easy to calculate. Really identifying when a high BMI is problematic requires more effort--a fasting lipid panel, for example, along with many other assessments.

One of our greatest challenges is that there are too few treatments for obesity. Intensive lifestyle interventions can work, but they don't always, and they aren't readily accessible to everyone. There are a few new drugs, but pharmaceutical treatment continues to struggle to overcome the black mark of Phen-Fen. Obesity treatment research is painfully hampered by the perception that obesity is the fault of the person with the obesity. The unremarkable success of current treatments has led to a focus on prevention, assuming treatment will never work. But we don't know that treatments won't work--we just haven't found them yet. What if we stopped trying to find cancer treatments because early efforts were not successful?

The "obesity epidemic" is not something that we can solve overnight. Prevention is a key element, but until we regularly use health-focused definitions, recognize the complex factors underlying obesity, and develop effective treatments, we will never succeed. Paraphrasing Ted Kyle, we are "writing off an entire generation, perhaps two generations." And we are doing this because of our unwillingness to accept that the failure is actually our own. We researchers, clinicians, and policymakers have failed people who have obesity because it's easier to say "people just need self-control" than "we have done a terrible job defining this disease and developing treatments."

Passing the blame is simply unfair. We will only ever be able to "Treat Obesity Seriously" when we take responsibility for developing serious health-focused definitions, step away from body size stigma, and focus our energy on real, effective treatments.

Obesity Stigma in Health Care Education

I'm sure I sound like a broken record.

Even though I'm not a physician, I regularly get emails about continuing medical education and "diagnosis of the week" challenges. This one was brought to my attention by a colleague, however.

Here's the email:

It's perfectly acceptable to present an accurate image, even if we don't like it, in medical education. However, there are multiple images available of the rash, including the arm. The image of the large stomach, cropped to ensure the breast is hanging over is the one chosen.

Most correctly identified the diagnosis--erythema ab igne. However, they are then presented with a menu of options for the underlying cause of the diagnosis:

 

Of course obesity is one of the options. It's an obvious physical characteristic of the patient, even though the patient is otherwise healthy.

But here are the responses by the community (green is correct): 

Most of the doctors respond that obesity is the underlying cause of a relatively uncommon condition that many could identify. Obesity is NOT the correct answer.

This kind of subtle (or overt, depending on your perspective) discrimination against people who are obese is what those people have long claimed to experience in health care. Nearly half of doctors would have told this young man to go lose weight, completely ignoring the real cause of his problem.

Many people with obesity deal with this regularly. While many health complaints may be related to obesity, few, if any, are directly caused only by obesity and nothing else. Obesity may contribute to the severity of some conditions, but many health problems of people with obesity are completely unrelated.

I've often heard people say that the perception of stigmatization in health care is just a perception secondary to a sensitivity towards being judged. But the kind of evidence above, where obesity is blamed when it shouldn't be, tells me that this bias is real. When in doubt, it's easy for doctors to fall back on the most obvious "problem" to fix. This is certainly not the case for all doctors--I know many who work hard to specifically NOT allow such bias to creep into their work.

I hope more doctors will start to realize the danger of blaming obesity for too many health ills. Obesity is incredibly difficult to change, especially without substantial resources unavailable to many. Focusing on health improvement will yield far more successful results.