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.