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.

Really, JAMA?

Definitely not what most of us want to see on our twitter feed.

Stigma in Children's Healthcare

Originally posted at the Obesity Action Coalition, so a little different than my usual posts. But do check them out.

I was talking with one of my public health students, the mother of an eight-year-old, when she told me that she was worried about taking her little girl to the doctor. She was embarrassed because she knew the doctor was going to tell her that her child was “overweight.” How awful, I thought, that advice about a child’s weight could be so uncomfortable that a parent, even a student of public health, would rather just avoid the visit.

Is this real? Are doctors stigmatizing children affected by obesity and their parents? If they are, how are they making their judgments, and communicating them to patients?

What exactly do we mean by stigma? It’s not easy to define. Stigma is the judgment of some aspect of a person’s physical appearance, health or behavior. This includes a person’s weight. Stigmatization happens when people are treated badly, blamed for their characteristic, or have assumptions made about their behaviors. For example, many people with obesity are judged for their size, with other people thinking that they are lazy or lack control.

Although we are used to seeing stigmatizing ideas and pictures on TV and in press, we don’t expect it at the doctor’s office. The unfortunate truth is that, although some doctors are careful to avoid bias, healthcare providers regularly pass judgment on children affected by obesity and their families.

Few doctors are stigmatizing children and families on purpose. Whenever a doctor sees a child for a regular visit, he or she has a long list of information and advice they want to share with the child’s parents. They want to see that the child is growing well, learning well, creating healthy friendships, and getting the right vaccines, among many other things. All of this is shared before the parents even get to ask their own questions; it can be too much to squeeze into just a few visits a year.

In the midst of all these discussions, doctors use growth charts to tell parents that their child is affected by excess weight or obesity. Many parents are surprised – children with obesity don’t look like adults would expect. Children are naturally very thin, and can look thin even if they are heavier than they should be.

This takes time to explain, and time is very limited in most doctor visits. The conversation can be difficult for parents and children. Many patients feel like their doctor is judging them because of their weight. They are often right to feel this way, as studies have shown that a majority of medical students and doctors have negative beliefs about their patients with obesity. It’s easy to see how these beliefs can affect how they talk with their patients, even if they don’t intend to be hurtful.

While most doctors agree that we should not pass judgment on children, some do believe it is beneficial to put pressure on parents for the child’s weight-loss, something that has been called “stigma lite.” Yet we know that stigma in any form just doesn’t work. In fact, it usually backfires, making families less motivated to make healthy choices.

Most doctors who are trying to provide advice about obesity are not knowingly stigmatizing the child or the parent. But, without a careful approach to the subject, it is easy to see how parents may feel that way. Doctors often give advice that seems easy, but is hard for many families. When faced with the difficulties of daily life, it can be hard to imagine how to help a child “just” be more active.

About the Author:
Asheley Skinner, PhD, is an Associate Professor of Pediatrics at the University of North Carolina at Chapel Hill. She has written many papers about the childhood obesity, including health outcomes and obesity stigma. She is committed to developing ways to improve obesity without causing unintended harm. 

Next Week…

Join us next week as we will talk about how to talk to your child’s doctor about weight, and how to help combat stigma with your healthcare providers.

"How much weight do you need to lose?"

Over the weekend, I was asked by a friend of mine: "How much weight do you need to lose?"

Now, she was three glasses of wine in, so perhaps not her most articulate. It was definitely not intended as the harsh question that it could seem from the outside--it was a genuine inquiry from a friend with whom weight is a not uncommon topic of discussion. I cocked my head and looked at her for a moment, trying to decide if this was a good time for honesty. I'm generally on the fence as to whether the lowered walls stemming from alcohol are useful opportunities for challenging beliefs. As is generally the case, honesty won out.

"How much weight do I need to lose until what?"

I watched the wheels spin as she processed the question. Because, of course, everyone is supposed to be trying to lose weight. I'm the largest of our group of friends, so if everyone else is trying to lose weight, then surely I must be, too. She stuttered through her answer:

"Lose until...until...until you are happy."

Ah, there we go.

We all have many reasons for wanting to change our bodies. I've spent most of my life on the "if I could just get to XXX pounds I'd be happy" bandwagon. Here, this beautiful, wonderful woman, a mother and daughter and friend with a generous heart and who never fails to make me laugh, wanted to understand how far she was from the happiness that is rightfully hers.

There are plenty of reasons to want to lose weight. I wouldn't mind losing weight because I think running would be a little easier on my ankles and I could probably jump a little higher in Jazzercise. It would be nice to easily find fun clothes, as my current 16/18/20 is the point where almost all stores have decided I'm not a woman worth clothing and the few who have do so in a typically boring fashion. I'm an academic in a world where my large size virtually always distinguishes me from others in the room. I'm by no means immune to the thin ideal in the world around me, but I answered her honestly:

"I'm already happy."

I said I was happy with my body as it is. That I use it to run and dance and enjoy food and house the brain that makes me who I am. That after spending years trying to change my body, I've decided to give it a go with the one I've got. And to be happy about it. It's an imperfect plan, and there are some bumps, but for the most part I'm succeeding. 

She looked at me a bit wistfully, and all the unspoken pressures of being a woman in the world passed between us. My heart ached for what we as a society do to each other. That, under the guise of health and beauty and self-control and puritan perfectionism, we aren't allowed to simply own our happiness.

"Wow," she said. "I really wish I could feel that way."

The Researcher's Promise

I've had one of those days where I'm questioning whether researchers should even be allowed to present their findings to the general public.

It started with the report on the increase in autism rates. I don't want to minimize the devastating effects of autism on families. But it reaches a point that it defies credulity. A jump from 1 in 88 to 1 in 68? In two years? And with a nearly fourfold variation between the lowest and highest states? (Alabama and New Jersey. Can you think of some differences between Alabama and New Jersey to explain that?)

Another study reported that a third of school-age kids have borderline or high cholesterol. These were kids between 9-11, a time we know cholesterol increases naturally--and is probably a necessary increase. And we have no clue how or if this affects them as adults. (By the way, this was just a meeting abstract, not a peer-reviewed paper.)

And, of course, there's the study showing that toddler obesity plummeted, one with significant issues I've already written about. Another writer posted about it recently, raising a different set of (equally valid) problems. An interesting tidbit there was that the author of that piece was not giving media interviews. (And I'm trying to not be bitter that no one cared when I made my arguments a month ago!)

As a researcher, I've had to learn to understand the media, and learn to understand how to present my findings. I'm sure I've stumbled. But this is something we, as researchers, absolutely HAVE to learn--how to explain what we've found. And we have to be absolutely sure what we are presenting is accurate, not just statistically, but in how it gets presented.

Why is this so important? These three studies tell me 1) autism is increasing at a rate that will eventually make it the scourge of the US, 2) a third of kids need intensive cholesterol interventions, and 3) obesity is all better. None of these things are true. Autism prevalence is still a mystery tied up in diagnosis rates and societal norms for "disorder". The only kids who really have cholesterol problems are a small group with genetic hypercholesterolemia--the rest are probably just growing. Obesity, or whatever we want to call this increase in body size, is pretty much unchanged.

Our studies, when promoted in the media, are the foundation of public discourse. They determine the policies that get developed, the programs that get funded, how the public perceives health problems. Carefully putting information in the public domain is our responsibility. We work so hard to do good work and get it into the journals. But that is only the first step. Of course we don't have complete control over the media--but too many of us denigrate journalists as not understanding researchers. That's not true at all, in my experience. We, the researchers, seem to not understand the rest of the world.

I think we need a researcher's promise (with some inspiration from the Girl Scouts).

"On my honor, I promise to always try to ensure my work serves the people of this world, to take an active role in translating the message to non-researchers, and to generously offer my knowledge and time in making research have only a positive impact."

I'm willing to consider edits on that promise!

Be Wary of the Headlines: Has Toddler Obesity "Plummeted"?

Yesterday, a study was published showing the prevalence of obesity in children and adults over the last decade.

The headline that was commonly seen was "Toddler Obesity Plummets". This insinuates that the main story out of this study is that we are winning the "battle against obesity".

Let's look at two things: What the study says about toddler obesity and what it says overall.

First, the study did indeed find that toddler/preschool (ages 2-5) obesity in 2011-2012 is much lower than it was in 2003-2004. However, what it also showed is that the drop happened right after--in 2005-2006. In fact, if you look at the authors' previous work, you can see that it was much lower in 2001-2002. For some reason, 2003-2004 was anomaly in NHANES, or in obesity rates. The rates went from ~10% to ~14% to immediately back down to about ~10%.

To say that toddler obesity has plummeted in the last decade in disingenuous at best. It has only decreased when making the very specific comparison of one two-year cycle. The trend over the last decade is not significant. The authors do acknowledge the importance of the comparison, but do not discuss the very important difference in 2003-2004.

Second, although obesity in young children dominated the headlines, the paper actually examined children and adults at all ages. The real story of this paper, in my opinion? Nothing has changed. It hasn't changed for young children or teenagers, for young adults or older adults.

Don't let a shocking headline distract you.

Doing Anything to Not Be Fat Anymore

Much has been going around today about the most recent "winner" on the Biggest Loser. Rachel won the contest, with an ending weight of 105 pounds--equivalent to a BMI of 18 for her height, which is underweight. There are plenty of good discussions I won't try to repeat, including this one, where the writer says that the message is "if you are fat, you should do whatever it takes to not be fat anymore".

That message is absolutely true, and permeates everything in our society. We had a lively supper discussion this evening, including my 14 year old daughter. I don't want to throw around "eating disorder", because that represents a diagnosis. But I will throw around ideas like "disordered eating", "unhealthy weight loss", and "obsessive relationships with food and or exercise".

Let's start with the science. One place obesity researchers turn to is something called the National Weight Control Registry. This is comprised of a group of people who lost at least 30 pounds and kept it off for at least one year. Now, this is certainly a bar lower than that achieved by contestants on The Biggest Loser, but plenty of the people within this registry have experienced such weight losses. Almost all of them report having eaten less and exercised more as part of their weight loss strategy. But let's take a look at what makes them the most successful. (Yes, it's a news outlet. If I link you to a journal, most of you will get stuck behind a paywall. Some trust must ensue.)

They never cheat, even on holidays and special occasions. Count calories constantly. They weigh themselves every day. Exercise every day, equivalent to nearly 30 miles a week. Eat up to 300 calories a day less than others--meaning less than other "thin" people. These are just the averages, so plenty of people are above that.

Like I said, I'm not going to toss around the idea of "eating disorders", but that seems a bit on the obsessive side to me. Maintaining a weight loss doesn't mean being active and seeking out healthy food. It means thinking about your weight ALL THE TIME. Even when you've already reached that Holy Grail of "Healthy Weight".

Is this what we want? We certainly advocate for people to lose weight. Since these strategies are some of the only ways to maintain that loss, it would seem it is what we want. However, these characteristics--obsessive restriction of food, obsessive exercise, obsession with weight--are hallmarks of eating disorders. It is, of course, much more complex, but my point is that perhaps we should consider whether the behaviors that lead to long-term weight loss "success" are potentially damaging to mental health.

What's more important is that these behaviors will often be overlooked by medical professionals, as was recently discussed with regard to adolescents. I could show up at my primary care doctor's office with a dramatic weight loss, perhaps 50 pounds, getting myself down into the overweight category. I would be congratulated on my success. Almost any obese person who did that would be. We forget to ask the question of "how did you do that?"

As for our supper discussions, we talked about how this "extreme" approach, being thin at any cost, is more than just an idea held by a few trying to succeed at the near-impossible task of maintaining weight loss. It is the only idea promoted.  

My daughter has a friend who, after trying many different ways to lose weight, and still being told by her doctor that she is overweight, has now decided to limit herself to weight-loss shakes. Her doctor is probably right, based on current definitions, but I seriously doubt this was his or her intended behavioral change. Consider what this child's day is now--constantly thinking about what she eats.

As a real sign of the extreme as the new normal, my daughter's PE class is the INSANITY Workout. I'm completely serious here. Where we live, most teenagers arrive in high school with virtually no physical education under their belts, a casualty of high-stakes testing and intense focus on academic skills. If a child arrives in 9th grade with no math skills, the school holds some responsibility for that. And we divide them up by skill level, ensuring that kids have a chance to succeed at an appropriate level. Not so with PE. After years without PE or other physical training, these kids are doing INSANITY. On top of that, a kid starting with a 15-minute mile--not a crazy speed for an overweight kid who has spent the last ten years relatively inactive, doing 3 hours of homework of night--has to get that down to about 8 minutes in order to get an A. In a matter of 9 weeks.

Oh, and the kids all get weighed before and after.

The expectations simply can't be achieved in a healthy way. Don't get me wrong--I want kids to be a healthy weight. I want them to eat well and be active. But I also want them to enjoy eating well and feel the benefits of being active. An ounce of prevention is absolutely worth a pound of cure. But once they've reached the point of being overweight, we don't just give up them, do we? Do we try to teach them reasonable, healthy behaviors, at the risk of them never achieving a "desired" weight? Or do we push them to extremes to reach that weight?

Obviously, I believe in the message of health and healthy behaviors. But the environment we live in, one comprised of The Biggest Loser and INSANITY and gorgeous women like Jennifer Lawrence being Photoshopped to remove nonexistent flaws, what do you think will win out?