Rebecca Puhl at TOS on obesity stigmatization

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Obesity stigma is a major barrier towards progress for both prevention and treatment. Dr Puhl reviewed how obese people are portrayed in the news and whether they were excessively stigmatized. Over 800 media pieces were analysed. She found that obese people were often portrayed in a very stigmatizing way (for example shown eating junk food while watching TV slumped on a couch) compared to normal weight people (eg often shown shopping for fruit and veg or exercising on a beach).

Programs that attempt to address obesity need to be informative without increasing stigma and shame, which has proven tricky in the past. Indeed, several obesity awareness campaigns have been stopped since they increased obesity stigma for the very people they wish to help, and were therefore (at least partly) counterproductive.

Interestingly, non-stigmatizing obesity awareness campaigns generated much more motivation to change than stigmatizing campaigns. Indeed, stigmatizing campaigns decreased self-efficacy for change and increased anxiety. Since campaigns want to grab peoples’ attention they often use shocking messages, which often produce stigmatizing effects. There is clearly a strong need for balanced and respectful obesity awareness campaigns that also grab peoples’ attention, a known communication challenge.

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Bullying and obesity go hand in hand in so many ways

If you have any working experience in an obesity treatment facility you would be very familiar with the many gut-wrenching stories of bullying that the patients have experienced. A routine question to ask the patients is if they have any clue as to why they gained the extra weight to begin with. It’s not unusual to hear that it all started with the bullying, usually from a young age.

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You may think that this is mainly peer-to-peer, but it can definitely be from parents as well. Usually this would be related to something they perceive to be not quite right with the child, perhaps carrying a tiny, tiny amount of extra weight. The child will then be told that there is something wrong with them. Obviously this is not the case, it’s the parent who is wrong for instilling the child with an erroneous negative self-belief (there is something wrong with me).

And how many stories have we not heard about  the completely insensitive bullying athletics coach/PE teacher who thinks that the child is overweight and needs to lose weight ASAP, and who always picks these children last for the teams, et cetera, et cetera.

The message for these bullied children is unbelievably negative: you are not good enough, there is something wrong with you, nobody wants to be with you. It’s not exactly strange that the obese in general have lower self-esteem and confidence than normal weight individuals, both as children and as adults.

Then there is the more classic case of bullying among children, sometimes from pre-school, because of a lack of tolerance and respect for what looks slightly out of the norm, particularly give our completely unrealistic body shape ideals. More and more studies are now confirming all those anecdotes about the toxic effects of bullying:

http://www.ncbi.nlm.nih.gov/pubmed/25157018

Indeed, obese children are much more likely to suffer bullying than normal weight children, which is confirmed by both the children themselves and also the teachers. But this does not mean that the bullying only happens during the childhood years. Studies on obesity bias and discrimination are becoming much more common, for example by Rebecca Puhl and colleagues at Yale. Please take the time to watch some if not all of this excellent talk, for example on how stigmatization has a profoundly negative effect on our physical, social, psychological and emotional health and well-being:

If we are serious about preventing obesity, we cannot emphasize enough the importance of zero tolerance towards bullying, in whatever form it comes in, and regardless of where it comes from. We also need to address all those negative self-beliefs and fears that arise as a result of bullying. This include things like body dissatisfaction because we perceived our body as the reason the bullying started in the first place.

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I also firmly believe that anyone who wants to lose weight long-term needs to overcome their more or less inevitable body dissatisfaction, and connect in a more positive way with their bodies, as opposed to rejecting them and seeing them as the source of shame and discomfort. The more you have of negative thoughts and emotions in relation to your body, the more weight you are likely to trap. It’s not exactly a surprise that more and more studies are now confirming that bullying leads to weight gain, which leads to more bulling, which leads to more weight gain, which leads to more bullying…

Erik Hemmingsson

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“In my end is my beginning” TS Elliot

ACE pyramidThe ACE study pyramid.

Today I am saluting what I consider to be absolutely groundbreaking research which modern medicine has been ignoring for far too long. The work I am referring to is the ACE study (Adverse Childhood Experiences). This is a large study from the US that convincingly showed that difficult early-life experiences is arguably our leading cause of death, disease, disability, drug use and smoking.  

Let me be a little specific because this subject really fires me up. The researchers measured things like childhood abuse, violence in the family, drug addiction, mental illness, and criminal behavior in the family. Then they performed an analysis to see how such experiences were associated with a wide range of outcomes, including obesity, but also attempted suicide, numerous diseases, smoking, drug use and alcoholism. 

More than half of the participants reported at least one such adverse exposure, a quarter reported more than two, and six percent more than 4. And these were not people from a deprived area, they were predominantly white, college educated, middle class Americans.

Not surprisingly, there were very clear associations between number of adverse experiences and health outcomes. For example, when comparing those with 4 or more adverse exposures with those who had none, the odds ratio of being a smoker was 2.2 (i.e. an increased risk of 120%), 4.6 for depressed mood, 7.4 for being a alcoholic, 10.3 for injecting drugs, and a truly staggering odds ratio of 12.2 for attempted suicide (it’s very rare to see such high odds ratios in medicine, it’s like smoking and lung cancer). In terms of common medical diagnoses, the odds ratio was 1.6 for obesity, 2.2 for ischemic heart disease, 1.9 for any cancer, 1.6 for diabetes, and 3.9 for chronic bronchitis.  

I hereby challenge anyone to find another exposure that comes even close to these risk estimates for the leading causes of death where there is also a very high proportion of the population that is exposed, i.e. population attributable risk. But because of the stigma, shame and taboo surrounding this difficult topic, there is also a staggering lack of awareness of these facts, and hence very little help avaliable.

This has to change and can change if enough people become involved. Please take the time to watch this 13 minute youtube video by the first author Vincent Fellitti (give him and his coworkers the Nobel Prize, I say) on the truly remarkable ACE study findings. 

I wonder how much longer we can go on ignoring this topic and the fundamental role our childhoods play in determining our future health and well-being. Yet modern medicine would have you take next to meaningless drugs, where we sometimes have to treat hundreds for preventing one single case of myocardial infarction or diabetes, with numerous safety issues attached.

But drugs is where the money is, and medicine has shaped itself to a truly gargantuan business model. In many ways, this is an absurd way to practice medicine, especially given the very toxic role of early-life adversity, and the potentially huge beneficial impact of therapy and other holistic methods to overcome such hurts. 

Erik Hemmingsson

If you liked this post, you will have my thanks if you help to spread awareness even more by re-sending it to family, friends and colleagues.  

 

Reference

Fellitti et al. Relationship between childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse life experiences (ACE) study. Am J Prev Med 1998;14:245-258.

Guest blog post at Dr Sharma’s Obesity Notes: Emotional distress and weight gain

Today I am a proud guest blogger at Dr Sharma’s Obesity Notes on the topic of psychological and emotional distress in weight gain and obesity development, see http://www.drsharma.ca. I have been subscribing to Dr Sharma’s blog for years, and I strongly recommend you do the same if you are interested in real solutions for obesity. Arya M Sharma is a Professor of Medicine & Chair in Obesity Research and Management at the University of Alberta, and a tireless researcher, clinician, debater and overall supporter for people with obesity. 

Hidden in plain sight

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Yesterday I gave a presentation at the Nordic Ophtalmology meeting on the topic of weight loss in idiopathic intracranial hypertension (IIH). People with IIH have a large risk of going blind and they have frequent migraines, so treatment is obviously a priority. Patients are usually young women with obesity, and weight loss tends to result in drastic improvements of migraine frequency and strength for these patients, and they reduce their chances of sustaining permanent eye damage.

While the mechanisms for this debilitating disease are poorly understood, there is a clear link with obesity. But when the other speakers on the panel were speculating about why this disease develops no one hardly mentioned anything to do with environmental factors. Instead there was a very clear focus on biological risk factors, such as the increased mechanical pressure exerted by excess adipose tissue, anatomical factors, hormones and the like. While these factors can obviously be important they are likely to be a long way down the causal chain. 

When you consider than the vast majority of patients are young women with obesity, the things that come to my mind as potentially causal are a lot further up the potential causal chain, and include things like social pressures to be thin, body dissatisfaction, stigma, shame, childhood traumas, and stress. These, in turn, lead to drastic changes in inflammation, as well as substantial hormonal and metabolic changes, which could eventually trigger the intracranial hypertension. 

Personally, when it comes to obesity, I am very much leaning towards the environmental factors, specifically psychological and emotional factors/responses that we develop during the early years of our childhood as root causes of the disease. I would not be surprised if this applies to patients with idiopathic intracranial hypertension as well. That is why I think these patients can really benefit from a holistic treatment approach that includes things like weight loss, stress reduction, exercise, body acceptance, cognitive therapy, yoga, and mindfulness.