obesity

This month’s column features our first guest-post from Liz Borkowski, MPH. Liz is the managing editor of Women’s Health Issues and a researcher at the George Washington University Milken Institute School of Public Health. She focuses on reproductive health, paid leave, and US health policy, and is a regular contributor to the public health blog The Pump Handle.

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What’s the best way to help lesbian and bisexual (LB) women lose weight, when their communities may question the very goal of weight loss? That’s a question behind the “Healthy Weight in Lesbian and Bisexual Women: Striving for a Healthy Community” (HWLB) initiative. The answer they came up with was to focus the program on physical activity and nutrition, rather than numbers on a scale. Their findings suggest that this can be an effective approach for helping lesbian and bisexual women adopt healthier habits. Nearly all (95%) of participants achieved one or more of the health objectives, which included nutrition and physical activity goals as well as weight reduction. That included 57% of participants increasing their weekly physical activity minutes by 20% – habits that, if sustained, could contribute to years of improved health.

The Women’s Health Issues supplement about the study contains lessons for healthcare providers who serve lesbian and bisexual women. As Natalie Ingraham and her colleagues explain in an article about provider interventions, lesbian and bisexual women may not disclose their sexuality to providers who seem to presume heterosexuality; lack of disclosure can lead to inadequate care. Weight bias can also be common among healthcare providers:

“…stigma and discrimination related to sexual orientation and gender identity may be compounded by stigma related to weight and body size.”

To address this, the researchers developed and evaluated two curricula for providers to enhance their ability to provide high-quality care to LB “women of size” (overweight or obese). Focus group participants explained that they wanted providers’ help in overcoming barriers to healthy habits, not providers making them feel shamed or blamed for their weight. Based on this feedback and prior studies, the team developed two curricula that involved cultural competency training and motivational interviewing (MI) techniques:

“Rather than trying to convince clients to change, providers trained in MI elicit arguments for change from the clients themselves…These techniques help clients to explore and resolve ambivalence, develop self-efficacy, and set personal goals.”

The team pilot tested the “academic format” training with physicians, residents, and medical students at universities in Washington, DC and Nashville, Tennessee. They pilot tested the “clinic format” training with staff and providers at Lyon-Martin Health Services, a Program of HealthRight360, which provides care to LGBT clients in the San Francisco Bay Area. Ninety-six participants completed tests before and after the trainings; results showed the most change on questions about patient-provider interactions and LB women’s avoidance of care.

Specifically, after the trainings, more participants (correctly) agreed with the statements “Lesbians and bisexual women may avoid health care because they don’t trust the practitioner to be culturally competent” and “Overweight and obese women often delay or avoid health care if they feel their health care provider holds a bias against women who are large.” More participants also (correctly) disagreed with the statement “Physicians/nurses should always instruct their overweight/obese patients to lose weight.” There was also more (correct) agreement with this statement, which encapsulates what providers can do to help overweight clients:

“Patients who are advised by their physician how to modify their behavior to lose weight are more likely to lose weight than those who do not get this advice.”

While the authors of this article note the need for additional research on these curricula – including studies to see whether they improve clinical practice – their findings, combined with the findings of the overall HWLB study, have some clear implications. Instead of instructing all overweight or obese lesbian and bisexual patients to lose weight, providers should offer advice on adopting healthier behaviors. It is key that this advice be presented in ways that don’t contribute to stigma on the basis of larger size or sexual orientation.  To better serve lesbian and bisexual patients, health care providers should familiarize themselves with cultural norms and problematic stigmas that LB women may face. Then, during patient interactions they should make sure to sensitively include “open and positive acknowledgement of sexual orientation.”

This month’s column features a guest-post by Mary K. Assad, Ph.D.: she critiques recent health debates on nutrition and encourages us to question the science behind medical claims being made about heart disease.  Assad is a Lecturer in the English Department at Case Western Reserve University who studies medical rhetoric, with a focus on health communication aimed at the general public.

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In The Big Fat Surprise (2014), investigative journalist Nina Teicholz “lays out the scientific case for why our bodies are healthiest on a diet with ample amounts of fat and why this regime necessarily includes meat, eggs, butter, and other animal foods high in saturated fat.” She argues that current medical guidelines are based on unproven hypotheses about dangers of saturated fat.

Teicholz’s book echoes arguments of writers including Gary Taubes, who in a 2002 New York Times essay and subsequent books urges that medical recommendations for a low-fat diet have caused America’s obesity epidemic. Multiple sources have condemned low-fat approaches and urged Americans to consume more fat and fewer carbohydrates: e.g.,  Dr. Peter Attia’s Eating Academy, Mercola Products and PCC Natural Markets.

As a medical rhetorician and writing instructor, I care about how health messages aimed at the general public transform medical information into public knowledge. We learn about our bodies and health through such discourse. However, distinguishing fact from fiction within these conversations is often more challenging than deciphering the original research studies because writers with competing arguments all cite “science” as their evidence.

While researching women’s heart health for my dissertation, my professional and personal worlds collided: I learned I had high cholesterol at age 29 despite a low BMI and regular exercise. Based on my doctor’s advice (which resembled the American Heart Association’s guidelines), I drastically revised my diet and realized that “burning off” calories is not the same as preventing arterial blockages. Yet, what if my doctor’s advice was misguided? What if reducing cholesterol and saturated fat would hurt rather than help me? The Big Fat Surprise and similar texts call into question decades of medical guidelines. They aim to do more than stir controversy: they seek to persuade us to change our approaches to healthy eating and to distrust medical advice that, presumably, was based on faulty science.

However, close inspection of these texts reveals that they often misrepresent medical research when translating it for the general public. For instance, Attia asserts: “Eating cholesterol has very little impact on the cholesterol levels in your body. This is a fact, not my opinion. Anyone who tells you different is, at best, ignorant of this topic. At worst, they are a deliberate charlatan…To see an important reference on this topic, please look here .” The linked abstract states, “the relation between dietary cholesterol and the risk of CHD [coronary heart disease] is not clearly understood.” Nowhere does the source state that ingesting cholesterol has “very little impact.”  Further, this article raises the possibility that 15-25% of the general population are “hyperresponders,” meaning that dietary cholesterol affects their measured LDL cholesterol more than usual. The researchers urge the importance of examining the relationship between dietary cholesterol and CHD among this group. Attia acknowledges none of this information.

By providing a link to a medical journal, Attia points to medical authority to support his argument without acknowledging how this source complicates or contradicts his claims. This tendency to draw on medical evidence by gesturing toward research, rather than actively conversing with it, is problematic: readers may be drawn in by liberating claims (eat as much red meat as you want!) because they believe them to be scientifically supported.

Indeed, the Amazon.com summary for Teicholz’s book proclaims, “science shows that we have needlessly been avoiding meat, cheese, whole milk, and eggs for decades and that we can now, guilt-free, welcome these delicious foods back into our lives.” In a culture where we are conditioned to feel guilty for eating indulgent foods, promises of dietary freedom may be persuasive because they tap into social — and particularly female — anxieties about weight, food, choices, and guilt.

As a woman, I am conscious both of the social pressures to “watch what I eat” and the medical guidelines that advise the same. However, navigating competing claims to scientific truth requires interrogation of not only the claims but also the ‘means of persuasion’.  A rhetorical approach creates a critical distance between health messages and our decision-making processes.  When reading an article, book, or website, we must ask several key questions: What is this text trying to persuade me to believe or do?  How does it go about accomplishing this task? What evidence is offered, and how is it presented?

Over the past year, I’ve read about cholesterol from many sources but have been most persuaded by a friend who told me how a vegan diet reduced his cholesterol. In closing, then, I ask: who or what has persuaded you to make a health-related decision in your life, and what made the claim convincing?  Conversations about health need to include attention to language and persuasion. Only then can we begin to make sense of what we’re being told and determine how to respond.

I’m happy to bring you this guest post co-authored by two researchers at the nonprofit, nonpartisan RAND Corporation: Chloe E. Bird, senior sociologist and co-author of Gender and Health: The Effects of Constrained Choices and Social Policies (Cambridge University Press, 2008), and Tamara Dubowitz, policy researcher. In this post they discuss recent studies which examine the impact of neighborhood environments on health and health disparities.

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If you had good options about what to eat but made bad choices and became obese, then the fault would be yours. But, what happens when you don’t have good options?

That’s the problem in America today – being overweight is not all your fault. You don’t make the decisions to put transfats, high-fructose corn syrup and excess salt in your food, or unhealthy snacks in the vending machine at work. You don’t dictate that the equivalent of 54 sugar cubes get put into an extra-large soda. These are so-called constrained choices – ones you don’t get to make. Yet, you live with the consequences.

We believe it is time to consider who determines the options for us and what can be done to put better ones on the table. We can’t all afford to buy only organic foods or even have access to them. And, we probably don’t make it a pastime to follow the latest research on nutrition. But, we can take a moment to think before we order a second soda.

And, we can choose to call on those who determine the options to shoulder part of the responsibility for America’s obesity epidemic and to stop the name-calling – like labeling medical researchers “food nannies” when they ask restaurants to deliver sensible portions, priced right. We need to hold vending-machine companies and their managers to account if they stock only junk food in those little compartments.

Consider a few statistics. The latest figures indicate that two of three adults and one of three children and adolescents in the United States are overweight or obese. The impending health and economic consequences are staggering. According to the Institute of Medicine, the medical costs alone of obesity-related diseases and disabilities exceed $190 billion a year. These costs comprise more than 20 percent of national health care spending. The number keeps rising. Want your health care costs to spike further? Then, keep eating the constrained choices that are not healthy.

RAND research, using data from the Women’s Health Initiative study, found that living where there is a higher density of fast food outlets is associated with higher blood pressure and risk of obesity; while, a greater density of grocery stores is associated with lower blood pressure and lower risk of obesity. These relationships hold even after taking into account women’s characteristics and socioeconomic status of their residential neighborhoods.  In other words, where you live can affect your weight and your health.

Moreover, another recent RAND study found that 96% of main entrées at all restaurants studied—including delivery, family style, upscale, fast food, buffet, and fast casual—exceed the daily limits for calories, fat, saturated fat, and sodium recommended by the U.S. Department of Agriculture.

Policy approaches to reduce obesity are not magic bullets. If we want to reverse the obesity epidemic, then we need environments which assure that we have good food options and the opportunity to choose them.

We will be more successful at stemming the growing tide of obesity and improving our own health if everyone accepts their share of responsibility for the obesity epidemic. We need to ask our favorite restaurants, the food vendors near where we work, even grocery stores to give us better options. We can always ignore them, if we wish, but then that’s our choice. Right now, too many bad choices are being made for us.

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Cross-posted on RAND’s blog