Hey, Everybody: Let’s Help Diane!

In Weight-Loss Maintenance on May 17, 2011 at 12:12 pm

First of all, thanks again to Dr. Sharma for hooking us in to the private world of obesity research where the erudite players who affect our lives talk about us.  Specifically, today he linked us to the Canadian Obesity Network Presentation Portal for the Second Annual Obesity Summit held in Montreal April 28 – May 1 of this year. 

Let’s give these CON-RCO people kudos for facility and detail.  If you click on the presentations, you receive a split screen with the speaker, in focus and centered, on the left and his or her Power Point Notes on the right.  How inviting!  Whatever trouble that took, please know it is appreciated!  Hooray.  

I scrolled through the selections to find some interesting conversation fodder, and my heels came to a screeching halt on page two, where speakers were talking about weight discrimination and bias.  I first was drawn in by this title:  So I am Biased, Now What Do I Do?  Michael Vallis, the co-director of the Capital Health Behaviour Change Institute and Associate Professor at Dalhousie University spoke well, and we may want to talk about him another day, especially how he seems to ice skate between talking about solving bias/discrimination and solving obesity – interesting and discomfiting.   He also talks about Motivational Interviewing, which we have talked about some in these pages’ comments.  As I listened to him I wore Hopefulandfree’s filter:  is this just sophisticated manipulation?  I don’t think he intends it to be, but I can see how it goes there.

But I digress.  TODAY, I want to talk about Diane Finegood’s talk, Weight bias and discrimination through a complex-systems lens.   About 22 minutes into the 26-minute speech, she presents us with a question, and with an earnestness that I think calls for reply.  I think we might be able to help her.

Diane Finegood is a professor at Simon Fraser University and Executive Director of the CAPTURE Project (CAnadian Platform To increase Usage of Real-world Evidence).  She’s also a radical weight-loss maintainer.   

Her presentation, in simple terms:  It ain’t easy to change a paradigm on a complex system, such as obesity bias as it relates to health care.  You’ll want to watch the whole thing, as she starts with a complex map of the issue and then reduces the problem downward several times to arrive at five steps.   The most important:  shifting the stinking paradigm.  This has to be done by attacking lower level issues – structural elements, goals, etc.  But at the very top is that paradigm, or root assumption.  She makes a stab at one-sentence statement to express what that paradigm should become, but she’s clearly uncomfortable.  Even her Powerpoint notes have a question mark.  Her attempt at a statement:

? “Obese people are no different because of their size.”

Is that the assumption we want our health professionals (and media, etc.) to start from?  I understand her discomfort, because the answer is no (there are differences that come with size), and yet I arrived at respect for her dilemma when I paused the video and tried to come up with my own statement.  (I use “fat” instead of obese for all the reasons that those of us in the Size Acceptance movement choose that word , but I imagine a scientist would have to use “obese.”)

Try #1:  Fat people are different but equal . . . NO!  Sounds like a throwback to the 60s:  “separate but equal” is not equal.

Try #2:  Fat people are not inferior to trim people . . . NO!  Defines using a negative.

Try #3:  Fat people should be defined by as many attributes as trim people, beyond weight. 

Too complicated, but I think I’m in the ball park.  We’re trying, after all to get professionals to look at their patients in a weight-neutral way.

Try #4:  “Fat people are as multi-faceted as people of other sizes.”

That’s my final answer, but maybe I’m too closed into Diane’s box and the question needs to be shaken apart and addressed from an entirely different vantage point.  I know that you all are good at hearing the unsaid and identifying those issues not considered.  Perhaps you have better ideas.   

In more than one past post I have called for the scientific community (or, more specifically, the scientists of the National Weight Control Registry) to throw their assumptions on the table and examine them.  It seems that Diane Finegood is trying to do just that.  I applaud her.  Now, let’s consider her dilemma and email her the link.

  1. Knowing a person’s weight does not equal knowing the person.

    People who are fat are as complex as people who are not.

    There are as many ways to be fat as there are people who are fat.

  2. this is worthy. will reply when brain and hands engage later. (post op has begun) 🙂 go Debra for staying on task and watching all our backs! i love you!!!!!! (yes, those last 2 !! are the drugs talking) 🙂

  3. A snarky part of me would start with this:

    Fat people are people.

    I also like:

    Your assumptions about the person sitting before you are most likely wrong.

    Are you treating the person sitting in front of you the way you would want to be treated? — this one is problematic because of the pervasive shame around fatness and some providers still clinging to the notion that hatred helps drive change.

    Over time, there has been massive dehumanization of fat people — I can think of two things I read today about discrimination, one of women who are larger than 200 pounds not being accepted by some OB/GYN practices, and another about the now typical treatment that Southwest gives its fat customers. The lines are drawn, and they are largely class lines, and privilege lines, and the hatred has intensified.

    So, to counter it, there needs to be humanization. Undermining of the idea that fat people are inherently different from people who aren’t fat. And the truly insidious part is that it appears that all fat people could become thin, if only they tried harder and wanted it badly enough. Just because some fat people want to, and do, become thinner, does not mean all can.

    I think that “stateways become folkways” is one pathway — making discrimination illegal. There is more than just that, and I need to put my kiddo to bed (already way too late) so I’ll stop here. But, I saw that presentation to but you’ve inspired me to watch it again.

  4. You know, “Obese people are no different because of their size” can be true. And since it can be true, it’s fine to say it. Not all of us have or will ever develop the health problems that we’re at greater risk for. Not all of us have issues with food. Not all of us have “trouble keeping up with…(whomever)” Not all of us find our lives being impacted significantly by our weight in any way. So, yes. It’s best to assume that we’re just like other people until we say otherwise.

    • Yup, it can be true. However (and I’m sure this is why she’s uncomfortable), it can be untrue, especially for the super fat. We who believe in size acceptance really need to figure out how better to acknowledge the unique fat-related issues of the super fat without subjecting them to additional tribulation. (I don’t know how to do this.) We want the doctor to acknowledge that a fat person’s joints may merit examination, for example, strictly because of the weight load they carry. We don’t want the medical profession in a state of denial so much as a state of respect. Actually, that goes for all of society. Respect.

      • Let’s consider the joint issue. You know that I have a bionic hip on the left side. My original hip went bad because it had been broken and dislocated in a car accident and developed trauma-induced osteoarthritis. My doctor initially tried to blame the hip problems on my weight. I said “Then why in my other hip in perfect condition? Obviously, my left hip is bad because it was broken and dislocated in that car accident.” And after a bit of discussion, she had to acknowledge that I was right.

        Who knows. Maybe the hip would have lasted another 5 years if I’d been lighter (or less active). However, researching it online, I found that a lot of thin people need hip replacements 20 years after a major injury like that, as well. So as far as I’m concerned, my weight was at most a minor factor in it.

        When she saw my X-rays, did the doctor say “you shouldn’t have done all that high impact exercise in your twenties; that probably contributed to this?” No. She didn’t even connect it to the primary cause until I questioned her judgment. My weight was all she thought of.

        When medical professionals focus on weight as a contributing factor in health issues, it almost always turns into a blame-fest. They tend to want to pin any health problem that could conceivable be associated with being heavy on a patient’s weight, and it is lazy and unhelpful. Most issues have multiple causes, and contributing factors should be discussed and addressed with the proper perspective. Very few things are all about weight.

      • DebraSY, thanks for inviting me into this discussion. I think my “discomfort” as you describe it has more to do with not having thought enough about the question what “paradigm shift are we looking for?” than due to the the possibility that “obese people are no different because of their size” might not be what we should strive for. Since a “systems” view would suggest that we are all different from each other, the idea buried in my statement is that size itself should not be a sole distinguishing feature.

        As you point out in your blog post it is difficult to articulate the ideal paradigm to strive for and your description of the players presents several different paradigms or belief systems of the various experts. I suspect my “discomfort” comes from being someone who likes a lot of the HAES ideas but also recognizes there can be health benefits from weight loss if the path that gets you there and/or helps you stay there is sustainable healthy behaviour change.

      • Diane, you are welcome to quote me or use my story as an example.

      • Thanks DeeLeigh for the offer.

        Heard a similar but reverse story from one of my students who is at a normal weight but has a significant sleep apnea problem. She struggled to get a physician to refer her to a sleep clinic because she was not overweight!

  5. Opps. “…could conceivably be associated…”

    And maybe that’s the point. You can see that someone is fat by looking at them. Doctors need to go beyond what they can see, visually. They need to review patient files and ask questions, even if they’re sitting across from a fat person who has a health issue that is associated with being heavy.

  6. How about, “Look beyond the fat.”

  7. Was finally able to view Finegood’s presentation. Applause for systems approach. Love, also, that she underscores the problem with analysis which remains at the level of individuals…a crucial distinction overlooked again and again. What if, for instance, it was imperative for group and species survival (and ability to thrive) when members of the group are able to care for other members BECAUSE of metabolic advantages not shared by all group members. Okay. Say it is advantageous for group’s adaptation to harsh environment when some members are fast runners with keen vision and, thus, excell at hunting. Yay. More group members survive because more food resources for group. Seems obvious. But. What if group survives and thrives because some group members are able to store fat more efficiently and can endure shortages better or longer without falling ill from immune problems related to shortages…I’m referring to those members who in fact, historically, have nursed the weaker members through periods of shortage (perhaps even famine) AND it has been critical to encourage those who CAN store fat to do so…for the benefit of all (including individuals). Perhaps they were even CELEBRATED (see fat goddess images in pottery and totem art), valued for a particular kind of strength in mass (and en mass, for all).

    Okay, please keep in mind I’m jacked on post op pain meds. LOL. We need to celebrate DIFFERENCE, KNOW that commonalities do not make more diversity, bit differences increase diversity and innovation (and ability to adapt) results from a group’s innovative capacity not its sameness capacity. Ugh. The problems are not with individual differences but in failure of groups to honor those differences.

    As for super obese people…it does not take much complexity to use a systems approach there, too. If we truly value difference, we don’t need to ostracize people and stress them to the point of

    Crap. Have used up own resources. Must return to traction (elevation) & no proofing or finishing thoughts here. Maybe others can springboard. 🙂

  8. gee, fat people are patients like any other. if you gotta explain this then we already know there’s a problem, as has been noted. fat patients are as individual as other patients. treat like person, not like fat person–’cause that is automatically gonna be a stereotype.

    was gonna say something else, something profound. lol ???

  9. oh yeah. not really profound. but. with one eye on legal aspects, perpetually, in health care settings, then a doc (for instance) may think in terms of potential lawsuit if stereotypical fat-related disease/disorder is not addressed, even though concern may be based more on stereotype…so by doc looking through lens of lawyer unfortunately and ironically ihis rhetorical stance (standpoint) may help perpetuate stereotype (and bias).

  10. I wonder if we can expand this discussion by talking about all the levels from our framework. DebraSY was trying to stimulate your thinking about what paradigm shift (deepest held belief) we need to achieve. But it might be helpful to look at other intervention levels like goals (what we want to achieve), structure (what systems need to be in place to shift away from a culture steeped in weight bias and discrimination or what feedback loops could help?

  11. the whitehall studies and other similar research are important to reveal the ways in which stress and hierarchy status interact to impact health of groups/populations AND individual members (such as differences regarding ways fat is stored and/or metabolized.) so it is crucial, i believe, to continue research that looks at what populations need (structures and systems) to improve health of more members. beyond so-called basic needs (which cultures are still struggling to establish), what general social needs must be met to result in fewer risks for diabetes, heart disease, and other illnesses that seem to be linked to some forms of obesity but correlate more strongly with specific social stressors (such as social inequities related to resource distribution). at a theoretical level the debates re: recognition vs redistribution of resources may be promising for reframing paradigm shift related to health outcomes. for instance, when fat people are not even recognized as equally deserving of care and/or resources (by health professionals, for instance), then redistribution of services/resources (attempts to decrease social determinants of health) may be compromised or limited by recognition biases.

    main point: scientists are not able to focus much research on social determinants of obesity-related diseases because economic incentives for those results are not currently constructed in capitalist systems.

  12. here’s a link that briefly introduces some social justice theorizing that will prove fruitful when applied to fat politics/bias:

    fraser’s book (with axel honneth) is rich with paradigmatic possibilities for applications in health care, and the above link provides a very brief glimpse of what probably sounds (otherwise) like gobbeldygoop in my comment above re: recognition vs (or) redistribution. such is the nature of blog comments.

    currently, identity politics (fat acceptance) often ignore intersectionality and when applied to health/health care the flaws in this thinking can be stark and destructive. A 350 pound “overweight” cis-gender hispanic adult male with secure employment in suburban L.A. (in U.S.), for instance, will not have comparable health issues to a transgender asian/black teen living in inner city sao paulo, brazil…well, it’s a stark example but you get the image. researchers *pretend* these differences don’t really matter because we’re supposedly looking at *biology* (as in “obesity”). social variables and social identities (all social constructs) not only inform access to resources but determine/transform health risks in ways we have not begun to understand as social theorists or as health care providers.

    when i compare my experience as a person who has lost a significant amount of weight and finds significantly increased life satisfaction (joy and empowerment) with no sense of burden or “effort”, with a different individual who is expected to lose weight to “improve” his/her health (expectations/pressures by his/her doctor and assorted others/aquaintances including people in positions of domination, such as employers etc), then in the latter case most observers (researchers) would not acknowledge (because unable to see or measure) the increased oppression (and thus increased health risks) that would result. in other words, reductionist approaches we see now in so-called health care settings and research (re)construct greater oppression rather than improved health outcomes.

    etc. 🙂

    • sigh. one last attempt to communicate. research that isn’t looking at systemic forces of oppression and oppressive conditions as a significant driver of overeating is research that will not find any systemic solutions.

      overeating is a symptom of internalized oppression in my case. this does not mean it is “simply” psychological or emotional in the sense of anything i can do, AS AN INDIVIDUAL consciousness, to change my body’s physiological drive to seek relief from severe emotional pain, pain which is blunted by physiological responses to overeating, pain which is unidentified when overeating continues, and pain which is much worse than the pain of being discriminated against for being fat–not to diminish what that feels like, but this psychic pain is worse in my experience and explains why I overate knowing that the consequences would be obesity; this pain is not hunger, these are not eating impulses; these are escape impulses driven by systemic (physiological) messages similar to fight or flight responses. as in endocrine messages saying: get the hell out of that situation, except the situation is party internal and maybe partly external (depending on current
      living conditions). so. we have this limited paradigm that puts traumatized people
      into this one category, PTSD, for example, or “neurotic” (etc), but those are socially constructed categories that don’t take into account systemic forms of oppression for human beings, things like oppression from lifelong racism or
      poverty or extended violence or insecurity experienced throughout childhood, or a homophobic culture, etc.

      solutions will be emancipatory throughout social systems–for individuals there may be hope in solidarity and participation in mass social changes, which will provide evidence of compassion and cultural willingness to change and adapt to create a less oppressive and horrifying world. solidarity is a promising construct which as yet has not been mined. fat acceptance approaches but fails to improve the roots of oppression, and focuses once more on an isolated group. honneth and fraser have some great ideas, along with other critical theorists whose perspectives are systemic and emancipatory.

      weight loss and maintainance is not difficult for me. that’s the rub. there is much joy here. but. the residue of oppression is a monster that easily gets
      sublimated into the “battle to diet” the “battle to lose weight” etc. i’m done with sublimating so the battle is about learning to survive with what i’ve described as a CONSTANT impending sense of doom. alongside joy, LOL. not anxiety. not depression. the after effects of long term oppression.

      our culture is still in denial about racism, about the impact of poverty, about all manner of social determinants of health. of course it is in denial about social determinants of (some forms of) obesity.

  13. oh, almost forgot. for folks like debra and others, for instance, who claim to be untouched or uneffected by oppressive conditions, i call b.s.–though not intentional b.s.
    you cannot be a member of humanity, look around you at the world’s horrifying conditions and our culture’s indifference, with the kind of social hierarchy we live in, and not carry deep scars from being a witness. i’m not saying that witnessing “causes” people to become fat or to want to eat excessively, i’m suggesting that witnessing the oppression and suffering, while BEING POWERLESS TO CHANGE IT, impacts endocrine systems in various ways. we can’t continue believing that oppression does not have far reaching and damaging results even for those who have not directly lived as its target.

    • I’ve never claimed to be untouched by the systems we live in. I’m just more interested and engaged with endocrine for the time being. I’ve committed no extraordinary sin in that, have I? No, I acknoweldge that I am touched, affected deeply by oppressive conditions. In addition to being witness to the social hierarchy, as you describe, I am beneficiary of privilege (and some guilt). That is a great effect, indeed. I’m not proud of it, nor do I feel particularly worthy. Most of the time, I am bamboozled. Sometimes I’m downright overwhelmed, But it seems most productive to simply live the most compassionate life I can muster and then sleep as well as I can. That’s it.

      Why are you feeling so, er, aggressive today? Are you in some extraodinary and different pain?

      • Obviously, i seem to be shouting and ranting. That’s not acceptable, and for you to feel attacked or a target of my anger is horrible. I apologize. Not my intention. No excuse. I’m working out some theoretical issues, probably need to be talking to my philospher friend(s) about “recognition and redistribution” (see fraser and honneth), a promising theoretic application to problem of fat/size bias and to overeating as normal self care in response to forms of oppression. i’m suggesting that the link between the two can be solidarity (between bias and emancipatory action). Really, the excitement i feel overlaps the daily buzz of stress over lifeworld conditions i cannot control or escape. Makes me feel very out of place in a blog that is a nice hang out to talk about medical paradigm stuff and offer support about shared bias. This is not nice or friendly to you and again i apologize. Sometimes I need a little kick in the butt to point me in a more appropriate direction, and i am grateful for it. 🙂 Trying to translate something like the theoretical positions i’ve been synthesizing into blog-style soundbites, i see now, only comes off as hostile, arrogant, or pathological. No one’s fault, here, except my responsibility to know when i’m not being helpful. That’s now obvious. Peace and love to you and to Diane. ❤

  14. First, @ Hopeful — we’re cool.

    Now, Diane. Hmmmm. I just went back and watched your presentation again. For what it is worth, it was still interesting a second time. And still confusing to me. I have some thoughts. Hope they are useful.

    I don’t know if this is entering the system at the goal level or the structural level, but it’s an entry one way or the other. In my mind it’s a goal.

    I would like to see government become weight neutral. Currently, in the states, at the USDA (My Plate), the National Institutes of Health, the CDC and even through the executive branch (Michele Obama’s “Let’s Move” campaign), the government recommends weight loss arbitrarily for all adults who exceed certain BMIs. The current surgeon general isn’t so bad, but past surgeon generals have declared “war” on obesity. Ack! That has become, to some degree, a “war” on the obese. Yeesh.

    This should not be government’s role. I looked at your systems hierarchy and I thought, on what logic would National, International (WHO), and other government forces, who have NO contact with the individual (are separated by several levels, in fact) give such personal medical advice as to lose weight? That’s ridiculous. In addition to promoting garden variety weight bias and yo-yo weight cycling (with health risks of its own), it may encourage eating disorders.

    I think what this would ultimately look like (throwing the solution out there, since you’re cool with that) is that government would present the idea that weight maintenance is challenging and beneficial to health (a truth, if there ever was one) and would present agency specific advice for doing just that. Government would further support the idea that Individuals wishing to change their weight (down or up) should ALWAYS do so in consultation with their medical doctors, registered dieticians and/or other professionals who can monitor them and structure a plan, if needed, based on their unique circumstances. Moreover, no specific BMI alone merits weight loss or gain. Health is a many-faceted ideal. That should be government’s message. No more.

    I think the way this would come about in the states is that the AMA and ADA, together perhaps with some other professional organizations, would issue position statements calling on government to promote weight neutral messages, to promote maintenance, regardless of BMI and to refer people to professionals for any weight change.

    Thought for the day.

    Oh, and your thoughts on strategic cooperation/competition. If government got out of the weight-loss business, maybe that would encourage doctors to become more informed, more sensitive, more nuanced on this topic — to compete with one another to optimize the health of their patients, not merely jump on the weight-loss bandwagon.

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