Advocacy for whom?

You’ve seen the recent news shows telling us of an epidemic of childhood obesity. The urgency of this problem cannot be overestimated, say advocates, as pictures of exceedingly fat, headless children scroll across the television screen. These drastic images are meant to horrify us and lead us to believe they accurately depict the crisis of “childhood obesity.”

That’s our first clue that we’re witnessing marketing, rather than factual reporting. Using innocent fat children is bad enough, but the more realistic vision of most children who’ve crossed the arbitrary BMI cutoffs to be labeled “overweight and obese” today wouldn’t have nearly the same shock value:

Yet, it’s so easy to not see when our emotions are being manipulated, especially when spokespersons seem to voice some of our own fears and experiences, and say things we believe or want to believe in.

Case Study

Let’s take a recent example. The media this week has been filled with reports about weight stigma that’s risking serious harm to the health and quality of life of fat children and adults. “The impact of weight stigma is damaging and long lasting. Thousands of children and adults are targets of weight bias and prejudice, leaving them vulnerable to serious emotional and physical health consequences,” said Rebecca Puhl, Ph.D., from the Rudd Center for Food Policy & Obesity, who co-authored a recent paper on stigma and obesity published in Psychological Bulletin. In 2001, Professor Puhl had also coauthored what is to this day the seminal work on discrimination against fat people in employment, healthcare, education and community settings, published in Obesity Research.

But advocating against weight discrimination, isn’t always the same as advocating for fat people.

The Obesity Action Coalition, in partnership with the Rudd Center for Food Policy & Obesity, just announced the release of its “patient brochure” entitled “Understanding Obesity Stigma.” It opens with an even more urgent message from Puhl:

The alarming rates of obesity have brought widespread attention to the medical consequences of this public health problem. Often ignored, however, are the social and personal obstacles that overweight and obese individuals face. Bias, stigma, and discrimination due to weight are frequent experiences for many obese individuals, which have serious consequences for their personal and social well being and overall health. Given that at least half of the American population is overweight, the number of people potentially faced with discrimination and stigmatization is immense.

While this Obesity Stigma brochure is for “patients” — presumably that means fat people — the content is more appropriately directed at employers, educators and medical professionals who might benefit from better understanding bias against fat people, and from the valuable section on how healthcare professionals can improve the healthcare setting to make it more accessible.

Fat people, on the other hand, already know about weight stigma and have spent their entire lives facing it every day. They hardly need or benefit from reading page after page (half of the brochure) of ugly things being said about them — from employers (who, according to the brochure, think fat people lack good hygiene or self-discipline; and are less likely to hire, promote or pay fat people as well, and more likely to terminate them, than if they were thin); teachers and peers (who, it’s reported, see fat people as self-indulgent, lazy, ugly, mean, stupid, untidy, and less likely to succeed in school or be accepted into college despite the same academic achievement as thinner people); doctors (who the brochure says see them as “dishonest, lazy, lacking in self-control, weak-willed, unintelligent and unsuccessful”) and nurses (reported as saying fat people “repulsed them” and that they not only “would prefer not to care for obese individuals” but would prefer to not even touch them) — and how, as a fat person, they’re more likely to be treated badly and receive inferior care than they would if they were thinner.

Just reading this, your anxiety level about your weight has probably skyrocketed and you’re feeling more self-conscious and awful about yourself. If you weren’t motivated to lose weight before, you probably are now.

And that’s the point.

Their Understanding Obesity Stigma brochure says that the source of weight stigma and bias is the erroneous perception that obesity is about self-control. If you’re fat, it reassures readers, it’s not your fault ... because you have a disease and can’t help but overeat and be sedentary. (There's that tragic "gluttony and sloth" myth again.) The causes of obesity are described much as they are in popular media and by Rudd Center for Food Policy & Obesity itself, which asserts that “obesity [at its core] results from poor diet and declining physical activity.” According to a Rudd publication, obesity is an “illness” due to a “toxic environment ...of modern food and activity.” They believe: “Modern conditions have created an environment which makes unhealthy behavior the default and childhood obesity a predictable and understandable consequence.” So, not surprisingly, Rudd Center focuses on "healthy" eating and exercise policies to address the issue. Already, this week's report on obesity stigma has been used to call for more societal-wide and governmental interventions for “healthy eating” and exercise to put a stop to this problem. OAC offers a different solution.

Readers of the OAC obesity stigma brochure are encouraged to turn to the OAC for help “to begin educating themselves about the disease and ... advocating for access to safe and effective treatment.” Everyone affected by negative stigma because of their weight are urged to contact the OAC to share their stories and be provided with “tools needed to take a proactive approach in the fight against obesity.”

Sufferers of weight bias are also offered resources and educational materials such as:

· Understanding Morbid Obesity

· Understanding Childhood Obesity

· Advocacy Primer: Your voice makes a difference

· Working with Your Insurance Provider: A Guide to Seeking Weight-Loss Surgery – a guide designed to help patients successfully work with their insurance provider for coverage of weight-loss surgery

· BMI Charts

· Take Action, and Start Advocating Today!

There’s no need to review these in detail, as they recite the identical stereotypes and unsound claims popular in all anti-obesity literature: the epidemic numbers of obese, the deadliness of obesity and exaggerated health problems associated with it, how much fat people are costing society, the virtues of bariatric surgery, etc. “We also encourage patients to support one another. There is no one better to share the social, emotional, physical and medical impact of obesity than someone who has been personally affected,” OAC says.

Advocacy through the OAC includes educating legislators, regulators, insurers, employers, media and the public to “make sure that obesity is treated as a disease, allowing increased access to safe and effective medical treatment.” Each advocacy page offers resources to keep up with insurance coverage issues and provides tips for fat people to share their stories of obesity and its complications. “We hope to use the stories to demonstrate to key decision makers (legislators, regulators, insurance companies, etc.) that access to and additional research in obesity treatment is important,” says OAC.

And every advocacy page takes fat people to the “Fact Sheet: Why it makes sense to provide treatment for obesity through bariatric surgery.”

Stigma is deadlier than fat

If your goal is to put a stop to weight stigma because it is hurting people and endangering their health, wouldn’t that be a focus of your outreach education, rather than putting an end to fat people? But when it comes to the harmful health effects resulting from weight discrimination, that’s where the OAC information is the most cursory and incomplete. Their obesity stigma brochure says only: “Physical health outcomes can include unhealthy weight control practices, binge-eating and avoidance of physical activity.”

That’s it.

Well, as we’ve repeatedly seen in case after case, weight prejudice and this war on obesity has far more serious and inexhaustible consequences that affect every aspect of life, health and welfare. Sondra Solovay, an Oakland, California, attorney and author of Tipping the Scales of Justice: Fighting Weight-Based Discrimination, for example, has chronicled the reality of weight bias and the rarely-challenged beliefs held about fat people in the courts, education, employment and income, healthcare and health insurance. The economic costs, alone, to fat people adversely impacts health.

A few of the effects on health that we’ve examined, for instance, include that “obese” women are significantly less likely to receive preventive screening from their primary care givers, irrespective of education levels, age and health insurance. Weight stigma, even among medical professionals specializing in obesity, was found to be so significant that it could affect the time professionals spent with patients and the quality of the interactions, their empathy, their optimism about patients’ chances for improvement, and their willingness to provide support. Worse, nearly two-thirds of fat women had been told to lose weight regardless of the health problem that brought them to their doctor, with large numbers receiving dismissive care and told their health problems were simply due to their fat. The results are repeated cases of care being denied, health problems going untreated or allowed to become more serious before they are treated.

As Carrie at Ed-bites wrote in a passionate post yesterday, “no wonder obesity kills.” Quoting the news — “Youngsters who report teasing, rejection, bullying and other types of abuse because of their weight are two to three times more likely to report suicidal thoughts as well as to suffer from other health issues such as high blood pressure and eating disorders.” — she said:

I can’t imagine having to say I live in a culture where it’s [seen as] better to have cancer than be fat....What is the moral difference between fat and thin? It's no more than the moral difference between black and white. It's the number of fat cells; it's the amount of melanin in your skin. Black people are more likely to have health problems that whites, but that's not because of their skin color.

The stress of living with stigma and the resulting lower social status, itself, is unhealthy and may explain some of the most serious health disparities seen among discriminated groups. Those of lesser social status have shorter lifespans and two to four times higher rates of heart disease, even among those with the highest incomes and educational achievements. Discrimination is a much stronger predictor of hardening of the arteries than BMI itself or any of the classic risk factors like blood pressure or cholesterol, as recently reviewed here. While the possible health effects of weight prejudice are seldom considered and certainly hasn’t been a popular area of research, what research is available consistently points to notable concerns. Even when controlling for other risk factors, diabetes and cancers have been found to be significantly more prevalent among discriminated groups, more than attributable to education and socioeconomic status alone.

Just like those brown-eyed children, stigmatized people absorb the negative beliefs about themselves which can have the greatest impact on their health and quality of life.

The health risks of weight stigma especially overlooked in OAC literature come from the resultant efforts to lose weight. Yet the strongest evidence for more than half a century is that voluntary weight loss, regardless of the method, is associated with increased rates of premature deaths, heart disease, stroke, type 2 diabetes and cancers — by as much as several hundred percent, as the National Institutes of Health found in 1992 and the medical literature continues to support. The other problems that have been documented include the physiological effects of restrictive eating, dieting and weight loss, such as eating disorders, diminished mental acuity and work productivity, loss of concentration, nutritional shortages, reduced bone mass, cardiac arrhythmias, long-term exacerbation of high blood pressure and long-term weight gain.

The medically-documented consequences of inadequate calories, protein and deficiencies in nutrients, especially being seen among older people, include delayed wound healing, increased risks of infection, damaged heart and intestinal functions, longer hospital stays and higher rates of complications and higher mortality rates, depression, apathy, functional decline, loss of muscle strength, falls and increased fractures.

No one dies of fat, but they do from weight stigma. And they do die from bariatric surgeries, which bring objectively documented risks of dying far and above those even associated with the most “morbid obesity.”

This is about so much more than just that the “fat is unhealthy” argument is another form of fat-bashing and prejudice, as Harriet Brown wrote: “[T]here are real, heart-breaking consequences to this. And one is that we are now seeing an unbelievably rabid set of anti-fat messages directed at a vulnerable population: kids....” Addressing eating disorders, she said:

There is and will continue to be a very real fallout from the "just eat healthy" messaging. Children, families, and adults will suffer. If you've never really known someone with an eating disorder, let me say that you have NO IDEA how much that person suffers. And not just that person, but their family, and friends....

And too many of these sufferers will die. Yes, die from eating disorders. And these young women and men are not negligible. They're not collateral damage in (yet another) stupid, ill-advised, mismanaged war. They are our daughters and sons. And I say, enough.

Consider the source

There are countless organizations profiting off the war on obesity and the “healthy” lifestyles and wellness movement, meaning it has never been more essential for all of us to be vigilant about fact-checking everything we hear, regardless of the source. Anytime we hear something that makes us feel upset, frightened or anxious, that’s our best baloney alert that our emotions are being played and that what we are hearing is marketing, not science. Looking at what they might be trying to sell us (political agenda, product or service, etc.), while not always evident, can sometimes help to better understand what’s going on.

The interests behind the OAC, for instance, has been described here previously when they joined the American Society for Bariatric Surgery in project OPERATE to compel insurance coverage for bariatric surgeries. OAC was founded in 2005 by Robin Blackstone, M.D., a bariatric surgeon who says she also serves as an educator for Ethicon Endosurgery, sits on the board of directors for Viking (3-D endoscopic technologies), and is Vice Chairman of the Surgical Review Corporation, Center Review Committee (responsible for certifying the “Centers of Excellence in Bariatric Surgical Care” in the U.S.). The OAC’s current Board of Directors continues to represent bariatric interests.

Examples of its advocacy have included ObesityVote.com, where it joined similar bariatric surgeon-funded “patient advocacy” groups to lobby for legislation mandating insurance coverage for bariatric surgeries. The Centers for Medicare and Medicaid Services had been heavily lobbied for years to ensure its guidelines include national coverage for bariatric surgery, which the OAC applauded last year. It continues to fight against any attempts to restrict or slow access to the surgeries, such as insurers’ pre-surgery requirements for psychological evaluations, which were spun to “discriminatory IQ testing,” or the completion of a diet program. And an eight-part Discovery Health documentary on bariatric surgery featured the OAC founder. As the East Valley Tribune reported, the program hosted a panel of experts who discussed the health risks associated with morbid obesity. “Education is the most important thing,” Blackstone told the paper. “Some of the primary care physicians don’t recognize what obesity is and how at risk those people are. We want to help them better understand.”

When the economic and political profit potentials of promoting popular beliefs about a discriminated group are so tremendous, it behooves everyone to keep their skeptic radar finely tuned. Learning to recognize true advocacy on behalf of a stigmatized group, dispelling stereotypes and prejudices, versus using advocacy, can be lifesaving.

© 2007 Sandy Szwarc