The O Word : Why the Focus on Obesity is Harmful to Community Health

Focusing on the obese and overweight individual alone and is not helping us address the broader social and economic issues that influence people’s lives. This paper discusses strategies to remove us from a focus on the O word and from blaming the individual for their condition. ©2005 Californian Journal of Health Promotion. All rights reserved.

In recent years, newspapers, magazines, and the electronic media have covered obesity and overweight extensively. The "O" word -obesity -seems to be everywhere. Indeed, media coverage of obesity almost quadrupled from January 1999 to April 2005 in the U.S. (International Food Information Council (IFIC) Foundation, 2005). This intense coverage even led the Center for Consumer Freedom (2005), a restaurant and food industry supported group, to label the obesity coverage as "hype" and an "obesity-mortality myth". Regardless of the controversy over the exact number of deaths associated with overweight and obesity (Kaisernetwork.org, 2005), clearly, the National Center for Health Statistics data shows the doubling of obese adults and the tripling of overweight young people (ages 6-19) over the last 30 years (National Center for Health Statistics, 2004).
Hidden in this confusing rhetoric is an important message that many will find startling: while there are real concerns related to 60 million obese adults and 9 million overweight youth, the single-minded focus on weight results in prejudice towards the obese and overweight and negatively impacts community health overall.
The truth is that despite the recent controversies surrounding the number of deaths attributable to obesity, it is a deadly serious health condition. It's also true that many people are eating too much and exercising too little. Furthermore, people can and do die from obesity-related chronic diseases, and obesity can be a significant contributor to decreased quality of life. However, the persistent drumbeat of "obesity" oversimplifies a complex issue. It places blame squarely on the shoulders of the individual, without taking into account the social and economic influence of where people live, work, and play. In this sense, the O word discourages all of us from focusing on social ecological changes that could make significant lasting improvements to people's nutrition and fitness.
While this focus on "obesity" and the implied individual behaviors (e.g., overeating, lack of exercise, etc.) distracts us from seeing the larger community picture, it also fails, often miserably, to improve the health of individuals. In fact, it may lead to mental health problems and, of course, the sequela of chronic disease. In addressing this, we need to acknowledge that while the word had a specific clinical definition; it does not have the same meaning within clinical practice --any more than in broader society. Instead, even in the clinical setting, "obesity" is often imbued with value judgments and biases that associate overweight not only with poorer health but also poorer character and lack of education.
If we want to address nutrition and physical activity in the most effective and affirming manner, we need to cast light on the five unintended consequences of our focus on "obesity":

Focusing on Weight Instead of Nutrition Leads Individuals to Adopt Popular Weight-Loss Diets Rather Than Eating Nutritious Food
On any given day, more than 25 percent of men and 45 percent of women in our country are dieting (Smolak, 1996), yet the United States continues to have the highest incidence of obesity in the world. Unfortunately, when obesity is the issue, people automatically focus on its opposite: weight loss. Playing into this mindset is the billion-dollar weight-loss industry which feeds more off of people's desire to look better, than the desire to feel better. As the public succumbs to the pressure to lose weight quickly, a consequence is the rise (and fall) of popular diets that increasingly shift focus away from what is known about good nutrition.
Of course, the latest popular diet is the highprotein, low-carbohydrate craze. The creators of the Atkins and South Beach diets have together sold more than 13 million copies of their books. These diets promote weight loss through eating plans that almost inevitably lead to increased intakes of cholesterol, fat, saturated fat, and protein. While long-term data on the health effects of these diets is not currently available, leading health associations such the American Heart Association (St. Joer et al., 2001) and the American Dietetic Association, among others, have published statements warning about the various dangers associated with lowcarbohydrate diets, including a potentially increased risk of coronary heart disease, diabetes, and several types of cancer. And perhaps even worse than the diet books are the diet pills that are marketed on TV and women's magazines and promise miracle weight loss. But, at what cost is weight loss occurring if it increases the risk of chronic disease later?
Crowded out of this fad-diet excitement is the important message that a diet rich in fruits, vegetables and whole grains is associated with blood pressure control, cardiovascular disease prevention, diabetes prevention and lower risk of some cancers (Apple et al., 2003;Joshipura et al., 1999;Joshipura et al., 2001;Maynard, Gunnell, Emmett, Frankel, Davey-Smith, 2003;Terry et al., 2001). Even more outrageously, some fad diets warn against eating certain fruits and vegetables, such as carrots and bananas, because they have a greater effect on blood sugar than other fresh options. At a time when only one out of five Americans is eating the recommended five servings a day of fruits and vegetables (Produce for Better Health Foundation, n.d.), the public does not need another excuse to pass on produce.
Yet another issue is the effect that the focus on fad diets ultimately have on people who are obese or overweight. The promise of the magic pill or diet is quickly overtaken by the reality of slow, if any, weight loss and the mental health effects of "another failed diet attempt" (Yen, 2005).

Focusing on Weight Alone has Serious Consequences for Mental Health
Research affirms that obese individuals face a pervasive stigma. Stereotypes attributed to the obese include laziness, lack of self-control, low intelligence and noncompliance with health recommendations (Puhl & Brownell, 2004). These stereotypes are played out daily in the popular media and in unrealistic "before and after" ads that emphasize personal control as the primary determinant of weight (Geier, Schwartz, & Brownell, 2003).
In a review of the literature on 'fat bias,' Brownell and Puhl note that "the stigma of obesity is somewhat unique from that of other marginalized groups, in that obese people internalize societal anti-fat and pro-thin biases." Obese people agree with society's assessment that "…an imperfect body represents an imperfect person" (2003, p. 22). In a qualitative study of 113 obese African American women, Davis, Rovi, and Johnson (2005) found that obese women had significantly higher anxiety levels and poorer perception of their physical health than overweight or normal weight women. The toll that living with this stigma dayto-day takes on individual mental health is significant and often tragic, as evidenced by the fact that obesity is associated with increased likelihood of depression, suicidal thoughts, and suicide attempts (Carpenter, Hasn, Allison & Faith, 2002).
The rise in childhood obesity raises additional concerns for mental health. In a study of ethnically and socially diverse middle-and highschool students, Eisenberg, Neumark-Sztainer and Story (2003) found that, "Teasing about body weight was consistently associated with low body satisfaction, low self-esteem, high depressive symptoms, and thinking about and attempting suicide, even after controlling for actual body weight" (p. 733). Further, these associations held across genders, racial and ethnic groups, and weight groups. However, and perhaps more striking, Eaton et al. (2005) found that how adolescents perceive their body weight may be more important than their actual weight in terms of increased likelihood of suicidal behavior and that regardless of body mass index, extreme perceptions of weight appear to be significant risk factors for suicidal behavior. Plainly, childhood nutrition and physical activity are important matters to address, but to address these we need to create an environment for our children that is as supportive as possible. Confronting the obesity stigma is an important step in that direction and should involve not just parents but also teachers, health practitioners, the clergy, and others who have a role in educating and protecting children.

Distorted Cultural Norms for "Healthy Weight" Can Lead to Eating Disorders
When discussing obesity, many refer to the need to reach and/or maintain a "healthy weight." Unfortunately, while the medical community may have a clinical definition of healthy weight (generally defined as a Body Mass Index within the range of 18.5-24.9), the public's idea of "healthy weight" is often based on unrealistic images in the popular media. When the models on the covers of fashion and fitness magazines are regarded as the standard for "healthy weight," too many individuals feel pressure to mirror this ideal at any cost. As Burns and Gavey (2004) remark in their study of bulimic women's conceptions of "healthy weight," "healthy weight" cannot be unhinged from a cultural imperative of slenderness (p. 549). The effects these norms have on health are most often observed in adolescent females. In a study of exposure to the mass media and weight concerns, Field et al. (1999) found that the majority of surveyed preadolescent and adolescent girls were unhappy with their size and shape. This discontentment was strongly related to the frequency of reading fashion magazines. However, concerns about these issues aren't isolated to adolescents or womenincreasingly, they affect men too. In fact, men comprise an estimated one million of the approximately ten million Americans fighting anorexia or bulimia (Crowther et al., 1992).
It is also important to note that the images promoted in popular media are most often of extremely slim Caucasian women. While these images are directed in advertising primarily to one segment of society -young, white, middleclass women -their pervasive nature has the effect of largely defining notions of beauty in our society. Indeed, standing in a supermarket checkout line, and recognizing the dearth of people of color or women over the age of 50 on the covers of popular magazines, gives one a good idea of the pervasiveness of such image marketing. In this sense, they present a particularly dangerous standard in that they promote a size unattainable by nearly everyone, while marginalizing those of different races or ethnicities as well.
Lastly, recent research has noted that norms and acceptability for body size vary by culture and race, with some groups being more accepting of larger body sizes. For example, Gipson et al. (2005) surveyed 200 black students at a historically black university and found that young black women are tolerant of a variety of body sizes. Our understanding of how these norms affect health is developing, but meanwhile the focus on obesity may not resonate with certain groups. As we learn more about the health behaviors associated with their attitudes, it is important to continue emphasizing the importance of nutrition and physical activity rather than slenderness.

The Obesity Stigma May Affect Preventive Health Care
We are not advancing the health of people who are overweight when going to gym means being silently judged and getting weighed at the doctor's office feels like receiving a negative report card. Yet, that is exactly the experience many obese individuals say they face when they choose to make medical appointments or start a fitness program.
Conscious and subconscious negative attitudes within the health community (including physicians, nurses, and dieticians) toward the obese have been documented in numerous studies (Hoppe & Ogden, 1997;Maroney & Golub, 1992;Obberrieder, Walker & Monroe, 1995;Price, Desmond, Krol, Snyder, & O'Connell, 1987). More recently, Block, DeSalvo, and Fisher (2003) found that despite solid knowledge of the conditions associated with obesity, medical residents have a poor grasp of the tools necessary to identify obesity. They also have negative opinions about their skills for treating obese patients. They conclude that residency training programs must not only improve knowledge of obesity but also must address physicians' negative attitudes.
These attitudes can be compounded by the fact that for more than 20 years clinicians have been using the term "good cholesterol" and "bad cholesterol" to describe medical conditions that, may leave people feeling that they are labeled as "bad" because of their elevated LDL cholesterol level. Indeed, even the NIH's National Heart, Lung, and Blood Institute uses these terms to describe the LDL and HDL lipoproteins (http://www.nhlbi.nih.gov/). These negative attitudes do not go unnoticed, and they are often cited as a reason for avoiding medical care. Studies have shown that the most important factor in women postponing or canceling medical appointments was the fear of being weighed, and that increased BMI is associated with decreased preventive health services (Adams, Smith, Wilbur, & Grady, 1993;Olson, Schumaker, & Yawn, 1994;Ostbye, Taylor, Yancey, & Krouse, 2005).
Further, when patients are encouraged or referred to exercise, the same issues tend to repeat. A study of exercise science students found that they, too, possessed negative associations with obesity such as laziness and lack of self-control (Chambliss, Finley, & Blair, 2004). It seems that obese individuals are faced with conflicting messages -that they need to exercise to lose weight, but that they should not exercise because they are overweight. Who could blame anyone for avoiding exercise under these circumstances?

The Emphasis on Obesity Keeps the Focus Away from Creating Healthy Lifestyles
For a variety of reasons -social influences, genetics, and other health factors, to name a few -weight loss is not a viable solution for all obese people. Meanwhile, our culture's endless obsession with weight loss and unrealistic ideals for thinness are hurting everyone, not just the obese.
A recently released two-year study of obese women who had been chronic dieters found that women who went through a program that focused on self-acceptance and a healthy lifestyle rather than weight loss experienced declines in their cholesterol levels and blood pressure and increased self-esteem, despite the fact that they did not lose weight (Bacon, Stern, Van Loan, & Keim, 2005). In contrast, study participants who followed a regimented weightloss program regained most of the weight they lost, reported poorer self-esteem, and did not sustain improvements in their cholesterol and blood pressure. These types of findings provide growing evidence for developing weight management programs that fit the characteristics and abilities of the priority population instead of the other way around.

Moving
Forward:

Creating Healthy Environments
We have tools and prevention concepts to address both poor health and the prejudice that often is encountered by both overweight people and the populace as a whole. One of the lessons of the approximately 40-year-old health promotion and prevention movement in the U.S. and Canada is that individuals and communities do care about their long-term health, and are willing to make environmental and policy changes that promote healthy behaviors. This was particularity noticeable in California where the tobacco movement created smoke-free environments in work, school, and dining settings. It is now even expanding into park and beach 'play' settings.
If we want to prevent people from jumping on the bandwagon of the next fashionable weightloss diet, we need to utilize a social ecological approach that can influence individual behaviors and does not isolate, discriminate, or marginalize the obese and overweight. We have an opportunity to transform our country's view of health by talking about healthy behaviors and environments in a real-life context instead of as a billboard ad ideal. More importantly, we need to address the external factors that act as barriers, or promoters, of healthy eating and active living. Examples of comprehensive approaches abound, including the Prevention Institute's Strategic Alliance for Healthy Food and Activity Environments which has created ENACT (Environmental Nutrition and Activity Community Tool), the State of Washington which has crafted a "policy cookbook", and the City of Chicago which has formed a city-wide collaborative CLOCC -the Consortium for Lowering Obesity In Chicago's Children. Specific approaches to changing environments which can have an impact on individuals include: 1. In Philadelphia: the Food Trust's Food Marketing Task Force which is working with local community civic and government leaders, and the supermarket industry, to address health disparities associated with unhealthy diets by increasing the number of supermarkets in the city's underserved areas.
In low-income neighborhoods, where there are no grocery stores, it is difficult and expensive to eat a nutritious diet. In 2004, they increased the availability of nutritious affordable food, and provided 258 well-paying jobs, by opening its first store. This type of environmental change is supported by the Moorland study (2003), which utilized survey data from over 10,000 households from the mid-west and southeast, and documented that fruit and vegetable intake by African-Americans increased by 32% for each additional supermarket in the neighborhood, while fruit and vegetable intake among White Americans only increased by 11% with the presence of one or more supermarkets.
2. In California: Safe Routes to School initiatives promote walking and biking as the primary means of transportation to school and enhance community safety. Safety is a particular concern in low-income neighborhoods where a high percentage of children walk to school and face real danger from traffic crashes. At one event the Oakland Mayor disseminated a Walkability Checklist, which parents and children can use to identify specific hazards and these forms were handed directly over to the Department of Public Works for follow-up action. Evaluation of the California Safe Routes to School by a research team from the University of California Irvine found that five of nine sites included in the evaluation had strong evidence of success, concluding that the program on the whole was highly successful, including improvements in pedestrian safety -with some evidence of increased walking.
Focusing on the obese and overweight individual alone and is not helping us address the broader social and economic issues that influence people's lives. Strategies such as those noted above remove us from a focus on the O word and from blaming the individual for their condition. It moves us towards conceptualizing and developing family, community, and governmental strategies that can involve the priority population in inclusive and respectful actions that can create healthy environments.