A Futile War on Weight

Yeah, it’s been a while since I’ve written on here. Lots of things to process and projects begun (but, TBD if they will be finished). When I began my time here at the medical center, I’m almost certain I didn’t think I would become disillusioned by health care’s efforts to “address” obesity. In fact I probably never thought about the obesity “crisis” before this job. Now that’s pretty much all I do.

As I’ve written about before, the obesity rhetoric – particularly on Mississippi – is loud and wild and abundant. The rhetoric that’s heard is all based on the basically the same premise, that consuming an excess of calories compared to those you spend (like money, right?) will lead to a gain (but a bad gain). And the converse is true – those who are seen as holding excess weight surely got that way because of their caloric gluttony.

The doctors feel like it’s their job to fix these people. Their job is to cure bodies. I attended a small conference on obesity, with interested GI specialists and administrators and physicians who are so frustrated with obesity and like the money it costs taxpayers. Insert comic relief with a laugh on this lazy culture in the US we’ve created:

<can’t say how many presentations I’ve seen with this image>

Or what about how gross fat bodies are? Let’s look at images of the failing fatty heart, diagrams of that visceral body fat, and hear about weight-loss regimens that externally drain your stomach with a tube. I just kept looking around at the shaking heads, the heads of clinicians frustrated and tired with noncompliant patients, the fat bodies, the money, the disease, the tired. They’re just tired.

What if the clinicians can’t do anything about obesity? And really, what if they’re not supposed to? Most diet/exercise routines don’t work to help people shed weight, particularly the people most overweight. Actually, more evidence shows that once people reach a certain weight, their metabolism slows dramatically, often preventing further weight loss. Physicians don’t know how to talk about obesity with their patients anyway, and have been shown to have stigma against people who are considered overweight.

Physicians want to change habits. They want people to do what they say: “doctor’s orders.” And this is crucial in most health care situations. But I’m not so sure that it’s obesity they can also get involved in – maybe yes for some individuals, but not for changing populations.

Food tends to be deemed the culprit for the obesity epidemic we see, and the related chronic conditions like type 2 diabetes, hypertension, and dyslipidemia. Really, it’s gotten to the point that this narrative is used (overused) all the time. We’re obsessed with food. It’s perhaps understandable that the narrative began with this, as prescriptive behavior change: drink less soda, cut out trans-fat, processed food; be sure to exercise, drink lots of water; eat only a handful of nuts. Eat small meals 5 times a day. Eat eggs (1 or 2?), eat only whole wheat bread (ok no bread), but avoid the high fructose corn syrup in the bread. Eat quinoa and drink kombucha and only pasture-raised certified beef, but anything else that isn’t easily identifiable, avoid. Avoid limit splurge cheat treat yourself, cut it out, be mindful balance, cleanse nurture…

In the early and mid-2000s we became increasingly aware that not everyone ate the same as each other. The more progressives noticed that more deprived areas didn’t have access to the same quality foods as those who lived in wealthier neighborhoods. These deprived areas also happen to have higher rates of hypertension, diabetes, and obesity. Diet quickly became considered as not only the most modifiable risk factor, but also the #1 reason for the obesity epidemic. We finally started recognizing that there are places with limited access to fresh, good quality produce and other staples – food deserts.

From the series, Weight of the Nation

But what else do deprived areas often have?

• Crime
• Poorly-funded schools
• Lack of access to reliable credit and banking
• Dearth of jobs
• Proximity to environmental hazards

And what else might people with lower incomes have?

• Unreliable electricity and clean, safe water, which makes food storage and preparation difficult (if not impossible)
• Overcrowded housing or housing in need of repair, which might have pest and mold control issues
• Unpredictable or inflexible employment that limits time and energy often needed for engaging in extracurricular *health* behaviors
• Dependents, younger and older, that require extra care

These all matter, yes?

Yet, I continue to hear that the answer lies in teaching people about proper nutrition and exercise, even though we know that education (and sometimes even access) cannot do it alone. There have to be conducive, representative, agency-enhancing environments and routines for individuals to comfortably, want to adopt. Long-term sustainable change requires organic change – through changing norms and values, not simply laws and clinical dictations directed toward individuals. And, these norms of health and wellness may not look the same for different groups of people – and we shouldn’t be afraid of that. Maintaining a healthy lifestyle might not get to include extensive meal prep, it might not include daily selfies at the gym, it may not be meticulous or regimented. Given the regular stresses of life, it might still include a rush to get out of the house each morning and an inability to keep up with all the daily news or trends. It might require not doing it all. Is it still *healthy*?

With all this discourse, about judging people’s food consumption and even food availability as a reflection of human character and worth, we run the risk of denying agency of the people, who are often depicted as wholly subject to their surrounding environments. Julie Guthman (2011) calls out food writer Michael Pollan (2006) for explicitly stating this narrative of the dubious consumer: “When food is abundant and cheap, people will eat more of it and get fat.” And simultaneously we isolate the narrative about obesity to one simply on food, eliminating the possibility for social structural imbalances leading to a propensity to chronic disease.

What I’m coming to learn is that yes, individual diet and exercise are the *most* modifiable risk factors ->  because they are the least politically disruptive, and they are easiest to quantify.

Obesity and chronic disease are symptoms of larger problems. In the short run, getting some to change their behaviors might work for a few. But when we’re close to 40%, and among some closer to 50% prevalence of obesity and running high risk for serious conditions like diabetes, bigger, looser policy changes are needed for the bigger change.

And so, I’ve come almost full circle here. At LSE,  frustrated by economics, now disillusioned by public health. Just ready to start talking different, start reading a different approach to health. My hope is actually that economics, or sociology, might have some answers. But I’m not convinced it’s medicine, and I don’t think it should have to be.

Works Cited

Guthman, Julie. 2011. Weighing In: Obesity, Food Justice, and the Limits of Capitalism.

Pollan, Michael. 2006. The Omnivore’s Dilemma: A Natural History of Four Meals.New York: Penguin.

Featured image from: https://www.theguardian.com/commentisfree/2014/sep/11/fat-shaming-slim-sanctimonious-cause-obesity-crisis.

Low Income Eaters

Deconstructing Dialogue on Obesity, pt. 2

“And, for a single mom who’s got three kids screaming in the backseat, it’s a lot easier to stop at McDonald’s and get a Happy Meal. But, if she felt that she had the time to go home and…make some taco soup with several cans of beans, and corn, and ground turkey, it would be cheaper to feed herself and all of her kids…”

In my last entry exploring the connections between obesity and low income, I looked at the assumption that low-income earners are primarily the fast-food consumers in this country. The research that has been done reveals otherwise: that actually, middle-income and higher-income earners consume more fast food and restaurant food than truly low-income individuals. Perpetuation of this myth helps reveal additional questions:

• What are low-income earners consuming?
• What does research say about what informs their decision-making around food?
• And why are “low-income earners” our primary focus? What does this mean for health intervention strategies?

How do we identify “low-income” patients?

There is a great lack of clarity in the clinical world when we talk about “low-income” individuals. My understanding is that “Medicaid beneficiary” is the primary indicator used to determine if the patient is low-income. This provides a narrowed picture for a number of reasons. Medicaid eligibility is very limited in the state of Mississippi. While about 25% of MS residents are on Medicaid (694,000 of the 3 million), more than half of these are children on Medicaid, and 100,000 are children under CHIP. As a side note, qualifying income limits are much higher for Medicaid children – they extend up to 194% of the FPL for some families. For adults, without a qualifying disability, household income cannot exceed 22% of the Federal income poverty line, and they must have dependent children to qualify. This means combined yearly household income can’t exceed $5,335. I think from this we should be very shocked that about 300,000 Mississippians (10% of the state population), possibly more who are not enrolled but do qualify, could be in considerably dire straits, living with dependent caregivers, with potentially very little opportunity.

On the other hand, this information most likely means that lots of people in MS just do not qualify for Medicaid – and as we know, many of these people are working jobs (the unemployment rate is only 6.6%, compared to 5% nationally).

By just looking at Medicaid status for determining “low income patients,” we’re not only leaving out those ‘hiding’ poverty, or still living with hardship – for instance, those who may be shuffling between credit cards each day (De Marco et al 2009), or providing any spare income for a disabled parent, pushing pennies to get by – we’re narrowing this idea of what it means to be “poor,” and we’re also perpetuating this focus on Medicaid itself, as some sort of indicator of the poor and the sick, as an indicator for those who really require our focus.

• Why is income the primary, or sole, indicator?
• Why are we so focused on ‘the poor’?

So who is it we’re really talking about here? Are we looking at Medicaid status, or living below the FPL, or making less money than what “I” personally make? When we say “low-income,” how we determine this varies by context (obviously, Medicaid beneficiaries will vary largely by state); it’s a vague term thrown around for labeling policies’ target groups, for political purposes. But there really is a thin, thin line between respect for those we’re targeting, for improvement, and a desire to control.

In the state of Mississippi, 35.5% of individuals are classified as obese. Yes, those on the margins experience health risks stronger because of their limited resources to escape and work around the situations they live in. But when nearly half of the people in the state are obese, and 70% of all adults are either obese or overweight, this is no longer just a “fringe” disease affecting 300,000 people – even though that’s still how we talk about it. Documentaries continue to go to the Delta, to interview its black residents and film the quick-stops serving the fried chicken and the collards cooked in pig fat. We don’t see the white folk, the Krogers in Madison, or the Square. Higher prevalence does not mean exclusivity. Obesity is just a symptom of much deeper issues than we’d care to admit.

Again, we must identify to whom this rhetoric is geared toward and ask ourselves, for what purpose does it serve? Secondly, we have to ask, who are the interventions and policies intended for? Then, are the interventions working for those for which they are intended? And to connect these questions – are all these groups the same?

Lots of questions here, that will be explored in future writing. Where we can begin to work right now is looking at what research says about low-income food consumption patterns and rationales, because if we’re saying that low-incomers are the problem in this obesity epidemic, we have to be very clear about their habits and what their contexts actually are.

What do we know about low-income food consumption

The very low-incomers likely include individuals who are food insecure; however, income alone doesn’t necessarily predict food insecurity. From a research perspective, defining food insecurity is a bit complex. In general, the USDA considers being food secure as having “ready availability of nutritionally adequate and safe foods, and an assured ability to acquire acceptable foods in socially acceptable ways (eg, without resorting to emergency food supplies, scavenging, stealing, or other coping strategies)” (Kempson et al 2002). After the emergence of food insecurity as a problem in the 1980s, the USDA now includes a food security supplement as part of the Current Population Survey. Families often float in and out of periods of food insecurity, so there is a need for longitudinal research to better understand the nuances of food consumption patterns; researchers estimate that 15% of US households experience periods of food insecurity (Franklin et al 2012).

When talking about living in poverty, scholars frequently frame the discussion around a life of scarcity. Pressed for resources in states of uncertainty, low-income earners are often thought of as making many of their decisions within this context.

People use a number of strategies to maintain food sufficiency in the face of limited resources. They may binge when food is available, a sort of “last supper” mentality that might have links to metabolic issues and obesity (Kempson et al 2002; Kempson et al 2003; Kendall et al 1996; Troy et al 2011). Lots of food is purchased at the beginning of the month, because of SNAP distribution schedules, and often, “splurge” purchases are made during this time of abundance (Dinour et al 2007). Mothers skip meals to save food for their children, drinking soft drinks instead and eating unconventionally – e.g. eating cereal for dinner, or foods they don’t prefer (Bove and Olson 2006). For women in particular, the link between food insecurity and obesity is strong and linear (Dinour et al 2007; Franklin et al 2012). The elderly poor have been known to consume pet food as a way to save money on fixed income. After food has spoiled or molded, people report removing or cleaning the ‘inedible’ parts, and then eating anyway (Kempson et al 2002).

There has been a significant amount of research looking at the links between food insecurity and weight gain, but most studies show mixed relationships dependent on age and gender, and in general, there is not a strong link. Weight actually declines with reported hunger and food insecurity (Ross and Hill 2013). However, researchers have attempted to expand this relationship further by including economic hardship into the analysis, defined as “a lack of the money necessary to meet family needs for food, clothing, shelter, and medical care” (Ross and Hill 2013). Beyond income alone, the economic hardship measure describes an individual’s own personal constraints and stresses, asking individuals about difficulty paying bills, putting off buying necessities, and ending the month without enough money. Ross and Hill (2013) found that “economic hardship, receiving welfare, and growing up in a family that received welfare are all significantly positively associated with body weight. Economic hardship has the largest and most significant association.” People who reported struggling to make ends meet, in all parts of their lives, weighed more.

Takeaway

There is a body of research that has looked into food consumption under stress, uncertainty, and fixed income contexts. However, there is a critical need for first defining, and second, better understanding intended target audiences in obesity policy and nutrition interventions. Qualitative research can provide great insight on families’ feeding practices, food management strategies, consumption patterns, and daily contexts, to inform policy and program development.

But missing the mark on perceptions of low-income food consumption, and food consumption patterns amongst all income groups, and failing to consider other social pressures at work here, causes us to miss out on the real problems, and therefore the real solutions. When “low-income earners” are the primary obesity targets (even though they aren’t the only ones obese), and they’re assumed to consume only fast food (even though they don’t), we miss out on creating programs that may harness the value of family meal time and the joy we find in food; we fail to acknowledge that many many Americans face simultaneous food insecurity, illness, and chronic stress; and we lose the opportunity to change the modern systems in which we live, in which so many of us struggle. As a result, we create health systems that are disjointed from reality, and by doing this, we fail to really improve health outcomes at all.

Works Cited:

Bove, Caron F. and Christine M. Olson. 2006. “Obesity in Low-Income Rural Women: Qualitative Insights About Physical Activity and Eating Patterns.” Women & Health 44(1):57-78.

Good, Byron J. and Mary-Jo Delvecchio Good. 1981. “The Meaning of Symptoms: A Cultural Hermeneutic Model for Clinical Practice.” The Relevance of Social Science for Medicine Eds. Leon Eisenberg and Arthur Kleinman. Dordecht, Holland: D. Reidel Publishing Company.

De Marco, Molly, Sheryl Thorburn, and Jennifer Kue. 2009. “‘In a Country as Affluent as America, People Should be Eating’: Experiences With and Perceptions of Food Insecurity Among Rural and Urban Oregonians.” Qualitative Health Research 19(7):1010-1024.

Dinour, Lauren M., Dara Bergen, and Ming-Chin Yeh. 2007. “The Food Insecurity-Obesity Paradox: A Review of the Literature and the Role Food Stamps May Play.” Journal of the American Dietetic Association 107:1952-1961.

Franklin, Brandi, Ashley Jones, Dejuan Love, Stephane Puckett, Justin Macklin, and Shelley White-Means. 2012. “Exploring Mediators of Food Insecurity and Obesity: A Review of Recent Literature.” Journal of Community Health 37:253-264.

Kempson, Kathryn M., Debra Palmer Keenan, Puneeta Sonya Sadini, Sylvia Ridlen, and Nancy Scotto Rosato. 2002. “Food Management Practices Used by People with Limited Resources to Maintain Food Sufficiency as Reported by Nutrition Educators.” Journal of the American Dietetic Association 102(12):1795-1799.

Kempson, Kathryn, Debra Palmer Keenan, Puneeta Sonya Sadani, and Audrey Adler. 2003. “Maintaining Food Sufficiency: Coping Strategies Identified by Limited-Resource Individuals versus Nutrition Educators.” Journal of Nutrition Education Behavior 35:179-188.

Kendall, Anne, Christine M. Olson, and Edward A. Frongillo. 1996. “Relationship of Hunger and Food Insecurity to Food Availability and Consumption.” Journal of American Dietetic Association 96:1090-1024.

Ross, Catherine E. and Terrence D. Hill. 2013. “Reconceptualizing the Association Between Food Insufficiency and Body Weight: Distinguishing Hunger from Economic Hardship.” Sociological Perspectives 56(4):547-567.

Townsend, Marilyn S., Janet Peerson, Bradley Love, Cheryl Achterberg, and Suzanne Murphy. 2001. “Food Insecurity is Positively Related to Overweight in Women.” Journal of Nutrition 131:1738-1745.

Troy, Lisa M., Emily Ann Miller, and Steve Olson. 2011. Hunger and Obesity: Understanding a Food Insecurity Paradigm: Workshop Summary. Washington, DC: National Academies Press.