Overweight/Obesity: Weighty Issues for the

MCH Population

Michael Rich: Before I start, I want to give credit to the AV people, who scrambled at the last minute to make this all work. The program I’m about to tell you about is actually exists through the support of the National Institute of Child Health and Human Development, and was actually developed and implemented in one of the Maternal and Child Health Bureau’s Leadership, Education and Adolescent Health Training program, so credits to all of you. Since we’ve heard about the epidemiology, I’m going to go through this fairly quickly. I think that we just have to recognize, once again, that this is now the most chronic medical condition in industrial societies, and that the prevalence is shooting up rapidly in our society. The risks are both short-term and long-term. As a pediatrician I see, not just Type II diabetes, which we talked about earlier, but hypertension, sleep apnea, pseudo-tumorserebre, gall stones, and a number of other musculoskeletal issues as well as psycho-social issues. Long term research indicates that there are decreases in the socio-economic status, diabetic complications, hyper-lipidemia, and we already have talked about cardiovascular disease and early death. So how do we get to the bottom of childhood obesity? It’s hard. It develops and is maintained in the home. It is stigmatizing and socially isolating. And it is incredibly resistant to intervention. That’s why we’re here today. Unfortunately, what many people have tried to research obesity has found, that the shame associated with it really limits our research and that, while we’ve done many, many surveys of children and their families, they have little sensitivity or validity. So in attempting to approach this problem, what we did is realize that we have to go to the experts. The patients, the people themselves, who are struggling with these issues and to find a way for them to be able to come out with what’s going on for them in a way that is both valid and sensitive to the data that we need get. We need to identify the influences and issues that are important to the patient. Oftentimes when we research something, we come from the things that are important to us, which we may or may not, which may or may not be shared by the patients. So what we sought to do was go from the inside out and ask the patient what was going on. In addition, patient-controlled data collection may be more sensitive because they have control of the information screen, because they are presenting it to us in terms of what they experience and what they need. They may be more forthcoming with data that, when we ask about it, may be perceived as judgmental. And finally, when patients examine their own experience, we found with other areas, that they tend to own the problem more, and be maybe more motivated to change. So we applied a methodology we’ve been using for almost 10 years now called Video Intervention Prevention Assessment, or VIA for short. And what VIA does, quite simply, is asks participants who suffer from the same condition, to create visual illness narratives. We give them camcorders and have them make video diaries of their lives with the condition. We couple that with a quantitative study of their health-related quality of life. In addition, we have what we call the CSVR, which is the fancy name for a medical and psycho-social history. The patient’s verbal report of what’s going on. And our goal is to examine obesity from the inside out with the hope that we would get improved research sensitivity and the increased therapeutic engagement of the participant. So we hand them these camcorders and say, “Teach us about what you’re struggling with. Teach us about your life.” They carry camcorders for four weeks and they record their day-to-day lives, their environments, the physical and psycho-social environments, eating, exercising, playing with friends, interactions with clinicians. If you want to do an interesting experiment, take a camcorder in with you the next time you go into your doctor. Interviews with family and friends who know them and their condition well and, in some ways, perhaps the most revealing what we call personal monologues. This is essentially the “Dear Diary” stuff. Turn on the camera and talk to it about what’s going on. What’s happening today?. How are you responding to it? What’s in your head? I won’t bore you with all the analysis details, but in short, what we attempt to do is analyze this, as you might imagine, very rich and complex data from a number of different disciplinary perspectives. From anthropology, to understand how this works in terms of the meanings they associate with illness, and their cultural responses to it. With a clinical social worker, who works with this condition, to look at issues of social stress, and access, with a psychologist, a nutritionist, and a physician, for all of their areas of discipline. We did this with a huge number of 13 kids, which, as with most qualitative research, is a small number by other standards, but generates very rich data and produced 160 hours of visual narratives. And what did we find? The level of physical activity was, actually, interestingly higher than anticipated. 38% of them, in addition, showed that they were fidgety, hyper-active kinds of kids. The kids who never sat still. And 62% of them played sports, danced, or exercised on a daily basis. And now, for our first experiment, we’re going to switch over to a little video clip. Show you some of that. These changeovers may take a moment because we have one person running from the front of the room to the back of the room to make this all work. Okay, if you can stop it. Actually, let’s, I’ll just abandon the slides for now. Let’s just do video if you don’t mind. You don’t need to run it, but I’ll talk about what else we found. As has been alluded to by other speakers already, we found that 100% of all the kids watched television, played video games, used computer, or listened to music for long periods of time in a sedentary, and usually solitary manner. And that we saw a lot of eating with media. What we are terming “unconscious eating” of high sugar, salt, and fat-containing foods while viewing something. In a sense, they were not responding to hunger cues, or satiation cues, but were stimulating their oral cavity as they were stimulating their eyes. In one case, and we don’t have video of this because the young man didn’t want us to show it. One young man ate an entire Tupperware full of gummy worms while watching TV in the space of about 15 minutes. If we can show some of the video. Actually, if we could turn down the lights a little, you folks might see this a little better. We found some unique eating behaviors in these young people. 92% of them self-comforted with food. They ate in response to emotional stimulus. 69% of them demonstrated voracious eating as if they’d been hungry for a long time, even when they had eaten just recently. In one case, a hot dog was consumed in four bites. In another, three double cheeseburgers in a single meal. Living with obesity was loaded for these kids. Lots of teasing and social ostracism in schools and in other community groups, depression, and family conflicts over food and weight issues. And if we could roll the tape.

Unidentified Speaker 1: I love large shorts and shirts and the laugh, like today.

Unidentified Speaker 2: If Kinston, like, not really teased me, but, yeah, teased me. If the kids didn’t tease me, then I probably wouldn’t have known that I was overweight.

Unidentified Speaker 3: Since you’ve gained all this weight, you’ve hid in the house for the last two, two-and-a-half, three years and never went outside. You don’t have any friends.

Unidentified Speaker 4: When you get on that scale, and you look down, and you see 224 as your weight, it is so depressing, I can’t even begin to explain that. It is so damned depressing.

Unidentified Speaker 3: Lazy, lack of direction, lack of ambition, lack of support.

Michael Rich: And pause it, please. The young people’s attempts to deal with obesity took various forms, but one of them is explaining to themselves over and over again why it’s not their fault. There were real issues with body image and self-esteem. If we can roll the tape on that one.

Unidentified Speaker 5: This is why, you know, I eat the way I eat is because either I’m mad, or I’m sad, or people look at me strange. I really don’t know the reason why, but it’s like, I’ll eat even if I’m not hungry. If I’m hurting, I feel like that’s when I eat the most, you know what I’m saying? And I know, for me as a young lady, I shouldn’t be like that, but that’s the only way sometimes I can see my way out.

Unidentified Speaker 6: Can you tell them that I have a big stomach, too?

Unidentified Speaker 7: My fellow, (inaudible), has a huge stomach. Look at that thing.

Unidentified Speaker 8: This is who I am. I like myself the way I am.

Michael Rich: Hold it, please. Interestingly, we also found in almost all of the participants, that they had very specific reasons why they liked being big. Those included the ability to have physical dominance over others. That it was a political statement, and it caused them to be a focus of concern for family and friends. If we could roll some tape.

Unidentified Speaker 9: What do you like most about your size?

Unidentified Speaker 10: That I can kill people when I want to.

Unidentified Speaker 11: Society’s image tells you that you need to be 125 pounds and 5’11” and that was part of the reason why I never lost the weight. You know, I could have lost, I could have lost the weight five years ago, but I never did because it was like me saying, “Fuck you,” to the whole world. You know, I don’t have to conform to your images of what you think a woman should be.

Unidentified Speaker 12: Optimal weight loss is what it means.

Unidentified Speaker 13: Yeah, optimal weight loss.

Unidentified Speaker 12: I went to three doctors today.

Unidentified Speaker 13: Doctors, huh?

Unidentified Speaker 12: I have a chance of getting diabetes, but not really.

Unidentified Speaker 13: He, why do you, no, really?

Unidentified Speaker 12: Possible, but probably not.

Unidentified speaker 13: Oh, I hope not because I don’t want you to die.

Michael Rich: If you could hold it there. An area of particular concern to adolescents is the relationship between their obesity and attractiveness and it had effects on their sexual attitudes and behaviors. One showed a great deal of resentment toward attractive movie stars. And again, this is the young man who didn’t want his tape used, but he went a long diatribe about Leonardo DiCaprio, and I’ll give you a quote from him: “Leonardo DiCaprio, he sucks. I think it’s just not fair that all he has to do is brush his hair back and he can have all the women in the world, while we have to work so hard just asking for a date.” He also went on to describe in great detail how he stood up and cheered when he sunk beneath the ice-cold waves in Titanic. The other piece of it, though, unfortunately, is that they are so desperate to be attractive, they are so desperate to be loved and included, that it makes them sexually vulnerable. They are seen as, and treated as, older than they are. They are also seen and treated as “easy” by people who will take advantage of them. And if we could roll some tape, please?

Unidentified Speaker 14: Do you know what I’ve realized? I’m, you know, I’m (inaudible). I am sexy. I’m sexy. Oh, yeah. Who would not want this? Fuck you all if you don’t think I’m pretty. You can all kiss my ass. If I’m pretty enough for guys to grab my ass, then I’m all set. Okay, if I’m pretty enough for a 38-year-old man to think that I would be “wifey” material, then I’m all right. There’s this 38-year-old guy at my work. (Inaudible), who is, like, he wants me to, like, go out with him, you know, like, go on a date. I’m smart enough to know that I’m not going to date a 38-year-old man, but it’s (inaudible), you know?

Michael Rich: And their attempts to control their weight took a variety of different forms. They confronted difficult changes in their lifestyle in a variety of ways and with varying levels of motivations. Some of them demonstrated or struggled with a disorder to eating, and there was a lot of distress over dietary restrictions. If we can roll the last piece of tape.

Unidentified Speaker 3: By working out more, by getting off the couch and stop watching so much television.

Unidentified Speaker 15: As long as I’m not feeling starving, you know, then I’ll do what I’m supposed to, and I’ll have control over my weight.

Unidentified Speaker 16: I am now becoming very obsessive and compulsive about what I eat, when I eat, how I eat.

Unidentified Speaker 17: There are a ton of those fruit cups in there, in the bottom, there’s apples.

Unidentified Speaker 18: I don’t want fruit cups.

Unidentified Speaker 17: They told you you could have sliced apples with peanut butter.

Unidentified Speaker 18: I don’t want apples, my God.

Unidentified Speaker 17: There’s carrots. You can have it with the fat-free dressing.

Unidentified Speaker 18: I don’t want carrots.

Unidentified Speaker 17: Okay, then you know something? You have whatever you want.

Michael Rich: Okay, and stop. And that may be the story of obesity in the home. Okay. Have whatever you want. We saw a remarkable glimpse into the world of struggling with overweight from the inside out with (inaudible). It is sensitive, but it is incomplete, and we are working with other aspects of our research capabilities to look at the other pieces that we need to add to this. What it does give us, though, is a better understanding from the inside out, from the young person’s point of view of the powerful forces that maintain that inertia, maintain that status quo of where they are. It is not just nutritional inertia, it’s social inertia. I had one young person say, “If I lost weight, I don’t know who I’d be, because I’m the fat kid.” He actually said that he had a social niche that he would have to abandon if he changed. We also found, unfortunately, that in this cohort of kids, medical and familial input had very little effect. And the kids that actually were able to change were those that found a personal commitment and motivation to make the differences. What we need to do to tackle this, both on an individual basis and on a population basis, is get a better understanding of what the patient, what the young person, him or herself needs to get a more accurate portrayal of that young person’s strengths and weaknesses, allowing a more honest and effective partnership with clinicians, and teachers and nutritionists and other people who they work with. And finally, one of the things that, giving them the power of information has done, has really empowered them to make choices and make changes. Several of the young people mentioned that this ability to reflect on themselves, to see the way they were behaving through the technological mirror, allowed them to understand where they were making mistakes. Understand what they knew and how they behaved fell apart. It also gave them a remarkable tool for self-advocacy. All of us work tirelessly to advocate for kids, but if we can give them the tools to advocate for themselves, it will be that much more eloquent, and that much more effective. When patients are able to teach us, health care providers, clinicians, what they experience and what they need, then both sides of the paradigm, the patient, and the clinician, will be able to engage more fully in the therapeutic endeavor. And clinical care will hopefully become more humane and effective. If you wish more information on VIA and our other projects as well as obesity, that’s a website where many of these videos are posted. Thank you very much.