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What You Won’t See in the Media Coverage of a New Weight-Loss Drug

See the original post on The Huffington Post

This week, the U.S. Food and Drug Administration made headlines for its approval of another obesity drug. News outlets worked hard to translate the meaning of this story, but they left out something important: heads.

After facing public backlash over the withdrawal fen-phen in 1997, the FDA exercised caution towards all subsequent obesity drugs, notably rejecting phentermine/topiramate, lorcaserin, and naltrexone/bupropion in 2010 and 2011. By 2012, the FDA approved the former two after seeing additional safety data. On Wednesday the FDA approved naltrexone/bupropion, and yesterday an advisory panel endorsed a higher dosage of the diabetes drug liraglutide for use as an anti-obesity medication, indicating that another approval is likely on the way.

Coverage has focused on the function of these drugs, their safety profile, theirregulatory history, the likely financial ramifications for their pharmaceutical brands, the larger obesity epidemic, and insurance coverage. These are all important topics to various audiences, but to see what they leave out, take a moment to scan through the images used in each of the linked articles. Wherever an obese person is pictured, they tend to be headless. Where heads are present, they are faceless.

London-based academic Charlotte Cooper first identified the “headless fatties” in 2007, arguing that these images further stigmatize obese people, who become “reduced and dehumanised as symbols of cultural fear: the body, the belly, the arse, food.” The Yale Rudd Center for Food Policy and Obesity performed a content analysis of 549 photographs used in news stories about obesity in 2009 and found that 72 percent of the images negatively portrayed overweight and obese individuals: often headless, with junk food, or without clothes. The press is not alone — professional settings, health care environments, and educational spaces join news media as domains where evidence of weight discrimination, bias, and stigma are well documented.

Some find no fault in this, such as bioethicist Daniel Callahan, who argued that fat-shaming should be used to combat the obesity epidemic in the same way stigmatizing smokers was used to decrease tobacco use.

Research on the relationship between stigma and obesity says otherwise. In a survey of 6,157 participants in the U.S. Health and Retirement Study, researchers found that individuals in the study who experienced weight discrimination were 2.5 times more likely to become obese within four years, and those who were already obese were three times more likely to remain so.

The Rudd Center reaches similar conclusions, explaining that stigma and discrimination can be associated with chronic stress and the denial of proper medical attention, which not only introduce their own health problems, but prevent a person who does desire to lose weight from developing the self-esteem and motivation to do so. In other words, we cannot simultaneously shame individuals for their weight andexpect them to feel good enough to initiate and maintain the grueling work of weight loss.

This is true of my experience with weight loss, too. As I grew up overweight and obese, I was taught that fat is lazy, greedy and compulsive. With this view reinforced by everything around me, that’s exactly what I came to believe about myself too. This didn’t stop me from trying to lose weight, but it did stop me from being successful. Over 15 years, I lost and gained weight, never fully reaching a healthy weight or keeping any losses off. It wasn’t until I went to college that I lost about 100 pounds. What changed? I had a clean slate, a facilitating environment, and a new strategy to motivate myself.

Rather than focus on the reasons why I looked disgusting or undesirable, I kept a catalog of success stories among folks who lost a lot of weight and kept it off through positive health changes. When the going got tough, I returned to these stories to remind myself that others had been there. My struggle with weight was inflected with people and images who did not look like me, telling me how I should feel. Reaching a healthy weight was a direct outcome of studying people who once looked like me, telling me how I could feel.

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I suspect that the editors these articles would tell me that obese individuals are necessarily headless because no obese person would consent to their face being shown in a story about obesity. That’s not a great excuse. To specifically address this issue, the Yale Rudd Center assembled a database of images depicting overweight and obese individuals in non-stigmatizing settings (I used one of their photos above). The point here is not to celebrate or encourage obesity, but to humanize it. These images are free to use with the proper attribution and allow stories about obesity to feature a relevant picture. The irony is clear: Before casting the obese as lazy, take stock of your own mindless practices.

Day 3 of ICO: The Future of Obesity Epidemiology, and the Future as Life Course Interventions

Opening Plenary

 

Dr. Anna Peeters accepted her award with a talk on her winding path, imbued with a love of ideas, an ongoing desire to make a positive contribution, and shared enthusiasm with her colleagues. She gained from her early work at Monash University the value of non-traditional backgrounds and approaches. This took her to the Erasmus Medical Center in the Netherlands, where she did a post-doc learning more about cardiovascular disease treatment, prevention, and mortality, eventually leading her to obesity. She learned here the value of a creative, supportive environment that encourages critical thinking. She there thought to apply the techniques of measuring life expectancy with cardiovascular disease to obesity. To do this she used the well-known Framingham Heart Study, translating relative risk predicated on BMI to life expectancy differences. She realized at this point that the enjoyed working on tools that can inform public health, integrating health risks associated with obesity, population distribution trends, equity implications, and health benefits associated with intervention. All of this led her to work on “obesity duration,” providing a rationale for early intervention approaches. She then spoke about the complexities of setting population targets for obesity prevention, noting that even optimistic projections fail to reach 2005 obesity prevalence by 2025. All of this is to say, Dr. Peeters argues, that we need to think about how we define success. With a nod to the future, she sees obesity epidemiology moving in the direction of bringing inequalities to the fore, developing a greater understanding of the combined effect of interventions, and building a more sophisticated view of evidence.

 

Afternoon Plenary

 

Professor Mark Hanson of the University of Southampton begin his talk asking and answering a question on the minds of many conference attendees: “Why are we losing the war against obesity? Because we intervene too late.” He proceeded to characterize the current vogue in obesity thinking: large agreement on the etiological roles of genetics and lifestyle, combined with the immovability of genetic traits, builds a preemptive consensus for lifestyle intervention. It is the lifestyle intervention, Professor Hanson argues, that leads to the unnecessary guilting of individuals, and later on, exasperated calls for drugs and surgery. He then provides an alternative paradigm, one that move beyond the genotype and lifestyle to consider the role of epigenetics. This paradigm, known as the “life course” approach recognizes that risk increases exponential through the progression of life. In some emerging cases, he demonstrated findings suggesting that more than 70% of the variably methylated regions (VMRs) in one gene associated with later adiposity could be attributable to genotype-perinatal environment interactions. What this means is that interventions can target the pre-conception period and display their efficacy within five years. Professor Hanson himself is collaborating on a project (Jom Mama) with the Malaysian Ministry of Healthy and other academic and industry partners to provide health promotion services to newly married couples soon to conceive their first child. Adding to the lifestyle, pharmacological, and surgical options for obesity intervention, the life course approach offers a compelling set of tools.

Day 2 of ICO: Energy Balance Physiology, Low-and-Middle-Income-Countries, and a Debate

Opening Plenary

 

Dr. Rudolph Liebel accepted his Wertheimer Award with a lecture on the physiology of the weight-reduced state that spanned its historical development, all the way up to the cutting edge. Research he and others have worked on over the last several decades build a convincing narrative for the role of leptin thresholds in energy homeostasis. His findings rebut the point that weight regain is mostly a function of decreased energy expenditure, arguing instead that a weight-reduced state is a leptin deficient state that drives increased intake. Put another way, it is unlikely obese individuals eat like birds — adding that “if they do eat like birds, it’s more like a pterodactyl than a finch.” Research builds the theory that evolution has made the wager that it is better to protect against fat loss than prevent against weight gain. For this reason, it is easier to raise leptin thresholds in subjects (through chronic weight increase, neuronal loss of aging, or pregnancy) than it is to lower the threshold (which seems to require lesions, leptin replacement, or cachectic illness). That said, Dr. Liebel called for reframing our understanding of weight loss. To develop effective treatments, it may be useful to see weight loss as a process that induces a non-physiologic state of hypometabolism and hunger, where the goal of treatment becomes restoring normal physiology under weight loss. One example of the cutting edge of this approach is research into Bardet-Biedl syndrome and dysfunctional cilia, which may lay the groundwork for transplanting brain cells to restore normal physiology.

 

Afternoon Plenary

 

Introduced by World Obesity President Philip James, University of North Carolina Professor Barry Popkins led the audience through a tour-de-force of data and insights on global obesity dynamics and policies. Notably, he demonstrated that there is a movement from undernutrition in low-to-middle-income countries (LMICs) to overweight across all regions, with a larger share of the increase in rural areas. Moreover, the BMI distribution is shifting rightward at all levels, rendering obesity all the more extreme. Remarking that “we’re not going to reduce obesity by forcing everyone to run a mile every time they drink a sugary beverage,” he called for action on the food supply. To this end he extolled the efforts of Mexico for enacting a comprehensive plan to tax sugary beverages. Dr. Popkin reviewed the fight in great detail, citing the need for coalition building, evidence-based policy, a rigorous public campaign and media strategy, and international support. The media strategy in particular was particularly intrepid for keeping the controversy in the news through regular press conferences, advertisements, and public actions. Concluding with brief examples taken from Ecuador, Thailand, Singapore and the Western Pacific Islands, Dr. Popkin criticized the rarity of action among high income nations.

 

Debate

 

The debate at the conclusion of Day 2 opened to a packed house of observers. Taking stock of the audience predisposition prior to the debate, the moderator recorded 64 votes for and 81 votes against the motion: “This conference believes that preventing obesity is the responsibility of the individual not of the government.” Professor J. Prins brought the audience to laughter multiple times as he made jabs at the moderator, his opponent, governments, himself, and even his own position. Ending on some serious considerations, he argued for protecting individual responsibility as the “mainstay of civilized society.” Professor Prins pointed to Singapore as a model for encouraging personal responsibility while maintaining that the government can play a role in supporting individuals.

 

Jane Martin of the Obesity Policy Coalition began her case as the opposition by invoking some lessons learned from Australia’s tobacco control efforts. Notably governments were slow to act (she showed a progressive tobacco policy in the 1960s that took decades to realize) and when they did, price changes were most effective. She sees an analogy if food policy, especially with respect to marketing. Questioning the freedom of individual responsibility, she declared: “The food industry does not provide us with choice, it provides us with the illusion of choice.” Demonstrating a collection of ridiculous real-life examples of food industry tactics, she sees child food marketing regulations as a no-brainer. The industry, she showed through another spate of absurd examples, cannot be trusted to regulate itself. In a nod forced dichotomy of the debate topic, she showed that individuals are in favor of such government intervention.

 

Then the audience got involved, with one observer asking whether Professor Prins thought the freedom of choice means obese individuals choose to obese. Another sarcastically asked him to come and talk sense into the UK government who has imposed all sorts of controls on food safety, traffic laws, and financial activity. One audience member invoked his belly fat, saying he “doesn’t know anymore who to blame.” The debate concluded with a clear landslide of support for Ms. Martin and the opposition, with only 45 in the post-debate audience poll favoring individual responsibility.

Ethno-Sensationalism and Awkwafina

Written for PolicyMic.

The late David Rakoff left us with this insight: “There are some questions in life, the very speaking of which are their own undoing. Am I fired? Is this a date? Are you breaking up with me? Yes. No. Yes.” One of these questions could be seen headlining an article in New York Magazine early this week: Can an Asian woman be taken seriously in rap?

Beginning from this premise, one need not get past the third paragraph of the short profile before Awkwafina (a rapper alter ego for Nora Lum) is compared to the literary heavyweight Haruki Murakami. Don’t be alarmed — the comparison is not made from race, but rather finds that both speak with the same “awe.” The writer really dodged a bullet with that one. Or maybe a throwing star.

To ask whether Lum can be taken seriously builds a frame for considering the rapper already. It precludes serious consideration by asking if a serious consideration can take place. Compare this to asking whether Awkwafina will be taken seriously — that construction has a decidedly different connotation. It presupposes that the rapper is already worthy of serious consideration, and that it is the task of everyone else to catch up to this realization. Alternatively, you could ask should she be taken seriously. That question poses a still more neutral frame; it actually sounds like a real question.

Still more doubting is the use of “Asian” in the question’s frame. That women can be taken seriously as rappers is not asked much, if at all, anymore. The question has lost its novelty to the the likes of Lil Kim, Missy Elliot, MIA, Azaelia Banks, Queen Latifah, Lauryn Hill, and until fairly recently, Nicki Minaj. It’s telling that we have to ask whether an Asian woman rapper can be taken seriously. What it tells is that there are still some salient expectations and stereotypes governing what can pass as normal in the game. The question therefore becomes self-defeating in its redundancy —translated, it asks: Can a stereotyped archetype be judged free of the stereotyped archetype in the rap game?

Unpacking one’s knapsack aside, there’s another reason this question is its own undoing — it is currently unanswerable. A reasonable definition for “taking something seriously” might include the option of finding the subject bad. But Nora Lum may not yet exist on the plane of good-or-bad. At the risk of sounding uncompromising, this argument will be made by analogy from the following clip by Hari Kondabolu:

In other words, the path taken by many to Awkwafina’s emergence on the scene is to celebrate her ability to emerge on the scene. When enough Asian female rappers join her such that we stop primarily identifying them as Asian female rappers, then it might be appropriate to judge them.

That sounds contradictory, hypocritical even. Why is it okay to celebrate a female Asian rapper for her Asian-femaleness when it’s not okay to judge her based on her Asian-femaleness? Because race and ethnicity are complicated. But more so because positive and negative judgments hold differing consequences. To pose negatively the judgment by linking it to the randomized qualities of Asian-femaleness perpetuates the social context that makes it weird for Asian women to be rappers. To celebrate Awkwafina’s Asian-femaleness doesn’t judge her as a rapper either — but as a judgment, it’s difficult to argue this is as deflating.

If you have to ask whether Asian women can be taken seriously as rappers, they aren’t, and won’t be. If you celebrate them as Asian women who rap — or better, as just rappers — that builds an emerging social context for more to come onto the scene.

If the asking of some questions are their own undoing, perhaps it is better to just do. Here is Awkwafina, on her own terms:

5 Things to Do When You’re Rejected From Your Dream School

Written for PolicyMic.

If you’re startled awake to the harsh reality of not getting into your dream college, how do you move forward? To those who have been through college, that appears in hindsight to be an amateurish concern, a parting manifestation of adolescent theatrics and teen drama. But it does matter. Having been there, the emotional memory I can most readily recall is the sense of starting the rest of my life on the wrong foot. I definitely didn’t, and at least part of that comes from receiving great advice and taking some intentional steps after the season of envelopes thick and thin ended. Here’s the best of that:

1. Get to Calm

Before anything else, take a nap. Sleep it off. Go to dinner with a group of friends. There’s disappointment in getting rejected, but you needn’t to deal with it all at once after the initial shock of a short email or thin envelope. Taking a little time to process the event will serve you well — when you think and act in the moments following a dramatic event, you’re not exercising much agency. You’re reacting. In order to take the best path forward, give yourself enough time to get to a place where you’re distant enough from the initial shock that you can act.

2. Reverse Engineer the Dream School

When you’re ready to move on and move forward, meditate on the qualities of your dream school. What about the school made it perfect for you? What kinds of classes were you likely to take, experiences likely to have, programs you wanted to get involved with, people you wanted to count amongst your peer group? It’s a good idea to put these qualities to paper, in a list so that you can see them in a form more tangible than your thoughts and feelings. It’s an ever better idea to enumerate these points as specifically as possible. You may find that your dream school doesn’t have quite has much on paper as you thought. Perhaps you’ll see that some of what you found to be dreamlike about your dream college was precisely that — ethereal in its articulation. The point of this exercise isn’t to undercut the allure of your dream school (though that may soften the blow). The point is to demonstrate that few of these qualities cannot be replicated elsewhere.

3. Decide how to deal with your dream school

Now that you’ve distanced yourself a bit from the rejection and thought a little about the nature of your pull to the dream school, there are four paths you can take with regards to the immediate decision. First, if you still feel you have to go to this school, you might consider writing a letter of appeal. This is a way to show your continued interest in the school, while at the same time adding to your profile some attributes that weren’t seen on the original application. Should you go this route, don’t do it alone. Seek the advice of your counselor or a teacher, and not only because it’s helpful to include a recommendation letter in your appeal packet. Your appeal should not ruminate on the undying bond you’ve forged with the college, nor how utterly amazing they are. Instead, work to craft a very precise and careful argument that incorporates your continuing desire to gain admission, your particular interests in the college (the previous step may help here), your reason for appealing, and what you’ve been doing since the original application.

Maybe an immediate appeal isn’t the strongest tactic for you to take. If you need some more time and space to develop an appealing application for admission, you might consider transferring. Do you due diligence to determine whether and how many transfers are taken by your dream college, as well as their requirements for transfer. Some education bodies, like the University of California, have a great system for transferring from California Community Colleges. Private universities, as you might guess, tend to be more restrictive in this area. Don’t be afraid to call the Office of Admissions to ask this question directly.

Let’s say you want to try your hand again at the dream college, but don’t think more classes and better grades are going to help. You may consider taking a gap year. New York Timescolumnist Nicholas Kristof is a big proponent, and as he points out, this is not an uncommon practice in other parts of the globe.

The final path you could take is to just accept admission to a different college. An intermediary step to this path is to take your list of qualities that make the dream school so and compare them to the opportunities of your given admissions. Depending on your feel of the school, the closeness of the alternate choice to the dream might be a good way to move forward without forgoing any of the college experience you might with transferring or taking a gap year. However, this is not to say you should attend another school pretending it is the substitute or next-best-thing to your dream college. Rather,

4. Make Your College Choice Your Dream College

This is accomplished by seeking out the analogous opportunities of the dreamy college in the chosen college, understanding that the chosen college has much to offer on its own terms, and really preparing yourself for the best college experience possible.

Let’s say that you adored your dream college because it offered a small classroom environment to pursue your studies — maybe it was a liberal arts college. Even at a large state school, it is possible to craft that kind of experience if you’re intentional about that need. Most schools offer honors programs with smaller class sizes, for example. And by forming early on a small group of classmates and frequently going to office hours, you can absolutely shrink even the largest classes.

But also prepare yourself to receive what the college has to offer. This means two things: First, you want to be open to drinking the Kool-Aid. If you’re going to be there for four years, you might as well be an evangelist for the school. This will make you happier in the long run and receptive to the deluge of opportunities every college affords. Perhaps more important, there’s a lot you can do to prepare yourself for the journey. Sure, it seems like this was the purpose of high school, but it’s worth asking yourself between now and August whether you actually know how to study, whether your grasp of fields is good enough to hit the ground running, rather than good enough to pass an AP test. The best time to learn how to be a better college student is when you’re supposed to be inflicted with Senioritis.

A dream college isn’t this castle in the sky that will shower upon your passive self amazing experiences and unparalleled opportunities. It is as much welcoming space as it is a product of your agency.

5. Write the Dream College a Rejection

If after all this you still need a hand coping with rejection, you could try writing a letter (that you’ll never send) to your rejecting college. Just don’t be a jerk about it. The following process is a modified version of what is called cognitive reappraisal. Start by writing a handwritten letter to the dream college, articulating everything you wish you could say to them, in every cringing detail. Sign this letter with your signature. Then, write a letter back to you from the perspective of the dream college. In this letter, write out everything you want to hear from them in an apology. Write the letter that, if you received it, would make you feel better. Sign this one too. (For added fun, you get to invent a signature for whole college.) Before going to bed — you may do this for a week, or however long it takes — read this latter letter back to yourself. Even though this plays a trick on your mind, you’ll feel better for it. And after doing this, you’ll have learned a valuable process for letting go of grudges.

97% Of Restaurant Meals Fail This Health Standard

Written for PolicyMic.

If 97% of restaurants failed their health inspection, you might never eat out again. And yet, there’s a sense in which exactly that happened just last week.

The nonprofit Center for Science in the Public Interest (CSPI) released a study that examined 3,500 kid’s meal choices at the top 50 restaurant chains in the country. They tested the nutritional content of these kids meals against criteria that allowed up to 430 calories per meal. Of the 430 calories, no more than 10% could come from saturated or trans fats, and nor can more than 35% come from fat. Other criteria considered the amount of added sugars and sodium. At 19 of the 50 chains studied, not a single combination of meal items could meet the CSPI criteria.

97% of the 3,498 meal combinations reviewed by CSPI did not meet experts’ health guidelines for children.

What’s the big deal if restaurants offer bad food — don’t we expect them to do just that?

First, that the environment of available consumer food choices has offered solely unhealthy foods is among the reasons we have an epidemic of childhood obesity in the first place. According to the Centers for Disease Control, childhood obesity has increased two fold and adolescent obesity threefold in the last 30 years. One-third of children and adolescents are overweight or obese, and are thus at risk for developing Type 2 Diabetes, among other medical, socioeconomic and psychological challenges later in life. Research has indicated that many of the “excess” calories can be attributed to eating outside the home. When it’s revealed that most food choices outside the home are not exactly pro-health, the writing is on the wall.

Second, recognize that menu choices condition children (and probably adults, too). They condition children for what food norms are outside the home, which determines what they can demand inside the home. The conditioning also tells them what they can reasonably expect from restaurant chains. It’s not until many restaurants offer affordable and healthy menu choices that affordable and healthy foods will become an expected component of our food environment.

To those who groan that groups like CSPI are making much ado about nothing, consider that the National Restaurant Association (the other NRA), the largest body representing the interests of the restaurant industry, itself has a criteria for healthy kids meals: Kids LiveWell. In many ways, this criteria mirrors that of CSPI, but allows more calories per meal. Even under the NRA’s own criteria, 91% of restaurants fail to meet their standards for kids meals.

If gallows humor has a place in this story, it should be noted that restaurants have actually performed better on this survey since 2008, when only 1% offered kids meals that met the nutritional criteria. But we shouldn’t be celebrating that. For restaurants to move so slowly when studies indicate that healthy foods draw a profit borders on alarming negligence. We should expect better.