Does size really matter for our health?

Posted by Peter van der Graaf, AskFuse Research Manager, Teesside University

A friend of mine recently posted on Facebook a story from a so-called “professional fatty”. In her story published in the New York Times, Sarai Walker took issue with what she called ‘obesity bias’: obese people being portrayed as the baddies. Or as Sarai herself puts it: "Even the most open minded critical thinkers become outraged if fat is spoken about in any positive way: a person can never be simply fat, a fat body always needs to be fixed”.

Instead she argues that the most significant problem for fat people isn't their bodies but the hatred and abuse they receive from society. And she is not alone in this thinking: protest movements have captured the attention of the media by rallying against what they describe as the narrowly focused weight based approach to health. An example is the Health at Every Size (HAES) movement. HAES proponents believe that health is a result of behaviour that is independent of body weight. This is a pretty bold statement that can easily be disputed with research evidence but that is not the point here. The point is that these protest voices chime with a lot of resentment at evidence-based public health messages. Sure enough, another friend joined the debate quickly on Facebook proclaiming her anger on the occasion that her daughter came home from school with a book saying sugar is bad. Public health’s head was once again on the block as the kill joy of everything good and fun and therefore worthy of disputing.

Picture courtesy of  Anna Deflorian/The New York Times

But if we keep getting the message wrong what do we achieve in the end with our evidence-based message? And what is the right message? Should we go along with the ‘Health at Every Size’ claim and focus instead on how to make life more enjoyable at every size? After some highly scientific browsing on Google I came across an article from David Katz, Director of the Yale University’s Yale-Griffin Prevention Research Center, in the Huffington post, which from its catchy title: “Why I can't quite be ok with 'okay at any size' appeared to promise an answer. David Katz also opposes obesity bias; he rejects the notion that widespread obesity among children and adults is somehow due to “an inexplicable global outbreak of personal responsibility deficiency syndrome”. Where he does not agree with HAES is the complete decoupling of weight and health: he is ok with any size if it includes a proviso: as long as health is not adversely affected. Flab is not always fab, he argues, and as a society we should not want to normalise ill health or the factors that impose it.

When I pointed this out to my friend on Facebook, her response was that these were two separate but related issues: one is that obesity carries health risk, which was a matter for the individual and perhaps their doctor. The other was the issue of stigma of obesity under the guise of concern for one's health which is a society problem. But is this really true? Should we define obesity as a private matter that is none of society’s concern and focus instead on developing a culture where people of all sizes feel accepted no matter the risk to their health?

The arguments and evidence presented by both proponents and opponents of the Health at Every Size seem to suggest to me that weight is as much a society/cultural issue as an individual behavioural choice. Hence the emphasis in Public Health on Whole Systems Approaches to Obesity and the impressive Obesity System Influence Diagram, developed in 2007 by the Foresight Project researchers. And perhaps therein lies the problem: if obesity is a complex issue at both individual and societal level (and not just complicated) we cannot simply choose one over the other (accepting fat as an individual’s prerogative for happiness or obesity as societies overriding health responsibility). We also cannot ignore the individual health risk of overweight and obesity but cannot accept the stigma we attach to individuals for failing to be thin. Instead, we might need to find new public health messages that frame individual choices in a cultural framework, for example: “You can be fat and fit but few of us are so why not try together to be a bit fitter?” Maybe it’s not the size but the message that matters more for our health.

Picture attribution: Artist - Anna Deflorian, used in Sarai Walker's article "Yes, I'm Fat. It's O.K. I said it" Feb 6 2016, The New York Times.

From school dinners to sugar tax: Jamie Oliver to the rescue!

Guest post by Dr Victora J. McGowan, Research Associate, Teesside University

I have to say thanks to Jamie Oliver, the media attention from his School Dinners programme led to research questions which went on to form my PhD project (the effect of school meal legislation on child malnourishment). After completing my PhD I thought that would be the end to my connection with the celebrity chef, little did I know that our paths would cross again a few years later. I began work at Teesside University in October 2014 charged with conducting a systematic review into the effects of fiscal strategies on sugar consumption in collaboration with Public Health England (PHE). PHE had recently published 'Sugar reduction: responding to the challenge' which outlined the work they would undertake to assess the evidence base and identify potential areas that would be effective in reducing sugar consumption.

While we were busy searching through over seven thousand research papers the media were just as diligent in searching for almost anyone (including me) to provide information on whether the government would introduce a sugar tax. As we inched closer to the final number of relevant studies which we’d include in our review, Jamie Oliver waded into the debate. I admire the way he uses his celebrity status to push a healthy food agenda, however, I’m often left thinking whether his involvement does more damage than good. In terms of school food, I interviewed school cooks who said his School Dinners series resulted in an almost immediate decline in children taking a school meal. Some might say this was a good thing if the food was as bad as Jamie portrayed it. Well, it wasn’t that bad everywhere and this reduction in school meal uptake had a detrimental effect on the cooks as their salary was based on the number of children taking a school lunch. So when he entered the debate on a sugar tax it made me nervous. Jamie was branded a "patronising bully" by Alex Deane Executive Board Member of the People Against Sugar Tax campaign and tory MP Andrew Percy said Jamie’s suggestion of a sugar tax was "a classic nanny state reaction and it won’t work". I truly believe Jamie means well but his celebrity status often clouds the evidence and can result in detrimental consequences.

As we were in the process of finalising our review of the evidence, a total of 11 published studies, Jamie’s sugar tax campaign was gathering momentum with an online petition to have the issue debated in parliament and a new series being aired, Sugar Rush. Jamie wasn’t alone in his campaign, groups such as Action on Sugar and the Children’s Food Campaign, had been pushing for a tax long before Jamie came along, however, the addition of one more cook had the potential to spoil the broth. The authors of the School Food Plan, John Vincent and Henry Dimbleby have also advocated the introduction of a sugar tax and already introduced a 10p levy on sugar sweetened drinks in their LEON restaurants. However, with great celebrity status comes great responsibility. A recent article by Sian Griffiths discussed how the proceeds from these unofficial sugar taxes could be used to pay for drinking fountains in public parks with the view that it may help children access free drinking water rather than purchase sugary drinks. A novel idea but would it work? I asked John Vincent on Twitter whether kids would use these drinking fountains, he hasn't responded.

Before the ink had dried on our final copy reviewing the scientific evidence, Jamie Oliver et al had already decided that a sugar tax would reduce consumption and the government must take action. When PHE published Sugar reduction: evidence to action (see annexe 2 for our fiscal review) in October 2015 it almost seemed like closing the barn door after the horse had bolted. The media furore around the topic was so great that articles were too busy calling Jamie names and telling readers it was nanny state gone mad to pay any attention to the evidence. Our review of the evidence, although based on a small number of studies, suggested that consumers are responsive to changes in food and drink prices and this supports the evidence from modelling studies which indicate a tax of 10-20% would have a significant impact on purchases. Moreover, recent evidence from Mexico has shown that purchases of sugar sweetened drinks declined by up to 12% after the introduction of a sugar tax.

The evidence collated by PHE indicates that a sugar tax could have an impact on population health if implemented alongside a range of other strategies such as reducing marketing exposure and price promotions on high sugar products (we also reviewed the marketing evidence see annexe 3). However, this seems to have been diluted by the media whose attention has been focused on taxation. There are benefits to celebrity chefs wading into the public health arena as they can help bring some attention to important issues. However, I think they need to be mindful that their high media profile could have negative consequences. Parents, children, and school meal staff did not take too kindly to Jamie “transforming” school lunches and the skewed media attention on a sugar tax has the potential to undermine the evidence base before any attempts are made to implement a potentially beneficial health policy.

Animation designers... a day in the life of a researcher (part 2)

Guest post by Dr Victoria McGowan, Research Associate, Alcohol and Public Health, Teesside University, @teamalphatees

Team Alpha recently spent a few days with Arcus Animation Studios and we were joined again by our two young people, Megan and Glen, from local schools who have been helping us develop the animation which introduces our SIPS JR HIGH study to participants. Arcus designed and produced our 2D cartoon animation and kindly let us into their studios for a behind the scenes peek at how they work. Here are some reflections on how it went:

The team at Arcus were so welcoming and introduced us all into their creative world. Megan and Glen were shown how animations are developed and given tutorials on using various different graphic design software and tools, such as the graphic tablet. Team Alpha spent time admiring their work environment (an Aladdin’s cave of toys, games consoles and a miniature Star Wars AT-AT Walker) and were eager to join in the weekly Street Fighter competition held in their fantastic common room.

The animation team at Arcus

While Team Alpha were reliving their youth, Megan (centre above) and Glen were hard at work developing animation characters and storyboards. On day two Megan was interviewed by Arcus and described how her passion for graphic design influenced her decision to assist us in the development of our SIPS JR HIGH animation.

She said: “I have been helping Teesside University in terms of creativity and research for the animation. The reason for this is because I am interested in graphic design myself and would love to get involved in some experience and voluntary work with animation and design companies”

The experiences of Megan highlights the benefits of participant involvement in the development of research, not only to the study, but also to the individuals. Megan and Glen were able to gain experience of working in an animation studio and see first-hand what a career in this area would be like.

“I like how the job will include drawing, animation and creativity. It also inspires me to be myself and not to follow instructions of what to do as part of designing something. I also like how you can design your office to what you like and enjoy, I think that it’s good for people to express their likes of designing and working with people that have the same interests as you”

Megan was very grateful for the opportunity to spend time with Arcus, this gave her insight into the life of an animation designer and gave her confidence to continue pursuing this career.

“I think Arcus has been very useful and they have given me ideas for further experiences and other work that I will be doing. They have given me a warm welcome into their company and also took me through tutorials of how their programs work and what they do to build up an animation. I have enjoyed my time at Arcus and the people here are very nice and outgoing! They each have their own personality which I like and they all have a story behind how they have achieved what they have done to become an animation designer.

Thank you Arcus!”

Doing the dots

Guest post by Jane Johnson, PhD Researcher at Teesside University

“You coming over to see the New Year in?” asked my sister, munching what I imagined was a handful of salted pretzels in the shape of small Christmas trees.

“Yes if I can do your posture.”

“What’s that?”

“You know, where you stand in your underwear and I stick dots on you.”

“Sure.” She didn’t need convincing, and as a blood relative was beholden to support my requests as long as I turned up with two bottles of something excruciatingly dry with an alcohol content that prevented you from driving anything other than an electronic wheelchair within the next 24 hours.

“Is she doing me?” said a voice in the background, my mum, no doubt trying to find when Downton Abbey was on. Not having had a TV for the last 10 years, period dramas pass me by unless any of the characters have interesting postural faults, not the kind of thing usually reported on in the review section of The Telegraph.

“Mum says are you doing her too?”

“Happy to. Don’t drink anything ‘til I’m done though, ok?”

“Don’t drink anything, it’s New Year’s Eve!?”

“I know. Postural sway. I need to minimize it.”

Many therapists believe there is a link between posture and pain. Postural assessment is carried out in order to help with diagnosis, inform treatment plans and monitor postural change. Most therapists do this with visual assessment alone, the inter-rater reliability (degree of agreement among raters) of which is poor, and despite reasonable intra-rater reliability (degree of agreement among repeated administrations of a test by a single rater), it's unlikely a therapist can visually detect what could be a clinically significant minor change in posture. For many years researchers have been looking into ways to measure posture more accurately and more reliably than with visual assessment alone. This is where my research comes in. Whilst there are ways to do this in research settings, there are none that are yet viable for practicing clinicians to use in situ. My PhD involves the development of a postural assessment app from existing software which has already been validated for use on a PC, which was initially designed for use with patients with scoliosis.

Mum stood first, fresh from a bath and eager for me to finish so she could cover herself in moisturizer. “No you can’t put it on,” I said sternly as she sat in a bathrobe snacking on savories from small china bowls, “otherwise my dots won’t stick.” I agreed she could keep her socks on. She was 80 after all. My sister was next. I only had to admonish for laughing during the procedure.

Once the self-adhesive dots have been applied to specific anatomical landmarks, software can be used to calculate the angles between the dots from photographs. The angles that are calculated describe different types of posture in different parts of the body, more so in the spine. There are other apps on the market but it is not known how reliable these are. Unlike these commercial apps, the purpose of my PhD is to create an app for data collection. It will be used in year three of the project by chiropractors, to record the posture of their patients with back and neck symptoms. Use by chiropractors is important because the project is joint-funded by the Royal College of Chiropractors and Teesside University. The patients of participating chiropractors already complete a validated Patient Reported Outcomes Measures questionnaire. Combining this data with the additional photographic posture data, we will hopefully identify whether postural change occurs as a result of chiropractic intervention and whether there is a relationship between posture and pain (symptoms). In the future we hope we can identify whether any postures increase the likelihood of a subject developing back or neck pain, and whether changing back or neck posture reduces symptoms. If we can do this, we can then advise people proactively and reduce their likelihood of developing symptoms in the first place.

With my sister and mum in their New Year’s Eve underwear I worked consistently, palpating the required anatomical points, peeling off and applying green dots to them. The initial satisfaction of fixing self-adhesive dots to skin wore thin after an hour. I took the 12 photographs knowing that photographs taken by candlelight would not be of publishable quality but were adequate for my purpose, which was simply to have some images with which to practice using the software. “Can we drink now?” asked mum and my sister together? “You can drink now,” I said.