In the second session of the workshop, moderated by Liz Skrbkova, associate director of U.S. obesity communications at Novo Nordisk, four speakers discussed the complexities of communicating solutions to obesity and examined data and insights that help illuminate and address those complexities.
Patricia (Patty) Nece, vice chair of the Obesity Action Coalition and chair of its weight bias task force, spoke as an advocate of people living with obesity and shared insights about how obesity communications have resonated with her from a patient perspective. Nece shared candidly her experience with obesity, describing a “lifetime full of stigma and shame and blame,” and pointed out that obesity is not a choice. She recalled numerous weight management attempts and feelings of increasing guilt and shame as various methods failed her.
Nece reviewed examples of messages that people with obesity encounter as they try to address their weight, such as both dieting and antidieting messages, claims about fast-acting weight reduction solutions, and exercise and fitness programs that exaggerate their purported results. The landscape is dynamic, she observed, constantly filled with new solutions as companies try to profit from nutrition and fitness ventures. She called this array of
confusing information and marketing materials “the noise.” In contrast, she said, topics that are rarely discussed include the biological, psychological, and environmental aspects of weight that help explain the challenges of weight reduction. She noted that other seldom-messaged topics include the long-term nature of weight management efforts and the role that health care professionals—beyond bariatric surgeons—can play in assisting with weight management.
In contrast, Nece pointed out that the messages pervading the communication landscape convey that people with higher-weight bodies are “less than” in society and are failures for not controlling their weight on their own. She shared examples of messages that convey weight bias and/or focus solely on personal responsibility and fail to acknowledge broader contextual factors that influence weight. Some messages are explicit and others are more subtle, she observed, citing examples of the latter: a series of dehumanizing photos in which people with obesity are depicted only from the neck down, as well as statistical reports about obesity disseminated in social media alongside graphics of French fries and donuts.
Nece shared that she still carries excess weight despite achieving and maintaining a 100-pound weight loss while working with an obesity medicine specialist, underscoring that personal choice is only one aspect of a complex issue. She referenced a survey indicating that 65 percent of people with obesity believe that obesity is a disease, compared with 80 percent of health care providers, and suggested that people with obesity do not seek treatment because they believe that managing weight is their own responsibility and think they already know what to do about it (Kaplan et al., 2018). She questioned the logic of this belief, pointing out that other disease states and physical problems are not necessarily believed to be solely a patient’s responsibility to manage. Furthermore, in Nece’s experience, patients may not be able to discern on their own what hinders them from reaching their goals. She disclosed that she had internalized a lifetime of bias and stigma, which she said led to negative self-talk about her weight, making it “virtually impossible” to change weight-related behaviors.
Next, Nece reviewed a variety of organizational viewpoints and movements concerning how to respond to and address obesity. One of the first movements was that of the National Association to Advance Fat Acceptance, which she described as a political mission to eliminate discrimination based on body size. The body positivity movement followed, she continued, which started as the concept of accepting and loving one’s body as is and celebrated a diversity of all body weights, shapes, and sizes. Reflecting on her youth, Nece remarked, “I wish I could have seen people in a variety of sizes in media … just to see myself represented. Maybe I would have felt better about myself.” Next, she referenced the Obesity Action Coalition and its views that obesity matters to health and is a disease, as well
as its opposition to weight bias and discrimination. Lastly, she mentioned the Health at Every Size® (HAES) movement, which she said stemmed from body positivity. The HAES philosophy does not equate weight with health or disease, Nece explained, and posits that such framing and use of the term “obesity” promote stigma. HAES also focuses on intuitive eating rather than dieting, she added, which its proponents view as an approach that may help avoid weight cycling and promotes listening to one’s body.
Nece suggested that although this diversity of viewpoints could contribute to “the noise” and consumer confusion, these entities all have positive elements and find common ground as they urge elimination of the weight bias, stigma, and discrimination that harm people of higher weight. She shared an example of diverse stakeholders coming together as they opposed a campaign that aimed to raise awareness about the connection between obesity and the development of cancer. The campaign equated obesity with smoking, she explained, and was criticized for promoting stigma and prejudice given its purported implication that individuals are largely in control of and responsible for their body size (and therefore cancer).
Nece emphasized the importance of tailoring weight management interventions to the cultural orientations of participants. She referenced an intervention that enrolled mainly socioeconomically disadvantaged African American women with the aim of halting their upward weight trajectory. The women were told that it was not a weight-loss program, and were given tailored behavior change supports for 12 months. In addition to 62 percent of participants maintaining or losing weight at the 12-month mark, Nece reported, a decrease in depression was also observed.
Nece ended her presentation by recounting a recent media incident in which two late-night talk show hosts discussed obesity. One advocated for “fat shaming” and perpetuated blaming individuals for their weight, while the other openly shared his personal weight struggles and pointed out that “fat shaming is just bullying … and bullying only makes the problem worse.” Nece concurred with the latter perspective, pointing out that shaming does not help people in any context. The second host’s personal story reverberated through social media, which Nece said gave people permission to share their own experiences. She underscored that conveying the real experiences of people with obesity can have a powerful effect on transforming society’s understanding of these people’s daily realities, perhaps helping to reduce weight stigma and advance positive change.
Brian Dunn, chief behavioral officer at Concentric Health Experience, described how behavioral economic concepts were translated into a marketing campaign that counters weight bias as it advertises a branded
medication for treating obesity. The campaign’s images and videos convey a narrative in which people with larger bodies are depicted as diligent, hard-working, and energetic individuals engaging in healthy behaviors as they pursue long-term weight management. Dunn said these aspects were deliberately crafted with the intent of countering fundamental attribution error. He explained that this error occurs when an individual (often automatically) assigns character flaws, such as the assumptions that he or she is weak-willed or lazy, to a person with obesity. This fundamental attribution error exists across social biases, Dunn added, such as poverty and unemployment, and results in a limited set of solutions to those issues.
According to Dunn, communications that use narrative and implicit messages have been demonstrated to be more powerful than explicit messages in countering attribution error. Current stereotypes about people with obesity reflect the frequency with which these stereotypes are perpetuated in society, he continued, adding that the ease with which something comes to mind serves as an index of how true one perceives it to be, a concept known as the availability heuristic. He emphasized that the goal of his organization’s campaign is to disseminate its implicit messages with high frequency in the communication sphere, which he said would help counter fundamental attribution error and cultivate a new availability heuristic regarding people with obesity. The diversity of characters and settings in the campaign was carefully shaped to identify with various groups of stakeholders, he explained, and each character’s narrative includes elements of a socially rich life. This was done, he elaborated, because the psychology of connectedness is often absent in obesity communications, with individuals pursuing weight loss often being depicted alone, self-absorbed with their appearance. Finally, Dunn stressed that the campaign accurately represents the epidemiology of obesity, realistically conveying the long-term efforts required to achieve weight management. “This is … the cognitive reorientation that we are driving,” he summarized.
Dunn then shifted his attention to quantitative linguistics, a strategy that he suggested could be applied to the rich, publicly available data in social media to help solve the problem of nonrepresentative sampling of the U.S. population. Social media data represent language and image inputs from nearly all populations, he indicated, in a massive volume that creates the opportunity for granular subgroup analysis. He added the caveat that people older than 65–70 are underrepresented.
Dunn presented preliminary data from a study of digital phenotyping in which more than 300 billion expressions of social media data language were captured and analyzed to identify people with overweight or obesity. He explained that as the study refined its keywords to identify more accurately individuals who self-identified with these conditions, the process differed for men and women based on the different and often gendered terms
(such as “curvy” or “busty” for women) they used to describe themselves on social media platforms. Dunn related his surprise at people’s willingness to disclose living with overweight or obesity, noting that disclosure of other disease states is less common. Ultimately, the study centered on a cohort of approximately 4,000 females and 7,000 males aged 25 and older that was then narrowed to people who were talking about treatments or were interested in seeking treatment.
A subsample of those people was geotargeted in 800 zip codes, Dunn continued, and he displayed graphical models of the sentiment in discourse among the subsample. The discourse was polarized in sentiment (see Figure 3-1), he revealed, labeling it a “stunning” near symmetry of positive and negative discourse, contrary to his hypothesis that negative sentiment would be associated with greater seeking of medical treatment to manage weight. He also remarked on the relatively small proportion of the sample with a higher rate of mentioning overweight-obesity keywords, noting that
the research group had hoped for a larger number of these people, whom they expected to be more receptive and ready for change.
Dunn went on to explain that more sophisticated models can branch out from identifying explicit disclosures about weight status to detecting language-based classifiers, which he described as subtle semantic and linguistic relations used to refer to a topic. He added that such words and phrases are often used predominantly by specific population groups, citing the word “thicc” as an example of a language-based classifier commonly used by people of color to describe the body in a positive way. He reported that the identification of these classifiers opens up another way to communicate about the topic with the campaign’s users.
Finally, Dunn shared data indicating the sample’s overwhelming and consistent negative sentiment regarding one’s own physical and emotional states (see Figure 3-2). People are in an emotional state of tremendous suffering, he said, contrasting these findings with the mixed-sentiment data that characterize samples of people with mood disorders. Given this finding, he urged compassionate treatment of people living with overweight and obesity.
Christopher Gallagher, president and founder of Potomac Currents, LLC, is the Washington policy consultant for the American Society for Metabolic & Bariatric Surgery, the Obesity Action Coalition, the Obesity Medicine Association, and The Obesity Society. Gallagher discussed successes and challenges associated with implementing and sustaining effective obesity communications with decision maker and policy maker audiences. Tremendous progress has occurred over the past decade, he observed, in helping federal and state policy makers understand that obesity is a complex, chronic disease warranting patients’ access to evidence-based treatment avenues across the care continuum.
Progress has, however, been theoretical in some ways, Gallagher suggested, observing that policy statements from organized medicine and state government associations support access to and coverage of a spectrum of obesity treatment modalities, but health plans continue to deny treatment coverage. As an example, he pointed to the American Medical Association’s (AMA’s) 2013 announcement recognizing obesity as a disease and its public support in subsequent years for using people-first language and encouraging health care providers to equip their facilities with proper-sized furniture, medical equipment, and gowns for patients with obesity. Despite strong policy statements, Gallagher said, health plans persisted in believing that obesity is a lifestyle condition or that treatment is elective and solely
for cosmetic purposes, and denied coverage for obesity treatment. This prompted a coalition of advocates to urge AMA that collective action to engage health plans would help break down barriers to care. Gallagher reported that in 2018, AMA indeed adopted policies to work with states and specialty societies to identify and remove outdated restrictions that prevent physicians from providing current standards of care for obesity treatment.
Gallagher called attention to examples of tangible progress, highlighting efforts from public and private health plans and state government associations to grant access for patients with obesity to science-based treatments under the same coverage guidelines and cost-sharing arrangements applied to patients with other chronic diseases. He recognized the Office of Personnel Management’s notice to health plans serving federal employees that noncoverage for obesity treatment must be supported by clinical rationale; the National Council of Insurance Legislators’ policy encouraging state Medicaid, state employee, and state health exchange plans to update their benefit structures to improve access to and coverage of obesity treatment, such as pharmacotherapy and bariatric surgery; and the National Lieutenant Governors Association’s policy to help reduce obesity stigma, establish statewide obesity councils and task forces, support additional training for current and future health care professionals, and support access to obesity treatment options for state employees and in other publicly funded health care programs.
Gallagher provided three examples showing that these efforts spurred changes in coverage policies. First, he recounted insurers’ softening or elimination of preoperative medical weight-loss requirements for bariatric surgery and expansion of coverage for the procedure. Second, he referenced the Food and Drug Administration’s four approvals since 2012 for obesity drugs, alongside renewed investment innovation in obesity care; and U.S. Pharmacopeia’s 2018 finalization of a new independent drug classification system that includes a category for antiobesity agents, which he said is expected to preclude public and private health plans from excluding coverage. Third, Gallagher pointed out that obesity screening and intensive behavioral therapy, which are guaranteed preventive services under the Patient Protection and Affordable Care Act (ACA), are more salient and readily accessible through a Bipartisan Policy Center initiative in which health plans and companies pledge to work with providers and beneficiaries to increase utilization of those benefits.
Gallagher then shifted to discuss how progress was accomplished. He stated his belief that the key to advocacy is willingness to initiate a dialogue with individuals and work to foster a relationship. He described additional integral steps, such as building a strong base of support through broad coalitions and growing their membership numbers, noting that such coalitions demonstrate that many voices are calling for change. As an example,
he pointed to the Obesity Care Advocacy Network, a coalition that unites and coordinates stakeholders in the health care community to elevate gaps in obesity treatment on national and state agendas. According to Gallagher, “the most memorable events in history happen when multiple groups across the spectrum come together for one common goal.”
Gallagher also underscored the importance of training advocates to lobby effectively for the changes they want to see, using role-playing exercises to coach and prepare them for dialogue with policy makers. Such training helped prepare members of the Obesity Care Continuum’s State Advocacy Representative Program, he reported, to educate state policy makers about gaps in the prevention and treatment of obesity. He highlighted a successful example in New York, in which various members of the obesity health care team provided their perspectives to congressional staff with members of New York’s delegation during an advocacy day on Capitol Hill.
In closing, Gallagher appealed for a leader to champion obesity issues, someone with a personal connection to the condition who can stand up for obesity issues and broaden their national visibility.
Brian Southwell, senior director of the Science in the Public Sphere program in the Center for Communication Science at RTI International and adjunct professor and Duke-RTI scholar at Duke University, discussed the complexity of communicating obesity solutions across audiences and amid competing media messages. Southwell opened by emphasizing a reason for hope: continuing opportunities to meet and engage people where they are as they pursue health and connectedness to others.
Turning to discuss challenges and opportunities in communicating about obesity, Southwell explained that audiences are not a blank slate; they have had a lifetime of socialization during which they developed mental models of how health processes work and were exposed to various information environments that shaped their thinking about obesity-related issues. He underscored that information environments form a steady drumbeat of narratives about how people engage with food and their surroundings, and called for better understanding of these shaping environments as a way to learn how society has come to interpret the issues and challenges associated with obesity.
Southwell emphasized that when considering how science communication can support public understanding of obesity, a key point is that such understanding reflects many inputs rather than any one source (see Figure 3-3). He cited the examples of mass media coverage, social network
diffusion, the iterative nature of science and its occasional variation in quality, and translation of peer-reviewed science by journalists, adding that human audiences receiving these inputs also have memory constraints and information-processing tendencies that influence their understanding. He emphasized the importance of considering all inputs in the quest to improve popular understanding. Public engagement exists at the intersection of laypeople, health and science professionals, and media organization professionals, Southwell observed, noting that on the whole, these groups are earnestly trying to enhance public understanding.
Best practices suggest that simply presenting accurate information is not enough, Southwell said, and he appealed for more attention to the dimensions of salience and trust. Obesity issues are not on most people’s daily radar, he maintained, and although public attention may spike briefly
in response to widely reported news on the topic, he suggested that a steady drumbeat would help keep particular ways of thinking about obesity more salient and improve public understanding. With regard to trust, he indicated that earning people’s trust in the source of information is crucial to achieving their adherence to and engagement with that information. He acknowledged that trust is not easily extended and can quickly erode depending on the relationships between publics and organizations.
Shifting to the plethora of inaccurate information in the communications landscape, Southwell proposed that humans misunderstand their own vulnerabilities to misinformation. People want social connection and hope for the future, he maintained, proposing that sharing information can fuel both of these innate desires, whereas lack of either desire poses potential science communication challenges. Southwell elaborated that people’s sharing of misinformation may be driven less by their assessment of its truth and more by a bias toward accepting information at face value (at least initially), as well as their desire to connect with others and seek information that is perceived as offering hope of improving their lives. He recounted the story of an Australian woman who gained an impressive following of her tale about curing her own cancer, only later to admit that she had never had cancer. But prior to that revelation, Southwell observed, people gravitated toward her story, and he encouraged stakeholders to explore how she succeeded in gaining such traction with her messages. The U.S. regulatory approach that emphasizes post hoc detection is another vulnerability to misinformation, he continued, explaining that misinformation is often addressed retrospectively. Moreover, efforts to correct misperceptions are difficult, he added, because for the debunking of misinformation to be effective, it must achieve exposures similar to those of the original content.
Given these insights about misinformation as a misunderstood challenge to public health, Southwell proposed three steps for moving forward: consider the complex interaction among human psychology, new institutional norms, governance structures, and various systems within the landscape; monitor and seek to understand, rather than prejudging, the public information environments that contribute to collective public understanding on an issue; and build and maintain trust between science institutions and citizens by acknowledging shared interests in promoting public health and well-being.
During a discussion period following the four presentations summarized above, speakers offered key considerations for effective communication of obesity solutions and addressed participants’ questions about unintended consequences of obesity communications, such as disordered eating.
Key Considerations for Effective Communications of Obesity Solutions
Dunn addressed consumers’ finite capacity to process information, pointing out that relatively dry messages requiring a reasonable degree of information processing cannot compete with messages from savvy marketers. This obliges public health messengers to better understand how consumers process information and to adapt content accordingly, he explained, referencing “snackable content” as a dominant format in which consumers currently receive relevant, tailored marketing messages. In Gallagher’s experience, anecdotes that humanize people and personalize issues have a profound impact. Nece emphasized truthfulness and authenticity of messages as a strategy for cutting through the confusion, adding that people turn to peers in a search for trustworthy sources. Southwell suggested that the existence of mass and social media content and people’s responses to this content are not absolute indicators of the information to which people are actually exposed, or of what is possible in terms of engagement. He encouraged hope in new ways of engaging with audiences, which he said will take a great deal of faith and effort, but he expressed his belief in a path forward.
Potential Unintended Consequences of Obesity Communications
Southwell affirmed the importance of considering unintended consequences of obesity messages, such as stigmatization. He also suggested adopting a multilevel perspective on the intersection between those messages and the environments they will reach. Nece shared that her own disordered eating habits originated not from the “diet culture” but from the shame and blame of carrying excess weight. According to Gallagher, consistent potential exists for unintended consequences associated with obesity treatment; however, it is important to consider those consequences alongside the risks of not treating obesity. He stated that the focus is often on the possible downside of a particular treatment plan as opposed to the benefits that come with treating obesity seriously (e.g., reduced comorbidities and improved health and quality of life). He reiterated the barriers to obesity treatment, noting that many nongrandfathered health plans still contain blanket exclusions surrounding obesity treatment or chronic weight management services, despite the ACA’s guarantees of coverage for preventive health care services, including obesity screening, and referral for intensive behavioral therapy.
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