We reduced medical errors by blaming systems instead of people. Why not do the same for obesity?
Fat people have been the pin cushions of public opprobrium since Roman times. Writing in the second century the historian Suetonius described how Emperor Vitellius achieved his considerable girth on a diet of “livers of pike, the brains of pheasants and peacocks, the tongues of flamingoes and the milt of lampreys”. But when Vespasian’s troops escorted Vitellius to his execution at the Germonian stairs the ministrations of onlookers were less exotic. They pelted the outgoing Caesar with dung and called him a glutton.
The shame and blame tradition would appear to be alive and well in the twenty-first century. Katie Hopkins, a former contestant in the UK version of The Apprentice, is already notorious for admitting she wouldn’t hire a fat person because, as she put it, “if you are obese you look lazy”. Now Hopkins has piled on three and a half stone in order to lose it on the upcoming TLC reality show Journey to Fat and Back. Her mission, says the straight-shooting businesswoman, is to get overweight people to “stop blaming everyone else for problems they can control”. Hopkins’ latest venture has drawn the ire of journalist Ed Cumming, himself overweight, who accused her in The Guardian of “perpetuating a culture of self-loathing” among the obese.
Cumming will find little comfort in a new study that attests to just how wide and deep those rivers of contempt run. The experiment placed normal weight participants in a MRI scanner and had them view videos of both normal and overweight people having their cheeks punctured with a needle. The pain of fat people elicited less activation in brain regions responsible for empathy, suggesting our predilection for stigmatising the obese is etched in the synapses. And it seems that accusations follow hot on the heels of disdain. A recent survey of 800 Americans found that 80% laid primary blame for obesity squarely at the feet of the fat with only 35% reserving their bile for food companies and even fewer, 18%, holding governments to account for soaring obesity rates.
But there is a realm of human endeavour that suggests blaming is not so much about attributing responsibility as it is a reflection of how our culture deals with causes. Until the early 1990’s medical errors were routinely blamed on the surgeon who operated on the wrong side or the nurse who gave the wrong drug. But thanks to health innovators like Harvard Professor Lucien L Leape things are changing.
Leape was a kickstarter of the patient safety movement which eschews casting stones in favour of finding solutions. “Safety culture” in healthcare adopts the tenets of systems analysis and apportions cause much like we carve up a block of Swiss cheese. If you place multiple slices hard up against each other there will be one configuration that aligns distinct holes, enabling a probe to pass freely across all. The probe is the medical mishap and the analogy renders the “perpetrator” but a single slice in the cascading causal chain. “Recognition that errors are evidence of deficiencies in systems, not deficiencies in people”, as Leape put it, is a pragmatic fix grounded in a drive to reduce harm.
Can we learn from medicine and create a “slim culture” that transplants causes for culpability and prescribes a remedy for obesity at each “slice”? A major hurdle is the dominant view that obesity is caused solely by the individual. In an ITV interview last year Hopkins spoke for millions when she remonstrated with Jay Cole, a 22 stone unemployed single mother, about her weight: “it’s totally within your remit to do something about it and you’re choosing not to”. But perhaps Hopkins’ single mindedness might be tempered if more publicity were shone on the other cheese slices that seem to have dodged the limelight. In his 2013 book Fat Chanceendocrinologist and obesity campaigner Robert Lustig brings the ineluctable potency of our very own hormones to centre stage.
When Lustig worked at St Jude Hospital in Memphis he treated kids who had damage to the brain’s hypothalamus after tumour surgery. Some of those children became morbidly obese because they could no longer sense signals from the hormone leptin which tells the brain you’re full. Their system was effectively locked into starvation mode with hunger prolonged and movement reduced to keep the calorie balance positive. As Lustig recalls “Those kids were stuck forever in bodies that kept storing energy instead of burning it…they would forever get fatter on fewer calories”.
If you’re looking for the paradigm case of diminished responsibility and control for weight gain hypothalamic obesity checks plenty of boxes. Yet obese people who’ve never had their hypothalamus surgically tampered with also develop leptin resistance. It’s not entirely clear why, although one possibility is that it’s an evolutionary adaptation to maximise food intake in preparation for future scarcity, a scenario now all but alien to the developed world. The point is, if we forgive the kids who survived tumours their big bellies, why not cut some slack to adults who have the very same hormone problem, just by a different route?
Other contributors to the obesity epidemic are starting to get more air time too. Bryan Walsh’s Time magazine cover story of July 2014, entitled “Don’t Blame Fat”, reports a widening scientific consensus that sugar, not fat is driving skyrocketing rates of obesity and diabetes. Insulin levels spike in response to fructose, pushing it into cells to be stored as fat. The result is a rapid lowering of blood sugar that fuels hunger and slows metabolism, driving excess calorie intake and reduced burning.
Yet sugar, in the form of heavily subsidised high fructose corn syrup, has found its way into almost every processed food, from bran to bread and tacos to tomato sauce.
At the same time marketers are making liberal use of an array of sophisticated techniques to get us to eat highly profitable junk food. Integrated marketing saturates the environment with messages across multiple platforms including TV, the Internet and social media. Australian researchers Paul Harrison and Michaela Jackson argue this inundation “perpetually primes” or cues us to consider unhealthy choices. These priming effects start young. In a study published in Health Psychology Jennifer Harris and colleagues from Yale University showed that primary school children ate 45% more snacks when exposed to food as opposed to non-food advertising.
And another study found people under time pressure were more likely to choose familiar brands over home brands in a virtual supermarket. Reason, perhaps, why the harried parent might end up with that litre bottle of Heinz tomato ketchup in the shopping trolley, containing 261 grams (65 teaspoons) of sugar.
The cheese slices come with a range of possible solutions. Governments could reduce subsidies for corn production (the US Public Interest Research Group fought the 2014 iteration of the Farm Bill on the grounds it failed to do this), tax foods that fail health benchmarks (a 2013 UK study found a 20% tax on sugar drinks would reduce obesity rates by 1.6%), restrict junk food marketing to children (instigated in the UK in 2009) and make clear labelling of fat, sugar, and salt with “traffic lights” mandatory (supported by the British Medical Association). Governments can also include obesity prevention in strategies to alter civic infrastructure.
And the science of choice architecture or “nudging” is also hitting its straps. It is a stark reality that countries have an average organ donor rate of 98% when it is made the default option. In those countries where you must actively decide to opt-in, donor rates are only 15%. Given this dramatic variance, it is unsurprising that the British Government’s so-called “Ministry of Nudges” proposes a similar tack for obesity. Their Behavioural Insights team notes that something as mundane as redesigning a shopping trolley with a section labelled for fruit and vegetables can bump up sales of those foods. And in Iceland simply rebranding fruit and vegetables as “sports candy” increased consumption by 22%.
But our psychological tendency to blame remains a major obstacle to considering and addressing these other causes. As Malle and colleagues point out in a recent article in Psychological Inquiry we are a blaming species. Blame is driven by emotions that sense “norm violations” in order to regulate that aberrant behaviour. On this theory fat people represent something of a threat to social order, perhaps in view of the costs associated with dealing with obesity. The Food industry is only too keen to tap into this propensity for vilification. Thinly disguised front groups such as Americans Against Food Taxes rail against regulation under the mantra of rejecting the nanny state. Lobbing responsibility for obesity back at the fat sits well with their goals. How, then, did medicine overcome this blaming culture in its quest to limit medical errors?
In short, it took a pragmatic leaf from the Japanese car industry copy book. A fundamental of the Toyota Production System is the maxim “start from need”. This philosophy jettisons finger pointing in favour of actions that solve the problem. Toyota couples this with the notion of “Kaizen” or “continuous improvement”which charges workers with mending flawed processes by speaking out and experimenting. Kaizen means that anyone can press the stop button on the production line if something is amiss, without fear of punishment. In “Toyota culture” the norm violators are those who blame individuals instead of exploring causes and solutions.
A key finding of the Institute of Medicine’s 2004 report Keeping Patients Safe was that healthcare leaders must commit to safety if a blaming culture is to yield to a safety culture. It follows intuitively that if Kaizen, or something like it, is to help stem the tide of obesity, the same commitment to harm reduction must be demonstrated by political leaders. Yet many governments languish in an inertia born of pressure from the well funded food lobby and fear of backlash in the face of unpopular food taxes. But as the cost of obesity, recently estimated at US$190 billion annually in the United States, begins to erode government coffers, the imperative to “start from need” is likely to become more pressing. Perhaps then the strategy to “start from blame” will finally be banished to the annals of history where it belongs.
- Graban M. Lean hospitals : improving quality, patient safety, and employee engagement. 2nd ed. New York: Productivity Press/Taylor & Francis, 2012. P. 1
- Institute of Medicine of the National Academies. Keeping patients safe: transforming the work environment of nurses. Washington D.C., 2004. P. 287
This article was originally published on the Doctus Project