Thursday, February 03, 2011

Half Ton Mom, the reprise

There have been five or six days over the past year when the Sanaworld hitcounter has gone suddenly nuts, say 500+ hits in a day - the usual being between 50 and 150. On every one of these exciting occasions, the majority of visitors have landed on this post about Renee Williams, through typing 'Half Ton Mom Documentary' into a search engine. Usually these visitors all come from a concentrated geographic area, suggesting that the program has just screened there and stimulated a flurry of curious post-program Googling.

It's easy to understand why people are so interested. A person that has become so very fat seems almost like science fiction. The most common reactions are a mixture of pity - that poor woman, incomprehension - how could she let herself get like that, why doesn't she just stop eating?? and disgust - how revolting, she deserves to lose her children/die/rot in her bed. One of the more frequent reactions concerns those that care for the bed-bound morbidly obese patient. The question being: who is feeding her? The implication is that someone is supplying food and that this person is therefore responsible for the ongoing situation. After all, they can't feed themselves. Just deliver salads three times a day, problem solved.


I think (i.e. this whole post is just my opinion - although I've done some bare bones research in journals and caregiver forums to get some perspective) that there are at least three interacting considerations here: The 'patient', the 'caregiver' and whatever 'issues' each may have, all of which are the product of, and exist in, any number of social contexts. You can see how trying to write something readable on the subject can quickly become a page of rambling alphabet spaghetti. I'm pretty sure that most people don't think that hard about the reality of these variables before having a knee-jerk 'blame the feeder/enabler' reaction.

The first consideration is the patient in question, a person who is clearly living with a severe biological/metabolic condition, probably along with some serious psychological issues. If they didn't have underlying issues pre-disposing them to their eventual obesity (unlikely, but not impossible), then they would almost certainly be impacted by living with such an obvious and highly stigmatised condition for so long. Just as with regular slimmers, these people will be at varying stages of knowledge and readiness to embark of what will undoubtedly be a very long, slow and daunting process of recovery. As with a type II diabetic or someone with smoking-related illness, just because the situation is life-threatening does not automatically render a person ready or willing to change their behaviour, although some do manage it, for example David Smith, the '650 pound virgin' - the media, so sensitive with nicknames.

The second consideration is that tricky question; who is that person responsible for the nourishment of a person such as the Renee Williams? I'm not sure how the system works in America, but I hold doubts that the government provides a full-time carer that is also a specialist in nourishing the immobile and versed in eating psychology. I suspect that care is given mostly by family and friends with possibly some part-time government (under)paid home help. I remember watching a UK documentary about a bed-bound obese man whose mum looked after him 24/7 without help (I can't remember the name of this doco - if you know it please post in comments). In one memorable scene the reporter asked mum why she continued to bring him junkfood. Visibly upset, she explained that he would verbally abuse her, loudly enough to disturb the neighbours, if she didn't. He was also capable of ordering up pizza from his laptop and seemed to honestly think that eating the whole thing did not represent excessive intake. To add to the surreality, in an earlier scene his mum had made, for the benefit of the camera, what she considered a healthy meal - a piled plate of cheese on thick, white toast with tomatoes. Neither of them had a clue why he was obese. I found myself considering how anyone could be so uninformed about nutrition. Or, maybe it was just easier for everyone to live in a condition of mutual denial?

There is, if you will excuse the pun, a fast-growing body of work showing that compulsive overeating may be correctly considered a real addiction. The loss of control, tolerance and withdrawal, cravings and relapse as well as the associated risk factors, such as impulsivity and decision-making problems, are remarkably similar to those of addictions like alcoholism or opiate dependency. Dealing with a compulsive overeater is exactly like dealing with an addict, except that their drug of choice is legal, cheap and everywhere. Now, I ask you. Have you ever dealt with an addict? A similar addiction would be cigarettes, in terms of availability. I used to work with a smoker and would dread being asked to pick up some 'ciggies' when I got my lunch. Saying 'yes' offends my principle of caring for her health, but saying 'no' would result in a truly impressive display of emotional manipulation. First big-puppydog eyes pleading, then stony silences, a huffed "ok.. FINE, just go then!", (i.e. not fine at all) and an unpleasant curdled atmosphere, usually accompanied by silent aggressive shuffling and filing of papers. I usually gave in, rather than deal with that on an almost daily basis.

The point is that addicts can be desperate, manipulative and are often in denial about the level of danger that their behaviour presents. If you are an underpaid caregiver that values a stressfree working environment or an unpaid relative that desperately wants to see your son or mum happy (and you know that pizza is guaranteed to make them happy), how easy would it be really to be so mean as to insist on the diet. This is even before considering the complicated logistics of nourishing an obese yet immobile person to achieve weightloss without creating nutritional deficiencies. Relatives especially are in a completely unenviable situation as they are both emotionally involved and, given that serious dysfunction occurs in the family and social context, quite likely have issues of their own.

It may sound by now as if I think that all caregivers are in an impossible situation and had might as well just hand over the mars bars already. Not so. I am simply observing that, in my opinion, the job would be a truckload harder than most people think. Blaming the caregiver is not useful to anyone, particularly if the patient - usually an otherwise rational adult, perfectly capable of exercising their freedom to eat what they want - lives in denial about their state; those featured in documentaries certainly seem to, judging by statements like Renee Williams' "I'm not the average fat stomach is still quite flat". Like any dieter they may plan to start 'next week' and could find any number of technological or emotional means to delay the diet, no matter how conscientious the caregiver. Most documentaries also seem to feature individuals that are holding out hope for salvation by gastric bypass operation and I wonder what this does psychologically, in terms of living in a permanent state of 'last supper'. Who could ration the icecream when, post-surgery, the patient will never eat icecream again?

Any journey of fatloss is always more complicated than it looks from the outside and extreme cases like that of Renee Williams are no exception. There are no simple answers to how the fat happened, why the fat is still there or who is 'to blame' for any of it. I think that removing the blame and moralising around obesity and understanding that, like addiction disorders, you have to take a holistic approach, in context of the person and their situation, is a good place to start. My opinion is that in most, but not all, cases the caregiver may be as much a victim of the situation as the patient and that, although they have a crucial role to play in cases such as The Half Ton Mom, it's in no way an easy ask! As someone who can't even effectively diet my obese cat down to a decent size before I give in to the pathetic yowling, I'm 100% convinced I wouldn't be up to the job, that's for sure.


  1. It's never as simple as many people seem to think. The woman must have had psychological issues, and it's a shame she didn't get the help she obviously needed long before she became so big.

    It appears from the short pieces of video footage I watched that, like so many people, she refused to take any responsibility for her weight. I mean, "I don't eat much"? "I don't know why I can't lose weight"?

    It's a very sad story.

  2. There's a wide range of obesity related issues. Most of us in the fitness field deal with a narrow range. We tend to run folks who've got 50-70 pounds or less to lose. These are folks who are mobile, can be worked with, and are frankly the bread and butter for fitness folks.

    They also don't tend to have significant physical or mental pathology. Weight is a function of some past injury, life catching up with them, or a lack of education.

    Once you move past 100 pounds, you start hitting very challenging clients. Mobility reduces and there is generally an associated psychological issue in there somewhere. Dig hard enough and you'll find abusive patterns in the individual's background. You don't put on 100+ pounds by accident.

    In this particular case, you've got a textbook example of various events which contribute to obesity.

    1)People honestly do not know how to eat. It boggles our little fitness minds, but it's true. In the push to find "one true way", we in the industry forget the importance of educating to the basics. Moderate intake, reduce sweets, lower consumption of liquid calories, and specific food education. (Note that the US does an incredibly poor job of saying do not eat food X.)

    I had a client convinced that the jelly in his jelly donut counted as a fruit. He was serious. College educated, business professional, good economic bracket. He's not unusual.

    2) Poor intervention methods. Physicians in the US are not trained to deal with weight related issues. They've got next to no training and no time. This is a moderate problem in obese people. In the morbidly obese, this is significant. We don't have referral programs in place to get people help early. Once you've got 100 pounds on you, it's not going to come off fast.

    3) Stigma. Being fat isn't cool. There's all kinds of movements trying to say being fat is fine. It's not. This leads to defensiveness on the part of the patient. That makes it harder to help elicit change behaviors.

    4) Addictive behavior patterns. Addiction medicine has the same issues as weight loss. If you look at the numbers, AA has similar success rates to long term weight loss. (90-95% resume the behavior within 5 years per US Natl. Weight loss Control Registry). AA doesn't report definitive stats, but several external studies show recidivism rates in the 90 percent range.

    Combine all these elements and you've got a mess. That's before you add in factors like family enablers. Let's also be honest. Improved medical care helps keep people like this alive longer. Medications to control high blood pressure, diabetes, and other conditions keep people alive who would have died in earlier times. Yeah it sounds harsh, but it's reality.

    There's no magical answer. Like many complex issues, one thing won't fix it. Long term it will be combinations of public health improvements, improved education, better food availability, and early intervention.

    I don't know if it's playing down your way, but I strongly encourage you to check out TLC's Inside Brookhaven Obesity Clinic series. It's a really interesting look into the world of super obese living and mindset. I watched bedridden patients bribe orderlies to bring in food.

    My last thought. It's VITAL we understand that super obese individuals with addictions tied in to food are rare. Those extremes of behavior are not normal. We just happen to see more of them due to the presence of television. It's dangerous to treat day to day clients like addicts. There's an abdication of personal responsibility that occurs in that situation.

    The goal should be teaching clients that you can control your situation and that you are 100 percent responsible for the decisions you make.

  3. Thanks Girls. Indeed we are not really close to cracking the obesity epidemic yet. I'll be getting into it quite heavily at uni this year from both a psychological and a nutritional science perspective and am anticipating a wild ride!

    We do get TLC , in spite of the fact of living in flax huts (*joking*!) and I'll look out for that Obesity Clinic series. It probably shows at 4am in the morning... ;)

  4. The thing to understanding obesity is that like crime, it's an event with multiple different causes AND cures. There's not just one magic bullet.

    Curious, in NZ, do you find higher rates of obesity among the Maori populations? Also, how noticeable is morbid obesity in NZ? Always curious to see how the rest of the world is dealing with obesity and more specifically morbid obesity.

    And I know you guys don't live in flax huts. You live in hobbit holes. ;)

  5. Maori health statistics are generally very poor - apart from for melanoma, which they are not susceptible to. This is true for indigenous minorities everywhere. Obesity for adults sits at about 24% for European NZrs, 41% for Maori and closer to 50% for Pacific. Asian NZrs are the slimmest at about 11% obese.
    As for how noticeable? I'd say about the same as European nations like Italy and Spain. I certainly noticed obesity as a 'phenomenon' in England, where there seemed to be dramatically more obese and morbidly obese. Then again, we are talking major differences in population density. The whole of NZ could fit nearly three times over into London alone.
    I have never been to America, but I think it is similar to England in terms of per capita morbid obesity.

  6. That would fit with my own observations. Rates of morbid obesity were much lower in Europe. Most of the obese folks I saw were American or UK tourists.

    For your further reading pleasure:

    Just a little snippet into the nightmare of family provided care.

  7. That's a really interesting article, Clara. It really is a whole lot more complicated than most people realise.


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