A
funny thing happened during development of this issue’s cover. A plan to run
the original consensus cover choice, a painting depicting an exuberant dancing
couple of heroic proportions, was abandoned when the artist withheld permission
— he didnt want his work associated with medical or health themes. His cautious
attitude proved prudent as it foreshadowed the Pandora’s box that cover image
selection would become.
A search for a replacement image that would be respectful of overweight people and make for a strong cover was discouraging. A range of images from classical to clinical was considered. There were plenty of pejorative images — overweight and obese people, looking sad or anxious; one image even was branded “Too Fat” lest the viewer miss the point.
What one person might see as an image that stresses the commonplace nature of obesity-a summertime backyard photo of people grouped poolside, among them a man with protruberant truncal obesity—another might see as mocking overweight people.
Certainly, featuring noticeably overweight people on the cover contrasts sharply with covers of contemporary magazines that feature improbably fit men sporting “washboard abs” and just as improbably thin women: While a five-foot-nine woman is considered a normal weight at a minimum of 126 pounds, most models weigh well below that, with one modeling Web site listing their average weight as between 108 and 125 pounds.
No single image seemed quite appropriate for tastefully representing obesity in America on a compelling cover. Moreover, it became apparent that any image chosen was likely to be judged offensive by someone. An abstraction, a landscape of corpulence, seemed the best choice. But this image too elicited surprising gut reactions.
If your first reaction to the cover image was “gross,” or “repulsive,” both of which were among our reviewers’ comments, consider that this image actually depicts the chubby infant boy pictured above; it’s worth noting that infants are perhaps the only group in America today for which “fat” is considered “cute.”
The power of the cover image to evoke a gut reaction is useful for challenging one’s personal and perhaps subconscious attitudes toward obesity; this becomes important given that discussion of a medical problem requires interaction between two people who each bring to the discussion personal attitudes and experiences.
Several studies have shown that physicians’ attitudes impact their interactions with overweight patients. One study of how physicians discuss weight with overweight female patients found that patients of physicians who used Motivational Interviewing technique, a cognitive-behavioral technique, were more likely to change behaviors and lose weight than the other patients. Another study found that obese patients particularly disliked the terms fatness, excess fat, obesity and large size, while “weight” was the most preferred term.
Keith Bachman, a primary care internist, argued recently in American Medical News that it is unethical for a physician to “make weight loss a condition for establishing a patient-physician relationship.” Dr. Bachman is an author of the “Preventing Weight Bias: Helping Without Harming in Clinical Practice” toolkit (https://www.yaleruddcenter.org/what/bias/toolkit), which calls for physicians to recognize, among other things, that being overweight is a product of many factors and acknowledge that many patients repeatedly have tried to lose weight.
As the cover focus articles demonstrate, excess weight compounds health-related problems for neurosurgical patients and poses serious economic challenges for society. Given the increasing prevalence of obesity, preparing for discussion of weight issues with patients—including assessing one’s own attitudes toward obesity — may be useful.
Manda J. Seaver is staff editor of the AANS Neurosurgeon.