The Biggest Loser: Who's Really Winning?

This week's guest post for Pop Health was written by Elana Premack Sandler, LCSW, MPH.  Elana writes a popular blog for Psychology Today called, "Promoting Hope, Preventing Suicide".  Written from both personal and professional perspectives, her blog explores suicide prevention, intervention, and postvention.  Often using current events as a starting point, the blog poses questions about what could be done better or differently, what contributions research can make to practice, and challenges and opportunities inherent in new technologies.  Elana earned a Master of Social Work and a Master of Public Health at Boston University and is a licensed social worker in the Commonwealth of Massachusetts. 

There’s a lot of TV I don’t watch, but there’s one show in particular. “The Biggest Loser.”



It’s true - I systematically avoid watching one of the most popular reality TV shows in history. What seems to have drawn in viewers is what bothers me so much about most reality TV. It’s like a car wreck you can’t stop staring at, even though you know it’s a tragedy.



But watching a car wreck is watching an accident, something that wasn’t designed for an audience. With an accident, there’s something very human about wanting to see what’s happened, wanting to know if everyone’s okay.



That’s very different from what I think happens when people watch “The Biggest Loser.”



The few times I watched (I kept trying - people I love and trust told me it was such a good show!), I just wasn’t able to get behind the premise of the show. Yes, I believe that people who have struggled to lose weight can benefit from personal training and major lifestyle changes. Sure, the power of competition can drive some people to work harder than they ever imagined possible.



But, shame? Does shame really help people change their behavior?

When I watched, I witnessed trainers shaming contestants, over and over, in different ways. I heard contestants talk about the shame they experienced as a part of being obese or overweight. The whole show was a shame-fest. Which made me extremely uncomfortable.



Because, when it comes down to it, “The Biggest Loser” is a game show. And I just can’t watch people shamed into losing weight just to win a game show.

  “But it’s not just a game show!” my friends-who-are-fans would say. “People change their lives.”

Oh, wait, you’re right. It’s not just a game show. It’s a franchise.



So, I guess what I really have a hard time with is people being shamed into losing weight to support a game show-Wii-resort-1,200 calorie-a-day diet franchise.



At my professional core, as a public health social worker, I know shame doesn’t work to change behavior. I had thought it was just me who thought that way, until I started reading researcher Brené Brown’s book, “I Thought It Was Just Me (but it isn’t): Telling the Truth About Perfectionism, Inadequacy, and Power.”



Brown has been researching shame for the past 10 years. But, even before she was a shame expert, she was a social worker, working with people. What did she learn? “You cannot shame or belittle people into changing their behaviors.”



She explains in the introduction to the book:


• Can you use shame or humiliation to change people or behavior? Yes and no. Yes, you can try. In fact, if you really want to zero in on an exposed vulnerability, you could actually see a swift behavior change. 
• Will the change last? No. 
• Will it hurt? Yes, it’s excruciating. [I cringed when I read that part.] 
• Will it do any damage? Yes, and it has the potential to sear both the person using shame and the person being shamed. [More cringing.]
• Is shame used very often as a way to try to change people? Yes, every minute of every day. 


“The Biggest Loser” gets exactly how to use shame to motivate people to make a “swift behavior change.” Body image - for people struggling with overweight and obesity, and for people at healthy or “normal” weights - is a tremendous source of shame. Obesity is even worse. I wouldn’t be the first to say that oppression - hatred, bullying, and discrimination against - overweight and obese people is one of the last acceptable oppressions in our society.



What’s extra-disturbing about how “The Biggest Loser” uses shame is that it doesn’t limit shame to contestants. The show projects shame into the viewing audience, reinforcing biases against people who are overweight or obese. The audience doesn’t root for contestants to work within the challenges inherent in their bodies to figure out a healthy, sustainable way to lose weight and maintain overall health. The audience roots for contestants to not be fat. (Please excuse my lax grammar- I hope it’s worth making the point.)

Finally, the drama of the show revolves around shame. There’s a big reveal every episode, when viewers find out who won’t continue to compete to be The Biggest Loser. If contestants can’t lose weight within the show’s parameters (which include unhealthy weight loss practices, like dehydration), they get kicked off. So, the ideal of working with a supportive trainer goes out the window - and you are shamed, shamed, shamed into returning home, still fat, and, well, not a winner. A loser.



“The Biggest Loser” raises several questions for me:

• Should a game show be allowed to promote unhealthy weight loss practices?
• What kinds of messages does the show send to young people about their worth and value? 
• In what ways are people at a healthy weight influenced by “The Biggest Loser”? 

But, the most important to consider is this one: How much money is being made off of shame?

"Starving Secrets": Does Lifetime's New Reality Show on Eating Disorders Offer a Path to Recovery or a How-To Guide to Disordered Eating?

Last night, a public health colleague (@bethg24) tweeted about the new Lifetime reality show called "Starving Secrets". The show will be hosted by Tracey Gold (who had her own very public battle with an eating disorder) and feature real individuals struggling from anorexia, bulimia and other eating disorders.

According to the National Eating Disorders Association (NEDA), as many as 10 million females and 1 million males suffer from an eating disorder in the United States. Therefore, it is a serious and relevant public health problem that (not surprisingly) gets media attention. "Starving Secrets" is not the first movie or television show to take a documentary-style approach to portraying those that suffer from these disorders:

1. MTV's series "True Life" (which I have long admired for their portrayal and stigma reduction efforts regarding various medical conditions...I have been less impressed by episodes like "I'm a Jersey Shore girl"). True Life aired "I have an eating disorder" on April 3, 2003.
   


2. HBO documentary "Thin": This special followed four women during their in patient stays at the Renfrew Center in Coconut Creek, Florida. It premiered on November 14, 2006. I remember this being both incredibly powerful and difficult to watch.



3. E! "What's Eating You?": Admittedly, I only watched one episode of this show. True to E! form (Ahem- Kim's Fairytale Wedding), they are more about sensationalism versus journalism and stigma reduction as compared to other networks.

As with the portrayal of other mental health disorders in the media, I hope that these shows will do something positive. Specifically- reduce the stigma around these disorders and normalize help seeking behaviors.

However, I am also greatly concerned that shows like "Starving Secrets" will actually endanger vulnerable audience members by offering a "how-to guide" to having an eating disorder. The concern stems from research on pro-eating disorder websites. They can offer "thinsperation" to stay skinny by the images portrayed. They can also give tips and strategies for hiding/refusing food or getting rid of it. Sometimes people don't realize that by telling their story in vivid detail, they are actually sharing their "creative tips" for sustaining an eating disorder.

That said, I will definitely be setting the DVR on December 20 to see the show and assess it more accurately. What do others think? Do reality shows like these have the potential to endanger the public's health? Or do their "pros" (e.g., stigma reduction) outweigh the risks?

Giuliana and Bill: A Reality Show Addressing the Real Stigma of Infertility

Talking about infertility makes people uncomfortable. Those struggling are uncomfortable because it is extremely personal. Perhaps they feel like they've failed at something that should come naturally...something that seems easy for everyone else. Perhaps it is difficult to explain why they cannot bring themselves to go to a friend's baby shower. Perhaps people at work ask them "when are you going to have a baby?"...not realizing that it is an incredibly painful question because they have been trying for years.

With this as the current state of affairs, you can imagine my surprise to see Giuliana and Bill Rancic come on The View two weeks ago and tell their story about trying In Vitro fertilization (IVF) and suffering a miscarriage. Their ordeal is also documented on their reality show: Giuliana & Bill. I just finished watching my DVR copy of their season premiere which follows them on their IVF cycle. What I really appreciated was the honest display of how difficult the cycle was. Were they both on board with this next step? How scary were the bags and bags of medication!? How would they coordinate their work schedules to make it happen? How could they keep it a secret from their work colleagues and their families? Who would stay home with Giuliana for her 48 hour bed rest? And of course it was difficult to watch them get the happy news of "you're pregnant!" at the end of the episode, since we already knew what was to come nine weeks later.

But what I really want to talk about are the huge strides they've made in reducing the stigma of IVF and miscarriage in just a few short weeks since they've come forward. I've spoken in previous posts about the importance of celebrity role models in reducing stigma of various conditions. Besides their appearance on The View and their very honest portrayal on their show, they have also partnered with key professional organizations like Fertility Lifelines and Resolve- The National Infertility Association. They have created a PSA for Fertility Lifelines encouraging couples to visit a fertility specialist. They offer statistics to help normalize the struggle to conceive and to build a community by letting viewers now that they are not alone.

Just three days ago, Access Hollywood reported that actor Kelsey Grammer came forward to say that the pregnancy he and his girlfriend had just announced in August had ended in a miscarriage. It is hard to imagine that the culture is changing this quickly...in all my entertainment news watching, I can count on one hand how many celebrities have shared this type of story.

I also think that having a "spokescouple" increases the effectiveness of their message. The stigma of infertility so often falls to the woman. "What is wrong with her?" The woman also has to endure the physically and emotionally difficult treatments. Having a couple remind us via this PSA that it can be 50/50 as to which person (or both!) is leading to the infertility helps take the stigma off the woman alone.

This situation also makes me think about the systems (or lack there of) that exist to support couples once they make the choice to see a specialist. Are these types of specialists/procedures even covered by their health insurance? Is it difficult for couples to take time off of work to deal with the physical/emotional demands that come along with this process (which is so often completely inflexible in its scheduling)? Are human resource departments/managers supportive of making accommodations and/or keeping this information confidential for their employees? Are there enough mental health professionals that specialize in infertility to help couples/individuals with the emotional challenges that go along with the physical?

As more couples wait longer to have babies and science moves forward to offer more treatments for infertility, we're going to have to grapple with these questions on a broad system level. However, that conversation is easier to have when stigma is reduced and more couples come forward to ask for what they need and offer to help each other.

Health Intervention Reality Shows: Are Participants Rescued or Buried Alive?

Last month I wrote on my Facebook wall "that hoarding show on TLC is both horrifying and fascinating". From the quick responses to my post, it is clear that I am not the only one feeling this way. Therefore, I was really interested in stories recently posted on the TIME website discussing how these types of shows can be harmful for the individuals that are featured.

There have been a slew of reality TV shows focused on staging interventions with individuals with a variety of mental illnesses/addictive behaviors. Some examples are "Hoarding: Buried Alive" (TLC), "Hoarders" (A & E), "Intervention" (A & E), and "Celebrity Rehab with Dr. Drew" (VH1). In one TIME article called "For Hoarders and Addicts, Drama is Trauma- Not Therapy", the author presents the argument that the needs of the mentally ill and addicts are the exact opposite of the formula of successful reality TV shows. Recovery for these individuals takes time and empathy and reality TV shows are looking for conflict and quick fixes within the hour allotted.

In all fairness (since I haven't seen all the reality shows in this category), I must say they are not all created equal. For example, A & E "Hoarders" seems to be much more of quick fix with cleaning crews clearing out houses over a two day period (which is very traumatic for the owners). In contrast, TLC's "Hoarding: Buried Alive" cleans out over a longer period and the individuals are more active participants/leaders in their own clean out. With the TIME article noting that effective clean outs for hoarding are a year on average, you have to wonder about the trauma of being confronted on camera about your "abnormal" behavior and then forced through a quick clear out. Also, the behavior of hoarding (or drinking or drug use) is usually just the tip of the ice berg, as it is a symptom of a larger problem. For example, I recently watched one episode of "Hoarders" where the woman shared that she began hoarding after surviving childhood sexual abuse. The therapist assigned to her clean out said "let's not talk about that right now". Therefore, I wonder about the long term repercussions of bringing out these emotions and not providing individuals with the support they need.

On the other hand, there could be potential positive outcomes from these individuals being featured on such a reality show. The primary outcome that I think of is access to resources. Many of the families/individuals featured are in great financial peril (often as a result of the money needed to continue with their addictions). The show is able to link them up with leading experts in their condition, offer ongoing care, assist them with legal concerns, etc. It remains to be seen whether these positives outweigh potential dangers.

Teen Moms and Teachable Moments

For one terrible minute on Monday night, my remote control found itself on ABC Family's "The Secret Life of the American Teenager". The show is completely unrealistic in showing 15 year olds pregnant and parenting with the maturity and vocabulary of people in their 30's. However, my remote control has recently become stuck on a reality show of the same topic on MTV called "Teen Mom". Now this is quite a leap of faith for me, as I pretty much gave up on MTV after its early quality reality shows (Season 3 of Real World with Pedro, anyone?) turned nasty and staged and scandalous. But according to a recent NPR story, I am not the only one thinking that this new show has some value and "reality". The Kaiser Foundation has funded reproduction of the series so that it can be distributed to schools, non-profits, and social service organizations that are working to reduce teen pregnancy.

The educators mentioned above believe that "Teen Mom" helps create and capitalize on a teachable moment. This is defined as "a moment of educational opportunity...a time at which a person, especially a child, is likely to be particularly disposed to learn something or particularly responsive to being taught or made aware of something". One reason to buy into this theory is based on the idea that modeling is important. People learn from watching each other. What high school students see other high school students doing is very important. Therefore, seeing the realistic struggles of the four girls on the show could help them think about potential consequences of teen pregnancy. We see the relationships with their family or the baby's father crumble. We see them working and paying bills in addition to waking up at all hours to a screaming baby. We hear about how one girl lost the father of her baby in a car accident before the child was born...now she is a single mom.

Of course anyone who reads this blog on a regular basis knows that I need to mention that this show is being used in schools as an educational piece. And of course an educational piece is not a silver bullet because it cannot address all the complex risk factors for teen pregnancy which include things like economic disadvantage and growing up with teen parents yourself. However, I think it is a step in the right direction. It is definitely an improvement in the quality of MTV reality shows. It also shows these girls in a pretty "real" light without being preachy or fear-based. Check it out and let me know what you think.

Talkin' Bout A Revolution...Jamie Oliver is much louder than a whisper!

So I just finished watching the premiere episode of "Jamie Oliver's Food Revolution". It is a new show on ABC that chronicles the journey of English chef Jamie Oliver as he tries to change the eating habits of residents in Huntington, West Virginia. Huntington was recently crowned the most unhealthy city in America.
It is obvious that Jamie has good intentions. He has left his family for several months to work on this project. He is especially concerned about the quality of food being served in the Huntington schools. However, my reaction to the first episode was "No, no, no! Stop what you're doing and talk to these people first!"

The most important part of any public health intervention is getting to know the community you are working with. The worst thing you can do is come in as an "outsider" and start barking orders. Some questions you should ask before getting started are: How does this community operate? Who makes the decisions? What are some of the barriers to serving fresh food in schools? What are the USDA guidelines? (which Jamie knows nothing about) Who are the individuals you want/need to get on board with your idea? How do the parents feel about their children's eating habits? How can you get their buy-in? What would be a realistic timeline for assessment/buy-in before trying to implement change?

Jamie went about this all backwards (which may very well have been to increase drama for a TV show, but it is still a great example of "what not to do"). His first day in town he was told he was viewed as an "outsider" by the trusted radio host...and still proceeded to go into the elementary school and lecture the chefs on how disgusting the food is (after only observing them for one day). And he's surprised he's getting push back on his efforts?! The only small victory he has is creating a partnership with "Pastor Steve" at the local Baptist church. Steve is a trusted leader in the community and knows the families and their challenges very well.

Too bad Jamie did not look to better models of this kind of community effort. Shape Up Somerville (Somerville, MA) began as a community based research study at Tufts University targeting 1^st through 3^rd graders in the Somerville Public Schools. Today there is Coordinator working on active and healthy living programs supported by the Health Department and a Taskforce that is a collaboration of over 11 initiatives and 25 stakeholders involved in working on various interventions across the city. Program components include a focus on the school lunch program, local restaurants, walk ability and safe routes to school, etc. (I'll give a shout out here to one of my public health heroes- Julia Bloom- who helped Tufts bring this model to more rural communities across the country!)

Shape Up Somerville represents a strong program that began with a strong base. The original program engaged key stakeholders and did not try to change the community without first finding out how it worked. The community and parent outreach were an obvious key to success...where that aspect is basically forgotten in the "Food Revolution". Jamie just seems like one man on a mission to change. At the end of the episode Jamie is visibly upset and says "they don't know why I'm here". Yeah- that's because you're an outsider lecturing them on how they should raise their kids!

I'll probably watch the second episode where he actually starts to engage the community...how about you?