Obesity in the UK has received significant regulatory attention of late. In July 2019 the Department of Health & Social Care (DHSC) published its policy paper ‘Tackling obesity: empowering adults and children to live healthier lives’, and one year on, the government published the new obesity strategy for England.
The coronavirus pandemic has also brought obesity – a term defined by abnormal or excessive fat accumulation that presents a risk to health – to the fore. It is a recognised risk factor for severe clinical outcomes of COVID-19, with early-2020 data revealing individuals who were overweight or obese made up 78% of the confirmed COVID-19 infections and 62% of COVID-19 deaths in hospitals.
Yet obesity is complex. A multitude of factors can play a role in weight gain, including food and activity, environment, genetics, health conditions and medications, stress, emotional factors, and poor sleep.
This makes obesity management, from a regulatory perspective, a challenge. Acknowledging the psychological impacts of ‘fatphobia’, is the UK Government’s output contributing to social stigma around obesity?
Weight bias and stigma in the UK
The World Health Organization (WHO) defines weight bias as negative attitudes towards, and beliefs about, others because of their weight. Such attitudes are manifested by stereotypes and or prejudice towards people with overweight and obesity.
Weight bias, the WHO continues, can lead to obesity stigma – defined as the social sign or stigma affixed to an individual who is the victim of prejudice.
In the UK, weight has been found to be the most common form of discrimination. According to 2018 data from the British Liver Trust, more than four in five UK adults believe people with obesity are viewed negatively because of their weight, and 62% of Brits think people are likely to discriminate against someone who is overweight.
This, the charity’s findings revealed, is higher than other forms of discrimination, including ethnic background (50%), sexual orientation (56%) or gender (40%).
For adults with obesity in the UK, nearly half have felt judged because of their weight in clothes stores or in social situations. Forty-five percent said they had felt judged in healthcare settings, and 32% in gyms.
Weight bias is a complex field, and one that, according to Sussex University’s Lavinia Bertini, is ‘unfortunately unexplored’. “I feel there is still very little understanding of how weight bias and stigma are important factors…in the public debates around obesity,” the obesity expert told FoodNavigator.
It is crucial to understand that the types measures, interventions, and language prioritised in government strategies and policies play an important role in either enforcing – or fighting – bias and stigma attached to obesity, we were told.
“People may not be aware of this, so it’s really important for the Government to be reflective in the way they send their [messaging].”
The power of language
For Bertini, the Government has failed to hit the mark concerning its use of language around obesity in recent years.
“Obesity is often presented as a burden to the NHS,” she told this publication. In the recently published strategy, the Government writes: “We owe it to the NHS to move towards a healthier weight. Obesity puts pressure on our health service.”
When listing ‘further measures [that] will be needed’, the strategy notes: “We will make prevention at the heart of this government’s health agenda to proactively tackle the burden of preventable ill health and empower everyone to make the healthy behaviours they want to make.”
This kind of language, said Bertini, is ‘quite weird’, especially when “we’re talking about something that is described as a health condition”.
The research assistant also highlighted a section of the strategy she finds problematic: “Tackling obesity would reduce pressure on doctors and nurses in the NHS, and free up their time to treat other sick and vulnerable patients.”
This statement implies people who are experiencing health conditions attached to their weight are wasting the NHS’ time and money, Bertini argued. “I do think that this is something that should be avoided, it is almost a way of shaming people into losing weight, which definitely shouldn’t be the way forward.”
The Department of Health and Social Care’s (DHSC) Jenny Oldroyd, deputy director of Obesity, Food, and Nutrition, says the Government is conscious of weight bias, and has worked to ensure its policies do not contribute to such stigma, “not just as the conversation around this picks up publicly at the moment, but over the past few months and years as we’ve been working on the strategy”.
At the Westminster Health Forum policy conference held last week, Oldroyd addressed the DHSC’s use of language in particular.
“I would hope that people have seen quite a shift in our language over the last year or so in this area,” she told delegates, “and very much in the strategy – starting, I think, in the strategy we published last July, but very much in the 2020 work.
“[Here], you’ll start to see different language around people living with obesity, and that language coming through to make sure that we’re very conscious of the concern around any contribution we might make towards [weight stigma] because that has never been, and would never be, our intention.”
An individualist approach?
The University of Sussex’s Bertini also criticised the Government’s messages themselves, which she suggested concentrate on individual responsibility and motivation, rather than systemic change.
“Unfortunately, most strategies that have dealt with obesity management in the UK are very much focused on individual responsibility and motivation. This can really perpetuate negative stereotypes that depict individuals with obesity as lazy, and lacking in control and motivation.”
Having referred to himself as being ‘too fat’ when he contracted COVID-19, Prime Minister Boris Johnson has since hired a personal trainer. Bertini told this publication she is concerned what messages this may be sending.
“Hiring a personal trainer is very much a personal choice, which is based on personal circumstance. [For someone] at the basis of public and national methods on obesity, [this decision] feeds into the idea that all it takes is to be motivated and have the resources to lose weight, through exercising and eating healthily.
“This in itself is a very simplistic way of thinking about losing weight, which is much more complex than that.”
Johnson’s actions are also ‘very dangerous’ when it comes to weight bias and stigma, Bertini continued, referencing obesity’s prevalence in deprived areas.
“If we send a message that losing weight is easy, and it’s all about your individual responsibility, then we do not address the systematic inequalities that create conditions for deprived areas to exist. Then we really are sending dangerous messages that can…demoralise and pass judgement around body size and education.”
Of the Government’s policies themselves, the DHSC’s Oldroyd said impact assessments have been undertaken for ‘all policies’, with particular attention paid to groups that could be at risk of harm, and to those that simply may not benefit from such policies as much as others.
“In the impact assessments and in the equality assessments, you can see [that work] played out, both at consultation stage [and in published consultation responses],” she told delegates at the Westminster Forum event.
Should weight be the only measure?
Negative stereotypes based on weight are built on pre-existing moral and aesthetic values around body size. It is undoubtably true that society values slimness as ‘desirable’, however today, slimness has also come to ‘validate good health’, Bertini explained.
“Fatness has become the visual representation of ill health, when being overweight doesn’t necessarily mean being unhealthy.”
Moving forward, the assistant researcher said she would like to see less focus on weight and more focus on health.
From an obesity management perspective then, perhaps we should be looking beyond weight to measure policy effectiveness. Could a decrease in anxiety, an increase in self-esteem, and better eating habits be used to measure a strategy’s performance?
According to Health Education England’s Janet Flint, who heads up the Population Health & Prevention and Maternity programme, the answer is a resounding ‘yes’.
“I think all those measures are important and should be for the policymakers to consider, absolutely. This is complex, it’s part of a bigger picture about mental wellbeing, increasing physical activity [etc.]. So yes, there should not just be one indicator for this in my opinion,” she told delegates at the Westminster Forum.
In composing the UK’s recent obesity strategy, the DHSC sought counsel from third party experts. Describing these bodies as being a ‘fantastic support’, Oldroyd said “we couldn’t have got as far as we have without the organisations that have helped us on it”.
Sussex University’s Bertini, however, believes more can be done. The researcher would like to see more participation from people described by their body mass index (BMI) as obese. “There should be an open dialogue with people with obesity who are often not represented or not listened to. I think there is a lack of voices from these people.”
Bertini is also calling for increased focus on the food industry in obesity policy, homing in on “how they can be held accountable and made responsible for some important changes that need to be made, and that could address the wider systematic production of food and food quality”.
Moving forward, the researcher suggested the UK take a leaf out of Canada’s book. Last month, Obesity Canada and the Canadian Association of Bariatric Physicians and Surgeons released the ‘Canadian Adult Obesity Clinical Practice Guidelines’ – described as ‘perhaps the most extensive review of published evidence yet conducted in obesity worldwide’.
The first step of five in the ‘patient arc to guide a health care provider in the care of people living with obesity’ is: “Recognition of obesity as a chronic disease by health care providers, who should ask the patient permission to offer advice and help treat this disease in an unbiased manner.”
This statement alone brings weight bias and equality into obesity management in general practice, said Bertini. “I think it is time the new strategy in the UK really addresses these key issues, if they want to be effective and fair.
“Addressing weight bias, and making weight bias central to policy and messages, would be a really important change.”