Last week the government launched their childhood obesity plan and it fills me with dismay. Apart from some wishful thinking in regard to industry self-regulation the initiatives are almost all education-based. There are plans to identify overweight children at an early age in the expectation that education and motivation of the parents (presumably) will result in their losing weight. The Children’s Commissioner Russell Wills said “the moves won’t cut obesity and could even harm children” and I agree.
Many people in the developed world are on a diet or feel they should be. The societal pressure to be thin eclipses the medical imperative for most individuals and there is a huge investment in dieting as the means of attaining a healthy body weight. The investment is by overweight individuals, gyms, personal trainers, nutritionists, weight loss programme and product purveyors, and most importantly, the fast food industry and government. At the core of the free market ideology with respect to food is the belief that it is our choices that determine the nutritional environment and we are fat because we choose to be.
Maintaining this myth is dangerous from a public health perspective as it deflects attention away from strategies likely to be effective in reducing obesity rates. Strategies which maintain choice but ensure that the default favours the eating of healthy food and maintenance of regular exercise. I am talking about fiscal measures which make healthy food affordable and accessible, and efficient public transport in the place of cars. But making weight an issue of personal responsibility is also powerfully stigmatising. Doctors contribute to this by asking people to do something most are incapable of.
The belief that we can control our weight, and that obese people choose not to, is the core of anti-obesity prejudice. In studies conducted with US and Australian university students a correlation is seen between attitudes of ‘disgust’ towards a range of social groups and the perception of control associated with the membership of that group. Mental illness didn’t rate very highly on the disgust scale because it wasn’t seen as something you had control over. Smoking, drug addiction and obesity were at the other end of the scale. We can debate the validity of these perceptions but the interest is in the linear association between disgust and control. The author of this paper wondered about the origin of the emotion of disgust in relation to obesity and suggested that there was a moralisation element – that opting to be fat when the ideal is for slim – transgressed some moral code. More support for the notion of control as a driver of anti-obesity stigma comes from an experiment in which students were surveyed to measure the extent of ‘anti-fat prejudice’ before and after a tutorial on obesity. For those who learned about diet and exercise as a means of dealing with obesity the prejudice measure didn’t change. For those who took part in a tutorial on geno-environmental causes of obesity, the anti-fat prejudice rating dropped.
Understanding the potential for stigmatisation is more than a moral or ethical consideration. In determining an effective public health strategy we can opt for either de-normalisation or de-stigmatisation. Framing cigarette smoking as a bizarre behaviour that’s dangerous not only to smokers but also to close bystanders led to the progressive banning of smoking on planes, in picture theatres, hospitals, most work places, restaurants and even bars. The sad sight of cold workers huddled outside on pavements looking for shelter while they smoke is about more than just protection of fellow workers. It is powerfully stigmatising and along with the very high cost of cigarettes is credited with helping people quit.
When AIDS was first identified and it became clear that a public health response was required a similar, stigmatising approach was taken. It was a disaster. The public panicked, those at risk of infection went in to hiding and engagement with programmes to reduce infection was low. A major breakthrough occurred when the approach changed to one of normalisation. I was a hospital doctor in the early 80s when AIDS was first recognised and we were all terrified of it. Now the illness is viewed like any other treated in medical outpatient clinics. It’s essential that we adopt an approach of de-stigmatisation in our public health approach to obesity. Not only because of the harm to individuals if we continue to consider it an issue of personal responsibility, but because this is the way to get on top of the problem.
Many if not MOST of the things we do currently fail the de-stigmatisation test. Anything that emphasises education and motivation of individuals certainly does so. Using a framework that divides up anti-obesity initiatives according to whether they are environmental or behavioural and grades their potential for stigmatisation as low, medium or high we see that environmental solutions such as taxation or restrictions on the placement of fast food restaurants have a low potential for stigmatisation whereas endorsement of weight loss programmes through the workplace depends on behavioural change, targets obese individuals, and is highly stigmatising. Even activities such as the provision of weight loss programs in primary care and increasing health education in school potentially increase prejudice by emphasising personal choice.
The evidence of prejudice on the basis of body weight leading to psychological and physical ill has led some to argue that governments need to deal with weight discrimination in formal legislation. I’m not sure legislating against discrimination in the work-place on the basis of body size (as has been suggested) is the right course of action but we certainly need greater awareness of anti-obesity prejudice. Before we berate individuals for failing to choose healthy food or lifestyles, the conditions need to be optimised to allow this. If there is ready access (in terms of price as well as physical location) to healthy food then it is likely that there would be a marked reduction in those who made the effort to purchase unhealthy food. Similarly, when the default physical environment is one which favours cycling as the means to travel to work and school as in The Netherlands, you see many more people on bicycles in Amsterdam than in a car-oriented city like Auckland.
We know that obesity is genetic; we know that our environment is stacked against thinness; and there is no evidence for people becoming lazier or more self-indulgent. Very few people want to be fat. The societal pressure to be thin eclipses the medical imperative for most individuals. But diets don’t work. Only 15% of people who embark on a weight loss diet have maintained weight loss at the 5 year mark. I stopped asking patients to lose weight decades ago.