The European Congress on Obesity met in Glasgow between 28 April and 1 May 2019. Within a packed programme, the People First campaign was launched by the European Coalition for People living with Obesity, a pan-European, patient-led group. People First advocates patient-friendly language: ‘people with obesity’ rather than ‘obese people’. It might seem like a small difference, but it is a crucial one. Having obesity does not define the person, only one aspect of them. We do not talk about ‘cancerous people’, but ‘people with cancer’. When it comes to obesity, language matters.
Obesity: highly prevalent and highly visible
Obesity is both highly prevalent and visible. Many consider it to be a disease state, and it is also a risk factor for developing other serious, long-term conditions. In the UK, over 26% of adults are now classed as having obesity and 35% classed as carrying excess weight, a total of 61.4% of the adult population (NHS Digital, 2016). One in three children in England leaving primary school are either overweight or have obesity (NHS Digital, 2018a).
Obesity is classed as having excess body fatness, and the health risks associated with it include type 2 diabetes, hypertension, cardiovascular disease, some types of cancer, osteoarthritis and dyslipidaemia (Public Health England (PHE), 2017; Baker, 2018). In regards to mental health, obesity increases the risk of depression and other serious health conditions (Gatineau and Dent, 2011). Despite this, it is not currently considered a disease in the UK.
The Royal College of Physicians (RCP) (2018) have called for obesity to be recognised as a disease, not just as a risk factor for other chronic conditions. The World Health Organization (WHO) (2000), the World Obesity Federation (Bray et al, 2017) and several countries such as Portugal, the US (American Medical Association (AMA), 2013) and Canada have given obesity disease status. In Europe, a written declaration was submitted by members of the European Parliament calling on the European Commission and Council to work for a Europe-wide recognition of obesity as a disease (Sant et al, 2016).
The case for
A major reason for advocating obesity as a disease state is the likely impact on obesity-related stigma. Obesity has been found to be an acceptable target of discrimination (Stunkard and Sorensen, 1993; Falkner et al, 1999). Acknowledging obesity as a disease takes the onus off the individual as being solely responsible for their own disease state. Much of the literature around obesity paints a very simplistic picture: move more and eat less. This ignores the complexity of the causes of gaining and maintaining excess body weight.
The Foresight report identified a multitude of contributory factors that affect a genetically susceptible species living in an environment that promotes excess weight gain (Butland et al, 2007). Apart from ignoring this complexity, many health messages focus primarily or entirely on actions that the individual with obesity can take, which fails to recognise the very real barriers to action, many of which are outside the individual's control. While we are all responsible for living as healthy a life as we can, the fact remains that it is easier for some than others. The prevalence of obesity differs with age, gender, ethnicity and socioeconomic status (NHS Digital, 2018b). These are not the fault of those concerned, nor are they within the individual's control.
The cost of obesity to the nation in terms of health and social care does not mean that we can blame those living with obesity any more than we blame people living with cancer or other chronic diseases. Another reason for recognising obesity as a disease relates to what is and is not covered by health insurance. While this may be less relevant in the UK, where healthcare costs are free at the point of need, there is evidence to suggest that those with obesity may be discriminated against in terms of the treatment they can access. It is not unusual as a dietitian to see patients who have been referred for unrealistic weight loss targets before they will be considered for surgery, with the unspoken assumption that whether or not they successfully lose the weight is a matter of personal choice.
The case against
The main reason given for not recognising obesity as a disease is the reliance on body mass index (BMI) as a diagnostic tool. Having a BMI at or above 25 kg/m2 is classed as being overweight, and BMI at or above 30 kg/m2 is classed as having obesity (Baker, 2018). This is accurate at a population level but not necessarily at an individual level, since BMI cannot distinguish between different tissue types (NHS Digital, 2018b). For example, it is likely that a professional rugby player would be classed as having obesity using BMI alone. However, in most adults, weight gain is likely to be fat tissue. Importantly, BMI does not indicate overall health, but only one aspect of it.
BMI does not indicate the extent to which an individual is affected physically, mentally or functionally by their weight (BDA Obesity Specialist Group, 2018). There are also concerns about the effects of such a change on insurance and employment. Recognition of obesity as a disease will overnight result in many people being diagnosed with a ‘chronic relapsing disease’ (Bray et al, 2017). What impact will that have on them and on healthcare services?
Why does it matter?
None of us want to consider that we may hold biases towards our patients. However, we live in a society which is highly discriminatory towards those with obesity. The subtext of much of the health-related literature around weight management suggests implicitly or explicitly that individuals are to blame for their condition.
Obesity is highly visible. Stigmatising images are used to portray those with obesity (Carels et al, 2013), often portraying them in activities which contribute to assumptions about their poor personal choices (eg watching television, eating junk food, drinking sugary drinks). How obesity is written about also frequently frames it in terms of individual control (Flint et al, 2016; Atanasova and Koteyko, 2017), and this influences us, as readers, to think the same. There is a difference between doing what we can to be healthy and being solely responsible for our own ill-health. Reinforcing the idea that obesity is a matter of personal choice and that people simply need to move more and eat less ignores the important roles of our pre- and post-birth environments and of our genetics (Butland et al, 2007). Weight and obesity-related bias and stigma are damaging (Obesity Health Alliance, 2018). They have been shown to increase the risk of exercise avoidance, unhealthy eating behaviours, depression, low self-esteem and poor body image (Gatineau and Dent, 2011; Kahan and Puhl, 2017). However, maladaptive eating behaviours and avoidance of exercise further increase the risk of obesity, and many of those with obesity report that they use food as a way of coping with weight stigma (Puhl and Brownell, 2006).
‘A major reason for advocating obesity as a disease state is the likely impact on obesity-related stigma. Obesity has been found to be an acceptable target of discrimination (Stunkard and Sorensen, 1993; Falkner et al, 1999). Acknowledging obesity as a disease takes the onus off the individual as being solely responsible for their own disease state. Much of the literature around obesity paints a very simplistic picture: move more and eat less. This ignores the complexity of the causes of gaining and maintaining excess body weight.’
Weight-related stigma
Weight-related bias is well documented. It has been demonstrated across education, employment and healthcare sectors (Puhl and Heuer, 2009). Nurses, doctors and dietitians have all been shown to hold weight bias (Brown, 2006; Puhl and Brownell, 2006; Swift et al, 2012; Teixeira et al, 2012). This is likely to affect both verbal and non-verbal communications with patients (Brown and Flint, 2013; Street et al, 2007), our expectations for their treatment (Foster et al, 2003; Puhl et al, 2009; Persky and Eccleston, 2010; Phelan et al, 2015) and even the time spent with them (Bertakis and Azari, 2005). That in turn is likely to negatively affect their outcomes (Sutin et al, 2015; Tomiyama et al, 2018), and the likelihood that those with obesity will seek medical treatment and support, or even avail of preventive services (Olson et al, 1994; Fontaine et al, 1998; Puhl and Brownell, 2001).
Health professionals are encouraged by Health Education England to make every contact count, and to raise the issue of weight opportunistically (PHE et al, 2016). However, without due care, health professionals may cause harm. An unintended consequence of this may be that patients with obesity opt out of medical treatments until absolutely necessary. It is not the case that weight doesn't matter or that the issue of weight should not be raised. But how it is done will affect our relationship with our patients, as well as their willingness to engage with us.
What can we do?
Firstly, we can all check for our own unconscious bias; there are a range of online tools available (Box 1). When writing about obesity, use people-first language. If those living with obesity find this helpful then the onus is on us to respect that. Images of those with obesity need to be representative and respectful. Having obesity is only one aspect of the person, and a range of free images are available for use from World Obesity (Box 1). Consider raising awareness of these issues on World Obesity Day (https://www.obesityday.worldobesity.org/), and supporting the call for obesity to be recognised as a disease. As health professionals, we can act as advocates and join the voices of those living with obesity.
Box 1.Useful resources
- World Obesity image bank: https://www.worldobesity.org/resources/image-bank
- Example of a People First language tool: https://www.obesityaction.org/actionthrough-advocacy/weight-bias/people-first-language/ or https://easo.org/people-firstlanguage/
- European Coalition for People with Obesity: https://www.facebook.com/ecpo.patients.7
- Implicit Association Tools to measure unconscious bias: http://www.uconnruddcenter.org/weight-bias-stigma-tools-for-researchers
KEY POINTS
- Obesity is highly visible and weight-related stigma and bias is well documented, including among health professionals
- Although a number of other countries recognise obesity as a disease, it is not yet officially recognised as such in the UK
- Such recognition may help to reduce weight-related stigma and bias, and aid understanding of the complex nature of the condition
- Non-stigmatising images of obesity should be used to and a bank of such images is freely available
- Using people-first language helps to demonstrate that obesity is just one aspect of a person, but does not define them