Is being overweight or obese really just a matter of personal responsibility – and if not, how can health stakeholders help people lose weight? Megan Haggan investigates
Australian waistlines are continuing to grow. According to the Australian Institute of Health and Welfare’s latest report on the subject, published in June 2018, almost two in three adults were overweight or obese in 2014-15.
Twenty-eight per cent were obese in 2014-15, an increase from 19% in 1995. And 26% of children and adolescents were overweight or obese in 2014-15.
Suzanne Carroll, an Assistant Professor (Public Health) at the Centre for Research and Action in Public Health, Health Research Institute, University of Canberra, says it’s important to differentiate between populations and individuals when considering obesity rates in Australia.
“For such a population-wide shift in body size to occur as has occurred, there really needs to be population-wide causes and it’s highly unlikely that there was a sudden shift in our genetic predisposition or strength of will-power,” A/Prof Carroll told the AJP.
“This highlights the importance of environments. There have been key changes to our environments over the last few decades, from the introduction of labour saving devices in the home to the availability of energy-dense nutrient-poor, well marketed, highly convenient unhealthful foods.
“Given high-stress, time-poor lifestyles, convenience becomes oh so important, and high motivation to eat well and be active can only get us so far when our environments support, even encourage, unhealthy behaviours.”
Alice Bastable, Healthy Lifestyles Campaign Manager, Prevention at the Cancer Council Victoria – in initiative of which is the LiveLighter campaign – said that access to public transport, for example, can make a big difference.
“By having easy and accessible public transport it’s a great way to boost incidental exercise. We’ve found that only 30% of Australians use public transport regularly.”
And the environmental impact begins early, she says.
“Junk food is everywhere. It’s cheap and detrimental to our health.”
And “advertising does influence children’s food preferences, requests and consumption and is a probable causal factor in weight gain and obesity.”
Fat-shaming and fat acceptance
Changes in weight are a hot topic in the media: from reporting in traditional outlets to grassroots discussions on social media. Some of the latter have spawned movements such as the fat acceptance movement, which seeks to address “anti-fat bias,” while in other circles, criticism of overweight people, including that targeting individuals, is encouraged.
When plus-size model Tess Holliday appeared on the cover of British Cosmopolitan magazine’s October 2018 issue, she and Cosmo experienced a backlash on social and traditional media, criticising the image as glorifying obesity.
Ms Holliday refuted these claims, telling This Morning that her message was not to encourage people to put on weight, but, “Let’s love yourself, regardless of how you look in your current body”.
“Your mental health is far more important before you can worry about your physical health,” she said.
This year, Netflix was criticised over its series Insatiable, in which a teenage girl loses weight after having her jaw wired together, and decides to seek revenge on bullies.
And in July 2017, Australian women’s news site Mamamia came under fire for its treatment of Roxane Gay, author of Hunger: a Memoir of (my) Body, after it discussed her “super-morbidly-obese frame” and whether its offices were suitable to host somebody of her size.
Dr Gay described these comments as “cruel and humiliating”.
Fat stigma can negatively impact physical and mental health, and demotivate healthy behaviours, A/Prof Carroll told the AJP.
“Being unhappy with your body, ashamed of your weight, experiencing weight stigmatization or being fat shamed can lead to worsening mental health. Fat shaming does not tend to motivate people to lose weight, but it can do a lot of damage.”
She says that fat shaming can include many different behaviours: from well-intentioned comments regarding concern for someone’s body size, through to comments intending to wound.
“The most obvious examples are words or images that intend to frame fat individuals in a negative way for example, as unattractive, lazy, or stupid,” she said.
“This both promotes and results from stigma relating to body size. However, fat shaming can also be inadvertent.”
Ms Bastable said that being fat-shamed can “internalise your weight stigma – and it can contribute to the person actually avoiding health care or taking medications”.
On 11 October 2018, the World Obesity Federation used World Obesity Day to highlight stigmatising image of obese people in the media, setting up a hashtag, #endweightstigma, to call out examples of discrimination.
New research, commissioned by World Obesity, showed that people with obesity are viewed negatively because of their weight and are likely to be victims of discrimination because they are overweight. This form of discrimination was more prevalent than other forms, including discrimination due to sexual orientation, ethnic background or gender.
The findings from adults in Brazil, South Africa and the UK show that people with obesity experience stigma and discrimination across all aspects of their lives, including in clothes shops, health settings and at the gym.
While fat-shaming is fundamentally unhelpful, fat acceptance is more of a mixed bag.
Ms Bastable says she agrees with some aspects of the fat acceptance movement.
“For example, every person deserves to be treated with dignity and respect, and diets and dieting are generally not good for people’s physical or mental health,” she says. “And weight is not necessarily a sole indicator of someone’s health.
“However I do think that we need to acknowledge that being overweight is certainly strongly linked to a number of chronic health conditions, and this evidence can’t really be ignored.”
Pharmacists and other health professionals are in an excellent position to help people who are overweight make some lifestyle improvements, but any approach initiated by a pharmacist is likely to be perceived as fat-shaming.
Jacqui Hagidimitriou, pharmacy manager of the award-winning TerryWhite Chemmart Samford in Queensland, has a strong interest in weight management and is currently pursuing a degree in nutrition. She told the AJP that cold approaches simply don’t work, but there are more productive ways to work weight into a conversation.
“It might come up in an alternate health check you’re doing: for example we’re doing blood pressure checks,” she said.
“If someone gets a high reading, they often want to know what else they can do to change it, and that’s when you can approach the subject.
“You never get anywhere with people if you tell them that they should do this, and they should do that, and these are things they already know they’re not doing. You have to work with people at the place they’re at during any given point in time.
“It helps to shift the focus more towards health, and away from weight. I think this is where more dietitians are heading at the moment, and with my studies my focus has changed; so I’m not worrying about carbs, but asking: why do we want to lose weight?
“Especially these days with Instagram and so on, there’s too much pressure, too much emphasis on the look.
“We want to be healthier. Let’s focus on that.”
Shifting the focus
“Health should definitely be the priority. We sometimes forget that you can be a healthy weight but still unhealthy,” says A/Prof Carroll.
“You could smoke, drink unsafe amounts, be on restricted calories but eating the wrong foods and therefore malnourished with vitamin deficiencies, and not be doing any exercise.
“Body size is often used as a quick judgement of health status and being overweight or obese increases your risk for chronic diseases, but health behaviours may be even more important. Eat well, be active and strive to be happy.”
It’s now well known that loss of just five to 10% of body weight can have significant health benefits, including for the cardiovascular system, an impact on diabetes, kidney disease and knee problems related to weight. This figure may be feasible, whereas loss of large amounts of weight may be more difficult.
Ms Bastable points out that mental health is also strongly linked to a person’s weight – as well as some of their lifestyle choices.
Lifestyle choices which promote weight loss or maintenance are in themselves of benefit, she told the AJP.
“We know that people with serious mental health conditions often experience higher rates of weight-related chronic diseases, for example diabetes and cardiovascular disease,” she says. “They’re two or three times more likely to have diabetes. They’re six times more likely to die of cardiovascular disease and more likely to die from chronic conditions, and live 10 to 32 years less than the general population.”
The interplay between mental health and obesity is somewhat of a “chicken and egg” situation, she said, citing research from Deakin University’s Food and Mood Centre which has shown that not only can mental health affect diet, but diet can affect mental health.
“They’re finding that if you have more junk food in your diet it can contribute to, or cause, depression and anxiety, and if you improve the quality of your diet you can help your depression – and that’s whether you’re on medication or not,” Ms Bastable says.
Diets, however, are not necessarily the answer.
“We know short-term dieting tends to have a very high failure rate, and that’s consistently backed up by the evidence,” Ms Bastable says.
People who lose weight on diet regimes need a follow-up plan to maintain the weight loss – otherwise they are likely to slowly put the weight back on.
“That’s detrimental to the patient’s psychiatric health and contributes to yo-yo dieting and a sense of failure,” she says. “Usually with these very low-energy diets people tend to do better if they are supported by a team of professionals to help monitor progress, and if it’s working, transition to the next stages.”
A/Prof Carroll agrees.
“If you lose weight on a restricted diet you then need to transition to a healthy eating pattern, something that is sustainable long term,” she says. “Weight loss programs that include a focus on behavioural change are generally more successful longer term than just dieting alone.”
Stakeholders say that steps need to be taken at a number of levels: individuals can learn to make some better choices, but governments need to consider how legislation, regulation and planning could help.
“As much as possible, we need to make healthy behaviour such as active transport, active recreation, and healthy diets, as easy, safe and convenient as possible,” says A/Prof Carroll.
“The built environment such as walkable street design, bike paths and public open space can influence physical activity, as can services like public transport.
“Food companies spend large amounts of money developing their products for mouth feel and taste so that we want more. Such products are highly available and very appealing, all supported by clever marketing strategies from advertising and packaging design to product placement within stores.
“These environmental factors influence our behaviours and consequently our health outcomes including overweight and obesity.”
Pharmacists are in a good position to help, says Ms Bastable – and to date they have been underutilised.
“Pharmacists often may have a better relationship with the patient than their doctor does, and they can position themselves as someone who can do something to help with nutrition, activity levels and weight loss.
“I think pharmacists are probably overlooked in that role, but I’d encourage them to realise what they say to people is probably gospel and they could probably have more success than a dietitian would. You might be more influential than you think.”
She encouraged pharmacists to take up training for health professionals offered by LiveLighter, available in Melbourne; training has finished for 2018 but more sessions will be announced next year.
A/Prof Carroll warned that shakes and supplements available in pharmacy may not be the best option.
“I have concerns regarding the use of shakes and supplements, especially without appropriate guidance,” she says.
“The long-term aim should be to develop a healthy lifestyle including physical activity and a balanced diet. I’m not convinced that diet shakes and other products necessarily support this long-term aim though they may be useful in the short-term for weight loss.
“Such products are probably best used under the guidance of a dietitian if at all.”
Great expectations: Jacqui Hagadimitriou says that it’s important to focus on reasonable expectations of weight loss, and not necessarily only on weight.
“Sometimes weighing yourself too often is not helpful. People can get really disheartened if they get on the scales each week and nothing’s happening, so I encourage people to take their waist measurement and have a discussion about where the weight is sitting.
“Healthy weight loss for females is around 250g a week – that’s normal. Some people are disappointed but that’s actually really good.”
Sleep: “People don’t understand the connection between sleep and their weight,” says Ms Hagadimitriou. “If you don’t sleep very well, your body will release a hormone that stimulates your hunger.
“Things like sleep apnoea can make you more likely to put on weight and be more prone to develop diabetes, as your metabolism is messed up.”
Simple changes: Ms Bastable says it’s surprising how many people still have not taken on board simple messages, such as the fact that eating an orange and drinking a glass of orange juice are not the same thing nutritionally.
“A glass of orange juice might have five oranges in it – you’d never sit and eat five oranges. A surprising amount of people don’t really identify those fruit smoothies as sugary drinks. The overall impression of the population is they think it’s healthy.”
Ms Hagadimitriou suggested that people who crave a chocolate bar at 3pm as tiredness hits could replace it with another sweet alternative – a piece of fruit, or nuts for protein.
Incremental exercise: Exercise builds up muscle strength, and as muscle burns more energy than fat it’s key in weight management, says Ms Hagadimitriou.
“Not many people watch normal TV with ad breaks any more, but if they do, every ad break they could walk around. They can get little pedal bikes – just the pedals – and pop them on the ground next to the couch and pedal as they watch.
“People are busy and have habits that are hard to totally upturn, but you can integrate something into what they’re doing and not necessarily call it exercise.”
Consider medication: “Some medications can contribute to weight gain, or interfere with being able to lose weight,” says A/Prof Carroll.
“These include some anti-depressants as well as anti-psychotics, anti-epileptics, insulin, glucocorticoids, beta-blockers and oral contraceptives.
“If weight is a potential problem, then choice of medication should be carefully considered.”