Obesity: time to turn around our biases

INTERNATIONAL and Australian experts are calling for a “new narrative” around obesity, including recognition of obesity as a complex chronic disease, to drive a more comprehensive approach to a condition that affects up to one in three adults worldwide.

Writing in The Lancet, the experts said a “misleading obesity narrative” had inhibited coordinated action, partly because the language and images that describe the problem could distort it.

“Obesity is not only a risk factor for non-communicable diseases, but it is also a complex chronic disease,” they wrote.

“Yet efforts to address obesity have been stymied, not by inadequate knowledge but by a faulty framing of the issue that has led to stigmatisation, siloed approaches, political inaction, and an absence of coherent strategies within food and health systems,” the experts wrote.

Professor Ian Caterson, one of the Australian co-authors of the article, said there had been little progress made in the prevention, management and care of people with obesity.

“We think that approaching the problem of obesity in a different way – recognising that it is not a simple disorder where you just need to walk more and eat less – but there are multiple factors that contribute to obesity in a population, region and a person, and that it is a disease [may be more effective than past efforts],” said Professor Caterson, who is Boden Professor of Human Nutrition at the University of Sydney.

“Once we approach obesity in this way, it helps health systems and government policies to deal with it in the same way as they might deal with diabetes or cancer.”

Professor Caterson said destigmatising obesity was also a crucial step in reducing the many health and social harms associated with the condition.

“There is still, to put it crudely, the perception that people with obesity are gluttons and are lazy,” he said, adding that this stigma affected individuals across a range of issues from accessing health care to gaining employment.

The Lancet authors wrote that a new narrative around obesity must incorporate four dimensions: recognition that obesity requires “discrete actors and sectors to work together simultaneously through many entry points; a change to the words and images used to portray individuals with obesity; the prioritisation of childhood obesity and the growing burden of obesity in low-income settings; and policy approaches that address inequalities and social and physical determinants of obesity”.

Professor John Dixon, Head of Clinical Obesity Research at Baker Heart and Diabetes Institute, said recognition of obesity as a chronic disease was an “enormous turning point” in the efforts to tackle obesity.

“We are now saying [that obesity is] a big problem and we are not going to fix it by blaming a group of people who have it. There are plenty of diseases where very specific lifestyle behaviour causes terrible disease, like smoking, but we get on and treat these people. And yet, there is one group we don’t treat. If we can’t, as a nation, take this on as a health catastrophe unfolding in front of us … we are in trouble.”

Professor Dixon said stigma around obesity remained widespread and was often perpetuated by health professionals.

“Health professionals, particularly medical professionals, are some of the most biased groups against obesity,” he said.

He also levelled criticism at medical organisations in Australia, particularly the Australian Medical Association (AMA), for their reluctance to recognise obesity as a disease.

“If we change the conversation and say this is a serious disease – it is a catastrophe driving heart disease, diabetes and cancer in our community – then we can make steps toward understanding and solving the problem of prevention and management,” Professor Dixon said.

He said bariatric surgery saved lives and money, and yet only 1000 procedures were conducted in Australian public hospitals annually, compared with 22 000 procedures in private hospitals.

“The evidence behind [bariatric] surgery is almost greater than any other surgery we do today – it improves quality of life and gets people back to work, and effectively treats obesity-related risks and complications, so why don’t we use it?” he asked.

Medications shown to be effective for weight loss – phentermine, liraglutide, orlistat, and topiramate (off-label) – were also available in Australia, Professor Dixon said, but were not funded on the Pharmaceutical Benefits Scheme and were not widely used.

Dr Richard Kidd, Queensland GP and Chair of the AMA Council of General Practice, said the AMA’s 2016 position statement on obesity was ”99.5%” in alignment with The Lancet article.

“We have made it very clear that obesity demands a whole-of-society approach, requiring participation of governments and non-government organisations, the health and food industries, the media, employers, schools and community organisations,” Dr Kidd told MJA InSight. “It’s absolutely imperative that the response is strategic and coordinated, with the setting of specific national goals, like we do around the road toll.”

Dr Kidd said the AMA’s decision not to recognise obesity as a disease in its position statement was taken after widespread consultation, and reflected the fact that the whole of the medical profession was yet to agree on this matter.

“The main issue is that obesity is something that we have to tackle head-on, it requires a multifaceted approach and we need to look at every aspect of how we live,” Dr Kidd said, adding that he, personally, would be comfortable with adopting the disease label. “[The AMA] acknowledges that [recognising obesity as a disease] might help get us there a bit faster in terms of funding and focus, but, right now, whether we call it a disease or not, obesity is the number one problem.”

Professor Louise Baur, paediatrician and Professor of Child and Adolescent Health at the University of Sydney, applauded The Lancet article.

“I love it. It ticks all of the boxes,” she said. “Health systems in Australia have responded more slowly than is needed [to the growing prevalence of obesity].”

Professor Baur agreed that bariatric surgery services were not adequately resourced in Australia, nor were secondary and tertiary services.

“It’s a chronic disease in the health system. You need comprehensive, universal health coverage and at the moment in Australia, if you need bariatric surgery, it’s much easier to access this in the private, rather than the public, system and that’s a form of institutional stigma.”

Professor Baur said in Australia one in four school-aged children and one in five pre-schoolers had overweight or obesity, and a wide range of measures were needed to turn around this [unacceptable] prevalence. While the data were less clear, obesity rates were also concerning in adolescent and young adults, she said.

“We have been too quick to focus right down near the individual – the kids, the families, the schools, the early childhood centres – and it’s really important to do so, but we have forgotten the upstream issues,” she said, adding that this was the case for all age groups.

“Of course, it’s appropriate to help families to make as healthy a choice as possible, but if we are making those choices very difficult because they live in an environment where there is rampant food marketing, there is no walkability, there is no pedestrian safety … then we are not dealing with the factors that actually cause the problems in the first place.”

Professor Baur pointed to a narrative review recently published by the MJA, of which she was a co-author, that outlined a suite of approaches to paediatric obesity in Australia, including the use of “appropriate language” to reduce stigma attached to the condition.

The narrative review authors wrote that words such as “unhealthy weight” or “BMI” should be preferred to words such as “extremely obese” or “fat” which could be perceived as stigmatising and blaming. The authors also highlighted the importance of creating safe and welcoming practice environments and adopting an empathetic approach to behaviour change counselling.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.