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Time To Change The Obesity Narrative

This week, I once again presented on the need for recognising obesity as a chronic disease at the annual European Society for the Study of Obesity Collaborating Centres for Obesity (EASO-COMs) in Leipzig, Germany.

Coincidently, The Lancet this week also published a commentary (of which I am a co-author) on the urgent need to change the obesity “narrative”.

So far, the prevailing obesity “narrative” is that this is a condition largely caused by people’s lifestyle “choices” primarily pertaining to eating too much and not moving enough, and that this condition can therefore be prevented and reversed simply by getting people to make better choices, or in other words, eating less and moving more.

As pointed out in the commentary, this “narrative” flies in the face of the overwhelming evidence that obesity is a rather complex multi-factorial heterogenous disorder, where long-term success of individual or population-based “lifestyle” interventions can be characterised as rather modest (and that is being rather generous).

This is not to say that public health measures targeting food intake and activity are not important – but these measures go well beyond “personal responsibility”

The established narrative on obesity relies on a simplistic causal model with language that generally places blame on individuals who bear sole responsibility for their obesity. This approach disregards the complex interplay between factors not within individuals’ control (eg, epigenetic, biological, psychosocial) and powerful wider environmental factors and activity by industry (eg, food availability and price, the built environment, manufacturers’ marketing, policies, culture) that underpin obesity. A siloed focus on individual responsibility leads to a failure to address these wider factors for which government policy can and should take a leading role. Potential health-systems solutions are also held back by insufficient understanding of obesity as a chronic disease and of the necessary integration across specialties.

It is also important to recognise that the prevailing “lifestyle” narrative plays a major role in the issue of weight-bias and discrimination:

Behind every obesity statistic are real people living with obesity. The prevailing narrative wrongly portrays people with obesity in negative terms as “guilty” of obesity through “weakness” and “lack of willpower”, succumbing to the siren call of fast and other poor food choices. This narrative leads to stigmatisation, discrimination—including in health services, employment, and education—and undermines individual agency.

Thus, it is time to change this narrative:

If the narrative is instead reframed around individuals at risk of or living with obesity as protagonists with agency who operate within physiological limitations and a much larger obesogenic environment over which their control is limited, then a better, more accurate story can be told.

This new narrative must incorporate four dimensions.

First, recognise that obesity requires multiple discrete actors and sectors to work together simultaneously through many entry points. Second, change the words and images used to portray obesity to shift blame away from individuals and towards upstream drivers. For example, photographs of anonymous or faceless people with obesity must be substituted with images of real people that foster respect and identification. Third, prioritise childhood obesity and the growing burden of obesity in low-income settings. Rights-based policy approaches that address inequalities and social and physical determinants of obesity are particularly relevant. Finally, appreciate that obesity is a chronic disease within the health system, with both its prevention and management embedded within calls for effective and comprehensive universal health coverage globally.

Following this line of reasoning we argue that,

Shifting to a human-focused narrative that encompasses this vulnerability and complexity will require effort and commitment across many sectors. We call on all affected by or concerned with obesity to come together with a common sense of purpose and shared accountability for building this new narrative and a more comprehensive response to obesity.

Not discussed in this paper (largely due to space limitation), is my pet peeve, that we also need a new non-anthropometric definition of obesity – one that relies on actual health measures rather than just scales and measuring tapes. As we move to a “disease” definition of obesity, we need to ensure that we are not mis-labeling healthy individuals as “diseased” just because they happen to exceed a certain body weight, as well as the corollary, mis-labeling individuals who may stand to benefit from obesity treatments as not having obesity just because they fall below an arbitrary BMI cutoff.

Leipzig, Germany

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