We Need To Change The Public-Health Narrative On ObesityWednesday, April 25, 2018
While at the level of the individual, clinicians are beginning to acknowledge the vast body of research now showing that “lifestyle” approaches to managing obesity (“eat-less move more”) result in minimal outcomes (3-5% sustainable weight loss at best), public health attempts to address the obesity epidemic continue to perpetuate the myth that obesity (and its prevention) is simply about getting people to eat better and move more (with very little evidence to show that such measures can be implemented at a population level to effect any noticeable change in obesity rates).
In an article I co-authored with Ximena Ramos-Salas, published in Current Obesity Reports, we provide an in-depth overview of current public health policies to address obesity in Canada and argue that the “narrative” underlying these policies is an important driver of weight-bias and discrimination and significantly hindering efforts to provide Canadians living with obesity better access to obesity prevention and treatment efforts.
As we state in the article (based on original research by Ramos-Salas and others),
“A critical review of Canadian obesity prevention policies and strategies revealed five prevailing narratives about obesity: “(1) childhood obesity threatens the health of future generations and must be prevented; (2) obesity can be prevented through healthy eating and physical activity; (3) obesity is an individual behavior problem; (4) achieving a healthy body weight should be a population health target; and (5) obesity is a risk factor for other chronic diseases not a disease in itself”. These narratives create the opportunity for Canadian obesity policy recommendations to focus mainly on individual-based healthy eating and physical activity interventions. By simplifying the causes of obesity as unhealthy eating and lack of physical activity, these policies may be contributing to the belief that obesity can be solely controlled through individual behaviors. This belief is a fundamental driver of weight bias.”
This “world-view” of obesity at the level of policy makers has a significant impact on the willingness and capacity of health systems to provide access to evidence-based obesity treatments to the nearly 7 million Canadian adults and children living with this chronic disease – in fact, the unwillingness to even consider obesity a chronic disease is a big part of the problem.
“..the conceptualization of obesity as a risk factor in public health policies has implications for government action, by prioritizing prevention over treatment strategies and potentially alienating Canadians who already have obesity. The review concludes that existing Canadian public health policies and strategies (a) are not sufficiently comprehensive (i.e., solely focused on prevention and mainly focused on children; exclude evidence-based management approaches; are not person-centered); (b) are based on reductionist obesity models (i.e., models that cast shame and blame on individuals by focusing on individuals’ responsibility for their weight); and (c) do not account for individual heterogeneity in body size and weight (i.e., generalize weight and health outcomes at the population level).”
In contrast we suggest that,
“Adopting a chronic disease framework for obesity would imply that both prevention and management strategies need to be implemented. Within this chronic disease context, public health should ensure that strategies do not have unintended consequences for individuals and populations, such as perpetuating weight bias. There is now sufficient evidence demonstrating that weight bias and obesity stigma are fundamental drivers of health inequalities. Public health has an opportunity to leverage existing health promotion frameworks such as the health for all policy framework and the global plan of action on social determinants of health to address weight bias and obesity stigma”.
Based on the analyses presented in this paper, we make the following recommendations:
Canadian provincial and territorial governments, employers, and the health insurance industry should officially adopt the position of the Canadian Medical Association and the World Health Organization that obesity is a chronic disease and orient their approach/resources accordingly.
Canadian provincial and territorial governments should recognize that weight bias and obesity stigma are significant barriers to helping people with obesity and enshrine rights in provincial/territorial human rights codes, workplace regulations, healthcare systems, and education policies.
In an era of people-centered health care, public health and health system decision makers should engage people with obesity in the development of policies and strategies. Having active participation of individuals with obesity can help change negative attitudes and beliefs about obesity and facilitate the development of compassionate and equitable health promotion strategies.
Employers should recognize and treat obesity as a chronic disease and provide coverage for evidence-based obesity treatments for their employees through health benefit plans.
Provincial and territorial governments should increase training for health professionals on obesity prevention and management.
Existing Canadian Clinical Practice Guidelines for the management and treatment of obesity in adults should be updated to reflect advances in obesity management and treatment in order to support the development of evidence-based programs and strategies by health systems, employers and health insurance companies.