The war on obesity: a social determinant of health more

Point of View The war on obesity: a social determinant of health Lily O’Hara and Jane Gregg Introduction In Australia we have developed an obsession with body size. The issue of increasing weight in Australia and many other parts of the world has been the subject of intense scientific, political and media attention.1-6 Weight is now presented to the public as an independent cause of disease and death, and terms such as ‘epidemic’ and ‘obesity’ are commonplace. In the 10 years from 1996 to 2005, the number of times the term ‘obesity’ was mentioned in a newspaper article in Australia or New Zealand increased from 40 to 2,734 (see Figure 1). In 1996, there was one mention every nine days; in 2005 there were 7.5 mentions per day.7 Obsession with body fat was once a cultural issue. In recent years, the health sector has increasingly contributed to the cultural definition of the ‘ideal’ lean body.6,8 ‘Excess’ fat is not just undesirable to look at these days; it is routinely described as being bad for your health.5 The ‘war on obesity’ is a broad, health-based set of policies and programs designed to problematise ‘excess’ body fat and create solutions to the ‘problem’. The framing of fatness as central to health status is described as the weight-centred health paradigm, the tenets of which are described in Table 1.9-11 There is a substantial body of literature that claims to demonstrate the harmful effects of ‘excess’ body fat. More recent critiques of ‘obesity prevention’ programs have highlighted the importance of focusing on environmental changes rather than individuals due in part to the risk of harmful consequences associated with individualistic, victim-blaming approaches.4,12 Beyond this, numerous authors have challenged the evidence on which the current emphasis on ‘overweight’ and ‘obesity’ is founded.10,11,13-16 Furthermore, there are suggestions that the very act of framing body weight as the source of health problems – known as the weight-centred health paradigm – is in itself a harmful approach.10,17,18 A recent article in the Californian Journal of Health Promotion called ‘The O Word: Why the Focus on Obesity is Harmful to Community Health’, proposed that focusing on fat people is not helping to address the broader social and economic issues that have an impact on health and well-being.18 The authors discussed strategies to remove the focus on weight and in doing so reduce the harm to individuals and communities. The editors of the New England Journal of Medicine were so concerned about the weight-centred health paradigm that they warned: “Until we have better data about the risks of being Abstract Issue addressed: The weight-centred health paradigm is an important contributor to the broader cultural paradigm in which corpulence is eschewed in favour of leanness. The desirability to reduce body fat or weight or to prevent gaining ‘excess’ fat is driven by both aesthetic and health ideals. The ‘war on obesity’ is a broad healthbased set of policies and programs designed to problematise ‘excess’ body fat and create solutions to the ‘problem’. There is a substantial body of literature that claims to demonstrate the harmful effects of ‘excess’ body fat. Recent critiques of ‘obesity prevention’ programs have highlighted the importance of focusing on environmental changes rather than individuals due in part to the risk of harmful consequences associated with individualistic, victim-blaming approaches. Beyond this, there are suggestions that framing body weight as the source of health problems – known as the weight-centred health paradigm – is in itself a harmful approach. The range of harms includes body dissatisfaction, dieting, disordered eating, discrimination and death. Health promotion policies and programs that operate within the weight-centred paradigm have the potential to have a negative impact on the health and well-being of individuals and communities. Key words: Weight-centred health paradigm, heath at every size paradigm, iatrogenic effects, harm. Health Promotion Journal of Australia 2006;17:260-3 So what? Health promotion practitioners have a responsibility to do no harm to people they work with. The ‘war on obesity’ is actually a war on fat people, and the casualties from such a war are felt both personally and by the community. Health promotion practitioners working within the weight-centred health paradigm need to be aware of the evidence that demonstrates the harms associated with working in this paradigm. There is a need for a more healthpromoting and compassionate approach to people’s health that is based on evidence of effectiveness. The ‘health at every size’ paradigm offers such an alternative. 260 Health Promotion Journal of Australia 2006 : 17 (3) Point of View The war on obesity as a social determinant of health overweight and the benefits and risks of trying to lose weight, we should remember that the cure for obesity may be worse than the condition.”19 The first ethical principle that all health professionals must follow is to do no harm. 20 As questions are raised about the consequences of operating within the weight-centred health paradigm it becomes critical to review the literature to ascertain the range of potential harms that may inadvertently result from health promotion efforts designed to improve health through weight management. Figure 1: Number of times ‘obesity’ was mentioned in Australian and New Zealand newspaper articles, 1996-2005. Weight-centred health paradigm The weight-centred health paradigm, with its focus on acceptable levels of body fat, mirrors precisely the broader social and cultural ‘ideals’ about body size and shape. The weightcentred health paradigm therefore makes a significant contribution to the broader range of effects that result from focusing on an ‘ideal’ or ‘healthy’ body weight. However, there is concern emerging in the literature about the unintended harmful effects of health promotion programs that focus on body weight. The iatrogenic effects include body dissatisfaction, dieting, disordered eating, discrimination and death.9,21-61 Numerous studies have demonstrated that obsessing about weight is psychologically harmful.21,22 Dissatisfaction with one’s body is extremely prevalent in Western cultures.23-26 It is more common for young women to be dissatisfied with their bodies than not, and young men are also expressing higher levels of body dissatisfaction.27 Children as young as six years of age are expressing unhappiness with the way their body looks.9 Media messages portraying the lean ideal for men and women are associated with increased body dissatisfaction.28-33 Body dissatisfaction in adolescents is predictive of a range of unhealthy weight control measures over a five-year period.34 As a result of dissatisfaction, the majority of Western women are dieting to lose weight.35 Most fat women started seriously dieting by 14 years of age.36 Dieting is a significant cause of mental distraction, and people who are dieting are less able to concentrate or learn effectively.37 While dieting may lead to short-term weight loss, over the medium and long term 95% of people regain all the lost weight.38 Dieting by adolescents and preadolescents is predictive of future weight gain, irrespective of initial body weight.39,40 Failed diets usually result in higher weights than before the diet, and the consequence of such failure includes significant physical and emotional harm.38 Weight fluctuation brought about by constant dieting, termed the ‘yo-yo syndrome’, is associated with higher rates of death from cardiovascular disease than heavier but stable weight.41 The most severe forms of disordered eating such as anorexia nervosa and bulimia nervosa affect between 1% and 3% of the general population respectively, with disproportionate rates among young women.42 Disordered eating behaviours, including fasting, fad dieting, use of diet pills, diuretics or laxatives, vomiting and smoking for appetite control, are practised by almost 60% of American Year 9 girls and 30% of Year 9 boys.43 Disordered eating also results in greater weight gain in the long term,39 as well as an increase in physiological risk factors for disease such as hypertension.40,41 Discrimination based on body size is a widespread phenomenon.44 Evidence of systematic bias against people of higher-than-average body weights has been found in health workers, health promotion practitioners, doctors, nutritionists, coaches, employers, landlords and teachers, and in all settings including hospitals and general practices, workplaces, schools and universities.44-56 Deaths resulting from losing and regaining large amounts of weight have been consistently linked with increased mortality rates from cardiovascular disease.38,57 Deaths from anorexia nervosa are 12 times higher than for any other cause of death for females aged 15-24 years, and 200 times greater than the suicide rate for the general population.9 The short-term death rate from gastric bypass surgery is one death in 50-100 surgeries, and from adjustable lap band surgery is one death in 3,000 surgeries. Although there are no long- Table 1: Tenets of the weight-centred health paradigm. 1. Weight is mostly volitional and within the control of the individual. 2. Weight is caused by a simple imbalance between an individual’s energy intake and energy usage. 3. Current health status of the individual can be assessed and future health status can be predicted based on BMI categories. 4. Excess weight causes disease and premature death. 5. Methods for successful and sustained weight loss are well known to science and include focusing specifically on changing eating and physical activity patterns. 6. Losing weight to achieve ‘healthy weight’ status will result in better health. Health Promotion Journal of Australia 2006 : 17 (3) 261 O’Hara and Gregg Point of View term controlled studies of weight loss surgery, there has been an increase in the reporting of nutritional deficiencies that were thought to belong in the past, such as berri berri and its associated permanent neurological damage.58 A small but increasing number of young people have been reported as dying from suicide as a direct result of bullying about body size.59 Adolescents who experience weight-based teasing and harassment are more likely to think about and attempt suicide.60 Studies that have examined changes in the prevalence of harms have demonstrated that they have worsened significantly. For example, stigmatisation of ‘obesity’ by children increased by 41% over the 40-year period between 1961 and 2001.61 body weight include dissatisfaction, dieting, disordered eating, discrimination, and death. The war on obesity is actually a war on fat people, and the casualties from such a war are felt both personally and by the community. Health promotion policies and programs that operate within the weight-centred paradigm have the potential to have a negative impact on the health and well-being of individuals and communities. There is a need for a more health-promoting and compassionate approach to people’s health that is based on evidence of effectiveness. The HAES paradigm offers a viable alternative health promotion approach. References 1. Queensland Health [home page on the Internet]. Brisbane (AUST): Queensland Government; 2005 [cited 28 October 2005]. Smart State Healthy Weight for Children and Young People Action Plan 2005-2008. Available from: www.health.qld.gov.au/phs/Documents/shpu/29187a.pdf 2. Queensland Public Health Forum. Eat Well Queensland 2002-2012: Smart Eating for a Healthier State. Brisbane (AUST): Queensland Health; 2002. 3. Swinburn B, Egger G. The runaway weight gain train: too many accelerators, not enough brakes. Br Med J. 2004;329:736-9. 4. Swinburn B, Kumanyika S. Obesity Prevention: A proposed framework for translating evidence into action. Proceedings of The International Obesity Task Force Workshop; 2004 April; Melbourne, Australia. 5. World Health Organization. Global Strategy on Diet, Physical Activity and Health. Geneva (CHE): World Health Assembly; 2004. 6. Stearns P Fat History: Bodies and Beauty in the Modern West. 2nd ed. New York . (NY): New York University Press; 2002. 7. O’Hara L. Australians to become the biggest in the world within the next ten years. Health at Every Size. 2006;19(4):235-47. 8. Paquette M-C, Raine K. Sociocultural context of women’s body image. Soc Sci Med. 2004;59(5):1047-58. 9. Campos P The Obesity Myth. New York (NY): Gotham Books; 2004. . 10. Robison J. The “Obesity Epidemic”: An alternative perspective. Healthy Weight J. 2003;17(1):1-3. 11. Gaesser GA. Big Fat Lies. Carlsbad (CA): Gurze Books; 2002. 12. Catford J. Promoting healthy weight – the new environmental frontier. Health Promot Int. 2003;18(1):1-4. 13. Campos P Saguy A, Ernsberger P Oliver E, Gaesser G. The epidemiology of , , overweight and obesity: public health crisis or moral panic? Int J Epidemiol. 2006;35(1):55-60. 14. Gard M, Wright J. The Obesity Epidemic: Science, Morality and Ideology. Abingdon (UK): Routledge; 2005. 15. Oliver JE, Lee T. Public opinion and the politics of obesity in America. J Health Polit Policy Law. 2005;30(5):923-54. Health at every size paradigm ‘Health at every size’ (HAES) is a new paradigm that moves the focus away from weight and towards health for all people, irrespective of their body size or weight. Table 2 describes the tenets of the HAES paradigm.62 There is a small body of evidence demonstrating the health benefits of health promotion programs that use the HAES approach. Outcomes from these studies include improvements in the following health indicators: mortality,63-65 morbidity,63 physiological factors such as blood pressure and cholesterol levels, 21,63 psychological factors such as self-esteem, 26 depression,35 body image,43 and behaviours such as restrained eating66 and sustained physical activity.21 Conclusion The framing of body weight is one of the most dominant health discourses of our times. This paradigm is part of a broader social and cultural paradigm in which ‘excess’ body fat is regarded as quite literally a fate worse than death. The literature revealed that the range of harms associated with the problematising of Table 2: Tenets of the ‘Health at every size’ paradigm. Health at every size supports: 1. Health enhancement – attention to emotional, physical, psychological, social and spiritual well-being, without focus on weight loss or achieving a specific ‘ideal weight’. 2. Size and self-acceptance – respect and appreciation for the rich diversity of body shapes and sizes (including one’s own), rather than the pursuit of an idealised weight or shape. 3. The pleasure of eating well – encouraging eating based on internal cues of hunger, satiety, pleasure, appetite and individual nutritional needs, rather than on external food plans or diets for weight loss. 4. The joy of movement – encouraging appropriate, enjoyable, life-enhancing physical activity, rather than following a specific routine of regimented exercise for the primary purpose of weight loss. Health at every size does not support: 1. Ideal weight – the indiscriminate use of the standardised ‘ideal’ weight category as a measure of a person’s health status. 2. Weight loss – dieting, drugs, programs, products or surgery for the primary purpose of weight loss. 3. Body assumptions and bias – that a person’s body size, weight or body mass index is evidence of a particular way of eating, physical activity level, personality, psychological state, moral character or health status. 4. Body size oppression – any form of oppression including exploitation, marginalisation, discrimination, powerlessness, cultural imperialism, harassment or violence against people based on their body image, body size or weight, and any approach to health, eating or exercise, the provision of products, services or amenities that perpetuates body size oppression. 262 Health Promotion Journal of Australia 2006 : 17 (3) Point of View The war on obesity as a social determinant of health 16. Robison J, Kline G. Surviving “risk factor frenzy”: the perils of incorrectly applying epidemiological research in health education and promotion. Internat Q Community Health Educ. 2002;21(1):83-100. 17. Solovay S. Tipping the Scales of Justice: Fighting Weight-based Discrimination. New York (NY): Prometheus Books; 2000. 18. Cohen L, Perales DP Steadman C. The O word: why the focus on obesity is , harmful to community health. Californian J Health Promotion. 2005;3(3): 154-61. 19. Kassirer J, Angell M. Losing weight – an ill-fated new year’s resolution. N Engl J Med. 1998;338(1):52-4. 20. O’Dea JA. Prevention of child obesity: ‘First, do no harm’. Health Educ Res. 2005;20(2):259-65. 21. Bacon L, Stern JS, Loan MDV, Keim NL. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005;105(6):929-36. 22. Bacon L, Keim NL, Van Loan MD, Derricote M, Gale B, Kazaks A, et al. Evaluating a ‘non-diet’ wellness intervention for improvement of metabolic fitness, psychological well-being and eating and activity behaviors. Int J Obes. 2002;26:854-65. 23. Botta R. Television images and adolescent girls’ body image disturbance. J Commun. 1999;49(2):22-41. 24. Cooper PJ, Taylor MJ, Cooper Z, Fairburn CG. The development and validation of the body shape questionnaire. Int J Eat Disord. 1987;6(4):485-94. 25. Friedman MA, Dixon AE, Brownell KD, Whisman MA, Wilfley DE. Marital status, marital satisfaction, and body image dissatisfaction. Int J Eat Disord. 1999;26:81-5. 26. Paxton S. Body image dissatisfaction, extreme weight loss behaviours: suitable targets for public health concern? Health Promot J Australia. 2000;10(1):15-9. 27. Rozin P Trachtenberg S, Cohen AB. Stability of body image and body image , dissatisfaction in American college students over about the last 15 years. Appetite. 2001;37:245-8. 28. Field AE, Cheung L, Wolf AM, Herzog DB, Gortmaker SL, Colditz GA. Exposure to the mass media and weight concerns among girls. Pediatrics. 1999;103 (3): 1-5. 29. Field AE, Camargo CA Jr, Taylor CB, Berkey CS, Colditz GA. Relation of peer and media influences to the development of purging behaviors among preadolescent and adolescent girls. Arch Pediatr Adolesc Med. 1999;153(11):1184-9. 30. Field AE, Camargo CA, Taylor CB, Berkey CS, Roberts SB, Colditz GA. Peer, parent and media influences on the development of weight concerns and frequent dieting among preadolescent and adolescent girls and boys. Pediatrics. 2001;107(1): 54-60. 31. Groesz LM, Levine MP Murnen SK. The effects of experimental presentation of , thin media images on body satisfaction: a meta-analytic review. Int J Eat Disord. 2002;31:1-16. 32. McCabe MP Ricciardelli LA. Parent, peer and media influences on body image , and strategies to both increase and decrease body size among adolescents boys and girls. Adolescence. 2001;36(142):225-41. 33. Thompson JK, Heinberg LJ. The media’s influence on body image disturbance and eating disorders: we’ve reviled them, now can we rehabilitate them? J Social Issues. 1999;55(2):339-53. 34. Neumark-Sztainer D, Paxton SJ, Hannan PJ, Haines J, Story M. Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. J Adolesc Health. 2006;39(2):244-51. 35. Paxton S. Research Review of Body Image Programs: An Overview of Body Image Dissatisfaction Prevention Intervention. [Health promotion – evidence based health page on the Internet]. Melbourne (AUST): Victoria Department of Human Services and Health; 2002 [cited 28 October 2005]. Available from: www.health.vic.gov.au/healthpromotion/quality/body_image.htm 36. Ikeda J, Lyons P Schwartzman F, Mitchell R. Self-reported dieting experiences of , women with body mass indexes of 30 or more. J Am Diet Assoc. 2004;104(6): 972-4. 37. Shaw J, Tiggemann M. Dieting and working memory: Preoccupying cognitions and the role of the articulatory control process. Br J Soc Psychol. 2004;9(2):17585. 38. Ernsberger P Koletsky RJ. Prevention and treatment of obesity: weight cycling. , J Am Med Assoc. 1995;273(13):998-9. 39. Stice E, Cameron RP Killen JD, Hayward C, Taylor CB. Naturalistic weight, reduction efforts prospectively predict growth in relative weight and onset of obesity among female adolescents. J Consult Clin Psychol. 1999;67(6):967-74. 40. Field AE, Austin SB, Taylor CB, Malspies S, Rosner B, Rockett HR, et al. Relation between dieting and weight change among preadolescents and adolescents. Pediatrics. 2003;112(4):900-6. 41. Ernsberger P Koletsky RJ. Biomedical rationale for a wellness approach to obesity: , an alternative to a focus on weight loss. J Social Issues. 1999;55(2):221-60. 42. Neumark-Sztainer D, Hannan PJ. Weight-related behaviors among adolescent girls and boys: results from a national survey. Arch Pediatr Adolesc Med. 2000;154(6):569-77. 43. Croll J, Neumark-Sztainer D, Story M, Ireland M. Prevalence and risk and protective factors related to disordered eating behaviours among adolescents: relationship to gender and ethnicity. J Adolesc Health. 2002;31:166-75. 44. Brownell KD, Puhl R, Schwartz MB, Rudd L, editors. Weight Bias: Nature, Consequences and Remedies. New York (NY): The Guilford Press; 2005. 45. Chambliss HO, Finley CE, Blair SN. Attitudes toward obese individuals among exercise science students. Med Sci Sports Exerc. 2004;36(3):468-74. 46. Crandall CS. Do parents discriminate against their heavy-weight daughters? Pers Soc Psychol Bull. 1995;21(7):724-35. 47. Crandall CS, D’Anello S, Sakalli N, Lazarus E, Wieczorkowska G, Feather NT. An attribution-value model of prejudice: anti-fat attitudes in six nations. Pers Soc Psychol Bull. 2001;27(1):30-7. 48. Dittman M. Weighing in on fat bias. Monitor on Psychology. 2004;35(1):60. 49. Friedman JM. Modern science versus the stigma of obesity. Nat Med. 2004;10(6):563-9. 50. Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001;9(12): 788-805. 51. Roehling MV. Weight-based discrimination in employment: psychological and legal aspects. Personnel Psychology. 1999;52:969-1016. 52. Schwartz MB, Chambliss HON, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11(9): 1033-9. 53. Teachman BA, Brownell KD. Implicit anti-fat bias among health professionals: is anyone immune? Int J Obes. 2001;25:1525-31. 54. Zhang Q, Wang Y. Socioeconomic inequality of obesity in the United States: do gender, age, and ethnicity matter? Soc Sci Med. 2004;58(6):1171-80. 55. Pearce MJ, Boergers J, Prinstein MJ. Adolescent obesity, overt and relational peer victimization, and romantic relationships. Obes Res. 2002;10(5):386-93. 56. Pauley LL. Customer weight as a variable in salespersons’ response time. Br J Soc Clin Psychol. 1989;129:713-4. 57. Dyer AR, Stamler J, Greenland P Associations of weight change and weight . variability with cardiovascular and all-cause mortality in the Chicago Western Electric Company study. Am J Epidemiol. 2000;152(4):324-33. 58. Szwarc S. Hey, Feds, Weight a Minute ... TCS Daily [journal on the Internet]. Washington: Tech Central Station; 2004 Oct 26 [cited 2005 Jul 19]. Available from: http://www.techcentralstation.com/021005F.html 59. Wann M. Fat! So? Because You Don’t Have to Apologise for Your Size! Berkeley (CA): Ten Speed Press; 1998. 60. Eisenberg ME, Neumark-Sztainer D, Story M. Associations of weight-based teasing and emotional well-being among adolescents. Arch Pediatr Adolesc Med. 2003;157(8):733-8. 61. Latner JD, Stunkard AJ. Getting worse: The stigmatization of obese children. Obes Res. 2003;11(3):452-6. 62. Robison J. Health at every size: antidote for the “obesity epidemic”. Healthy Weight J. 2003;17(1):4-7. 63. Blair SN. Special issue on obesity, lifestyle and weight management. Obes Res. 2003;11:1S-2S. 64. Lee CD, Blair SN, Jackson AS. Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men. Am J Clin Nutr. 1999;69:373-80. 65. Wei M, Kampert JB, Barlow CE, Nichaman MZ, Gibbons LW, Paffenbarger RS Jr, et al. Relationship between low cardiorespiratory fitness and mortality in normalweight, overweight, and obese men. J Am Med Assoc. 1999;282:1547-53. 66. Ciliska D. Evaluation of two nondieting interventions for obese women. West J Nurs Res. 1998;20:119-35. Authors Lily O’Hara and Jane Gregg, Centre for Healthy Activities, Sport and Exercise, Faculty of Science, Health and Education, University of the Sunshine Coast, Queensland Correspondence Ms Lily O’Hara, Centre for Healthy Activities, Sport and Exercise, Faculty of Science, Health and Education, University of the Sunshine Coast, Sippy Downs, Queensland 4556. Tel: (07) 5430 2824; fax: (07) 5459 4639; e-mail: lohara@usc.edu.au Health Promotion Journal of Australia 2006 : 17 (3) 263