Rethinking the public health approach to obesity

In July 2019, Cancer Research UK (CRUK) launched yet another anti-obesity campaign. Plastered on billboards and public transport services in Britain, CRUK’s campaign warned: ‘Obesity is a cause of cancer too. Like smoking, obesity puts millions of adults at greater risk of cancer.’ Intentionally designed to look like the front of a cigarette packet, the campaign implies that people with obesity need to give up junk food if they want to minimise their cancer risk. Just like smokers need to give up cigarettes. This message is reportedly backed by research showing that excess fat is associated with an increased risk of developing 13 types of cancer, including bowel, kidney and liver cancer, as well as breast cancer in post-menopausal women (Bhaskaran et al., 2014; Kyrgiou et al., 2017). The purpose of the campaign is to raise awareness among the public about the dangers of obesity, encourage people to lose weight, and push policy makers to double their efforts in addressing the ‘obesity epidemic’.  

Since its launch CRUK has received numerous complaints regarding their campaign. Among critics of their approach are health professionals, researchers, size acceptance activists, and those who have experienced or witnessed the devastating effects of eating disorders. Collectively, these groups have asserted that the campaign shames people with larger bodies and fuels weight stigma. Critically, they have suggested that the stigma elicited by this campaign will harm people with larger bodies (or body image issues) without having the intended positive health effects (e.g., an increase in physical activity or healthy eating). Instead, many health professionals and academics warn that this approach may reduce engagement in healthy behaviour, increase mental health issues, and even cause weight gain. In sum, the complainants argue that anti-obesity campaigns that aim to shame higher-weight people into losing weight – like the one released by CRUK – are likely to be counterproductive (in terms of weight), and harmful (in terms of health). While CRUK has dismissed these complaints, the evidence suggests that these concerns are actually well founded.

Anti-obesity campaigns are designed based on three assumptions: 

1. Weight is a reliable indicator of health 

2. Weight is fully within individual control 

3. Stigmatising people with obesity will motivate them to lose weight 

Let us explore the evidence for each of these assumptions. 

Assumption #1: Does weight equal health?

Weight is associated with a number of health outcomes. For example, excess weight has been linked to an increased risk of developing cardiovascular disease, type II diabetes, some cancers, and kidney disease (Bhaskaran et al., 2014). The key word here however is ‘associated’. While there is much evidence that weight is somehow associated with various health risks, this evidence does not tell us much about the causal direction of these effects. Therefore, although it is often assumed that weight gain leads to poorer health, it is possible that poor health may actually cause weight gain. Further, while some research has found that people with overweight or obesity have a higher risk of all-cause mortality, other research has found that these people actually appear to have a lower risk (Lewis et al., 2009). This conflicting evidence suggests that larger bodies are not always unhealthy. In fact, there is substantial evidence that people with obesity can still be healthy if they eat a balanced diet and exercise regularly (Fogelholm, 2010). What’s more, some research suggests that weight loss may be just as harmful to our health as weight gain. For example, one study found that, regardless of initial BMI, the risk of all-cause mortality for people with diabetes was 1.86 times higher if they lost 10 per cent or more of their weight over a two year period, relative to those who maintained their weight (Kim et al., 2019). A review by Montani and colleagues (2015) also found that fluctuations in weight due to dieting and subsequent weight regain were associated with an increased risk of cardiovascular disease, as these changes in weight put stress on the cardiovascular system.  

All this is to say that the relationship between weight and health is by no means 1:1 – just because someone is overweight doesn’t necessarily mean they are unhealthy. 

Assumption #2: Is weight within the individual’s control? 

Around the same time that CRUK launched their campaign, the British Psychological Society released a report explaining that obesity is caused by a complex interaction between biological, psychological, social, and environmental factors. For example, our genetics; experiences of stress, adversity and trauma; the availability of nutritious foods and safe spaces to exercise; and our mental health, are just some of the factors that contribute to how much we weigh and our risk of developing obesity. In short, while maintaining a balanced diet and being physically active is beneficial to health, there are many predictors of obesity risk that are outside our control. 

In spite of this, weight is often perceived as something that can be largely controlled by the individual, usually through diet and exercise (Diedrichs & Puhl, 2016). As a result, the presence of excess fat is seen as evidence of gluttony and a general failure to manage one’s weight (and therefore one’s health). Therefore, weight is not only seen as an indication of someone’s health, but also their moral character. Decades of research has found that higher-weight individuals are negatively stereotyped as being lazy, incompetent, unmotivated, overindulgent, and lacking in self-control – qualities that we don’t value as a society (Major, Tomiyama, & Hunger, 2017). These beliefs about weight and people with larger bodies has led higher-weight individuals to become the target of weight-based stigma and discrimination. This brings us to our third assumption.  

Assumption #3: Does stigmatising larger-bodied people motivate them lose weight? 

Having a stigmatised identity – in this case, living in a larger body – has implications for health beyond that of one’s actual weight. In 2018 The Psychologist published a special feature on a growing body of research called the ‘social cure’ (Haslam, Jetten, Cruwys, Dingle, & Haslam, 2018). This research has found time and time again that our social groups have a profound impact on our health and wellbeing. Belonging to social groups that are positive, supportive, and valued is predictive of better mental and physical health. However, our social groups can have a detrimental effect on our health if they are disadvantaged, stigmatised, and devalued by society – a phenomenon coined the ‘social curse’. This is because our group memberships form part of our sense of self, so that when a group we belong to is stigmatised and devalued, we as individuals also feel stigmatised and devalued.  

In line with this work, over two decades of research has found that exposure to weight-based stigma is associated with poorer physical and psychological health (Hatzenbuehler, Keyes, & Hasin, 2009; Tomiyama, 2019; Vartanian & Shaprow, 2008; Weiss, et al., 2007; Yoon, et al., 2019). 

People who are exposed to weight stigma:

• Experience increased levels of stress, depression and anxiety
• Are more likely to engage in disordered eating behaviours
• Feel like they are unable to manage their weight
• Are less motivated to exercise and maintain a healthy diet 
• Are more likely to gain weight over time

So does weight stigma motivate weight loss? In sum, the answer is a definitive no, weight stigma does not motivate people to engage in healthy behaviours and it does not lead to weight loss. It actually does the complete opposite: weight stigma poses a serious threat to health and is a key barrier to reducing and preventing obesity. In light of this evidence it is perhaps unsurprising that as the prevalence of weight stigma has increased, so too has the prevalence of obesity (Andreyeva, Puhl, & Brownell, 2008; World Health Organization, 2018).  

Stigma is an established public health tool

Despite the evidence that weight stigma is harmful to health and ineffective at encouraging weight loss, obesity campaigns regularly use weight stigma in an effort to motivate positive behaviour change. In addition to CRUK’s recent campaign, some other examples include Australia’s national Measure Up campaign that was launched in 2008, and the controversial childhood obesity campaign launched by Strong4Life in Georgia, USA in 2012. The use of weight stigma in obesity campaigns is often justified by drawing parallels between smoking and obesity. The argument here is that stigmatising smoking was effective at reducing smoking rates, and thus stigmatising obesity should also be effective in reducing obesity rates. This argument was made in 2019 by American talk show host Bill Maher, who called for fat shaming to ‘make a comeback’ and stated that ‘some amount of shame is good. We shamed people out of smoking… Shame is the first step in reform’. However, it’s vital that public health strategies are based on empirical evidence. While stigma may work to discourage some behaviours, the evidence just does not support its use as an effective public health strategy for addressing obesity. 

A new public health approach

So how do we get people to make positive behaviour changes to improve their health without making them feel ashamed of their bodies? A weight-neutral approach may be the answer. Weight-neutral approaches like Health at Every Size (HAES®) are gaining support among health professionals, including dieticians, psychologists and general practitioners (Hunger, Smith, & Tomiyama, 2020). These approaches have moved away from weight as an indicator of health. Instead, they encourage healthy eating behaviours and enjoyable physical activity, without prioritising weight-loss as a goal or treating weight as an indicator of health.

Although this is a fairly new area of research, the evidence suggests that a weight-neutral approach may be a promising way forward. In particular, a review of randomised controlled trials (the gold standard for testing intervention effectiveness) found that, compared to traditional weight-loss interventions, weight-neutral interventions led to greater improvements in blood pressure, disordered eating behaviour, self-esteem and depression. Weight-neutral interventions were also as effective as weight-loss interventions when it came to improvements in cholesterol, blood glucose, and other biochemical markers of health (Clifford et al., 2015). These findings are particularly important in light of evidence that neither interventions led to significant changes in weight, challenging the notion that shifting the focus away from weight(-loss) may lead to weight gain and poorer health. 

It appears then that weight-neutral interventions may be a more effective approach to improving people’s health than traditional weight-loss interventions, with the added advantage that they significantly improve psychological well-being at the same time. The question is whether these positive effects can be harnessed in public health campaigns. That is, are weight-neutral health campaigns more effective at promoting better health and well-being, in comparison to the stigmatising obesity messages we are typically exposed to? Initial studies suggest that campaigns that avoid mentioning weight, use non-stigmatising imagery, and provide concrete suggestions for positive behaviour change (e.g., eating more fruits and vegetables) are received more positively by the public (Puhl, Peterson, & Luedicke, 2013), and are perceived to be more motivating (Pearl, Dovidio, & Puhl, 2015; Puhl, Luedicke, & Peterson, 2013). However, at the moment, it is unclear whether they also lead to the uptake of a healthy or healthier lifestyle. 

We need to ask whether shaming people into losing weight is doing more harm than good. If we want to encourage and enable people to lead healthy and happy lives, free of disease and illness, the evidence so far suggests that stigmatising people because of their weight is not going to help us achieve this goal. Although it is early days, weight-neutral messages that promote healthy, positive lifestyle changes may be a more promising way forward. As we begin a new decade, let’s learn from the past, listen to the empirical evidence, and find a more effective way to encourage everyone to lead healthier and happier lives. 

- Joanne A. Rathbone is a PhD Candidate in the School of Psychology, University of Queensland

- Professor Jolanda Jetten is ARC Laureate Fellow and Professor of Social Psychology, FASSA, in the School of Psychology, University of Queensland

- Associate Professor Fiona Kate Barlow is an Australian Research Council Future Fellow and Director of the Centre for Research in Social Psychology in the School of Psychology, University of Queensland

- Jasmine Russell is a BComm/BA(Hons)(Psychology) Graduate at the University of Queensland

Editor's note: Originally posted online on 15 May 2020.

References

Andreyeva, T., Puhl, R. M., & Brownell, K. D. (2008). Changes in perceived weight discrimination among Americans, 1995–1996 through 2004–2006. Obesity, 16(5), 1129-1134. doi: 10.1038/oby.2008.35

Bhaskaran, K., Douglas, I., Forbes, H., dos-Santos-Silva, I., Leon, D. A., & Smeeth, L. (2014). Body-mass index and risk of 22 specific cancers: A population-based cohort study of 5.24 million UK adults. The Lancet, 384(9945), 755-765. doi: 10.1016/S0140-6736(14)60892-8

Clifford, D., Ozier, A., Bundros, J., Moore, J., Kreiser, A., & Morris, M. N. (2015). Impact of non-diet approaches on attitudes, behaviors, and health outcomes: A systematic review. Journal of Nutrition Education and Behavior, 47(2), 143-155.e141. doi: 10.1016/j.jneb.2014.12.002

Diedrichs, P. C., & Puhl, R. (2016). Weight bias: Prejudice and discrimination toward overweight and obese people. In C. G. Sibley & F. K. Barlow (Eds.), The Cambridge Handbook of the Psychology of Prejudice(pp. 392-412). Cambridge: Cambridge University Press.

Fogelholm, M. (2010). Physical activity, fitness and fatness: relations to mortality, morbidity and disease risk factors. A systematic review. Obesity Reviews, 11(3), 202-221. doi: 10.1111/j.1467-789X.2009.00653.x

Gillison, F. (2019). Psychological perspectives on obesity: Addressing policy, practice and research priorities. Retrieved from British Psychological Society: 

Haslam, C., Jetten, J., Cruwys, T., Dingle, G. A., & Haslam, S. A. (2018). The new psychology of health : Unlocking the social cure. New York: Routledge.

Hatzenbuehler, M. L., Keyes, K. M., & Hasin, D. S. (2009). Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population. Obesity, 17(11), 2033-2039. doi: 10.1038/oby.2009.131

Hunger, J. M., Smith, J. P., & Tomiyama, A. J. (2020). An evidence-based rationale for adopting weight-inclusive health policy. Social Issues and Policy Review, 14(1), 73-107. doi: 10.1111/sipr.12062

Kim, M. K., Han, K., Koh, E. S., Kim, E. S., Lee, M.-K., Nam, G. E., & Kwon, H.-S. (2019). Weight change and mortality and cardiovascular outcomes in patients with new-onset diabetes mellitus: A nationwide cohort study. Cardiovascular Diabetology, 18(1), 36. doi: 10.1186/s12933-019-0838-9

Kyrgiou, M., Kalliala, I., Markozannes, G., Gunter, M. J., Paraskevaidis, E., Gabra, H., . . . Tsilidis, K. K. (2017). Adiposity and cancer at major anatomical sites: Umbrella review of the literature. The BMJ, 356, j477. doi: 10.1136/bmj.j477

Lewis, E. C., McTigue, M. K., Burke, E. L., Poirier, H. P., Eckel, V. R., Howard, B. B., . . . Pi-Sunyer, X. F. (2009). Mortality, health outcomes, and Body Mass Index in the overweight range: A science advisory from the American Heart Association. Circulation, 119(25), 3263-3271. doi: 10.1161/CIRCULATIONAHA.109.192574

Maher, B. (Writer). (2019). New rule: The fudge report [Television series episode]. In B. Maher (Producer), Real Time with Bill Maher. Los Angeles, CA: HBO.

Major, B., Tomiyama, A. J., & Hunger, J. M. (2017). The negative and bidirectional effects of weight stigma on health. In B. Major, J. F. Dovidio, & B. G. Link (Eds.), The Oxford handbook of stigma, discrimination, and health. New York NY: Oxford University Press.

Montani, J.-P., Schutz, Y., & Dulloo, A. G. (2015). Dieting and weight cycling as risk factors for cardiometabolic diseases: Who is really at risk? Obesity Reviews, 16(S1), 7-18. doi: 10.1111/obr.12251

Pearl, R. L., Dovidio, J. F., & Puhl, R. M. (2015). Visual portrayals of obesity in health media: Promoting exercise without perpetuating weight bias. Health Education Research, 30(4), 580-590. doi: 10.1093/her/cyv025

Puhl, R., Luedicke, J., & Peterson, J. L. (2013). Public reactions to obesity-related health campaigns: A randomized controlled trial. American Journal of Preventive Medicine, 45(1), 36-48. doi: 10.1016/j.amepre.2013.02.010

Puhl, R., Peterson, J. L., & Luedicke, J. (2013). Fighting obesity or obese persons? Public perceptions of obesity-related health messages. International Journal of Obesity, 37(6), 774-782. doi: 10.1038/ijo.2012.156

Tomiyama, A. J. (2019). Stress and obesity. Annual Review of Psychology, 70, 703-718. doi: 10.1146/annurev-psych-010418-102936

Vartanian, L. R., & Shaprow, J. G. (2008). Effects of weight stigma on exercise motivation and behavior. Journal of Health Psychology, 13(1), 131-138. doi: 10.1177/1359105307084318

Weiss, E. C., Galuska, D. A., Khan, L. K., Gillespie, C., & Serdula, M. K. (2007). Weight regain in U.S. adults who experienced substantial weight loss, 1999–2002. American Journal of Preventive Medicine, 33(1), 34-40. doi: 10.1016/j.amepre.2007.02.040

World Health Organization. (2018). Obesity and overweight.   Retrieved from https://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight

Yoon, C., Mason, S. M., Hooper, L., Eisenberg, M. E., & Neumark-Sztainer, D. (2019). Disordered eating behaviors and 15-year trajectories in body mass index: Findings from Project Eating and Activity in Teens and Young Adults (EAT). Journal of Adolescent Health, 1-8. doi: 10.1016/j.jadohealth.2019.08.012