Sizing up obesity
Healthcare Counselling and Psychotherapy Journal, January 2021

The pandemic has once again turned the spotlight on obesity. The Government’s response so far seems to be to drive the public towards quick-fix, weight-loss strategies that are often either ineffective or potentially harmful.¹

I would like to focus in this article on an alternative response, which neither ignores the health implications of obesity, nor proposes unworkable solutions that shame individuals into changing their diet. Instead, it offers a middle way – a compassionate perspective on an important public health issue.

Obesity is often catastrophised as a risk to personal health and a burden on the health service. The discourse about COVID-19 is no different, exhorting us to do something about our lifestyle, both for our own sake and to protect the NHS.

We are told, for example, that people of larger size with COVID-19 face a 113% higher risk of being taken to hospital and a 48% higher risk of death.² Vaccines already in routine use are also less effective on people with a higher body mass index (BMI), according to Danny Altman, Professor of Immunology at Imperial College London.³ So, we are advised that ‘bulky Britons’ are less likely to benefit from a coronavirus vaccine.

Fatness epidemic

Successive government initiatives have emerged over the years to save us from an epidemic of fatness. In July, the Government announced its latest strategy to tackle obesity, with a campaign to encourage weight loss. It also plans to put calorie labels on food in cafes, pubs and restaurants, impose a ban on junk food advertising on TV and online before 9pm and restrict buy-one-get-onefree promotions on food high in fat, sugar or salt.

At the launch of the campaign, Boris Johnson explained that he had ‘…wanted to lose weight for ages and ages’ and had been ‘way overweight’ when he was in intensive care with coronavirus.⁴ The Prime Minister told the nation that ‘…if you can get your weight down a bit and protect your health, you will also be protecting the NHS’.⁵

A great many people from across the social divides gained weight during the lockdown of spring 2020, blaming higher levels of snacking and greater alcohol consumption.^6,7 Some people did lose weight during the first lockdown,⁶ but I believe it had little to do with public health messages.

Perhaps people who lost weight ate out less and had more time to cook food at home. Maybe they had more time for exercise. I wonder also whether people who are able to manage their diet during lockdowns are wealthier and so able to afford healthy food?

Maybe they are financially secure enough to tolerate food waste and resist the two-for-one offers on junk food in their local supermarket. Perhaps, too, wealthier people are more likely to have access to pleasant places to exercise, such as a garden or a park.

The National Institute for Health and Care Excellence (NICE) issued its guidance on obesity identification, assessment and management in 2014.⁸ But a recent report, published in the British Medical Journal, raised questions over the extent and transparency of drug industry funding of patient organisations. The report found that: ‘Notably, patient organisations contributing to appraisals by NICE have widespread, and often not entirely transparent, financial relationships with drug companies.’⁹

A 2007 report¹⁰ from the Government Office for Science identified obesity as a complex biopsychosocial issue, but public health messages continue to target an individual’s diet and lifestyle, perhaps because these variables can be more readily influenced than the deeper causes of obesity, such as genes, the food supply and the built environment. Governments and their advisers target errant individuals, because it’s easier to blame them for being greedy, lazy, or too weak to resist temptation.

Obesity stigma

The outcome is a common belief that if we can’t lose weight – and keep it off – we lack responsibility, not only for our own health but for the wellbeing of society. Failure to change therefore becomes a moral issue, or a sign of a character deficiency.

The narrative of obesity contributes to the stigmatising of fatness in regards to both appearance and character. People of larger size experience this stigma in a variety of ways – medically, professionally and in their personal relationships – and it doesn’t help them lose weight.¹¹

People exposed to stigma are at risk of internalising it, resulting in low self-esteem, as well as poor self-efficacy, less willingness to exercise or to eat healthily, increased risk of substance abuse and higher levels of anxiety, shame and depression.

Shame can lead to desperation for weight loss, but desperation can also act as a negative motivator, making it less likely that weight-loss behaviour can be sustained. We all know people who lose weight successfully – over and over again – ending up in a place of learned helplessness.

In recent times, several anti-dieting movements have emerged to confront the problem of serial dieting and the obesity stigma. For example, Health at Every Size promotes intuitive eating and physical activity, not to lose weight but to enhance wellbeing. Body Positivity seeks to celebrate all sizes, shapes and appearance. Fat Activism promotes obesity as desirable, as a lifestyle choice and as a rebellion against slimness as an aesthetic ideal.

What these movements share is an insistence that dieting makes you fat and that a person can be both fat and fit. They claim that the health risks of being overweight are due to neglect and stigma on the part of health professionals and that cyclical weight change could make a person ill. The claims are enshrined in evidence,¹ but fiercely resisted by slimming organisations, which are heavily invested in getting our business, via good, bad and ugly strategies for losing weight.

Of course, dieters lose weight, but the weight loss is rarely sustained, as the body mounts an irresistible physiological defence against fat loss in a number of ways. These defences show up as increased appetite, especially for fattening food, easy weight gain and emotional effects. Few dieters maintain their loss over the course of 18 months and many engage in cyclical dieting attempts, ending up fatter than ever.¹²

The fat scares emerging during the pandemic have destabilised the anti-dieting and fat activism movements. Thanks to COVID-19, we can no longer convince ourselves that fatness isn’t important. The public once again is caught in the middle of competing arguments, perhaps knowing from experience that quick-fix solutions don’t work, but unsure what else can be done.

I believe that we need to step outside the current panic about obesity and COVID-19, to look more intelligently at the narratives about obesity. At the heart of this debate are real people, many wishing to lose weight for a variety of reasons. They might want to gain social approval, to be able to play soccer with a child without losing puff, to live to see their grandchildren grow up, or to reverse diabetes. It’s not a crime to be interested in losing weight.

Psychological treatment

If diets don’t work, is it more effective to think of obesity as an emotional pathology? Many therapists offer psychological treatment for obesity, which might encourage people to think of larger size as a mental health issue, again potentially contributing to stigma.

There is, for sure, an association between obesity and poor mental health, but this relationship is bi-directional and complex. For example, it’s possible that poor diet alone leads to neurological changes, cravings and emotional distress. Conversely, adverse experiences and stress might lead to inflammation and the physiological processes that prompt appetite change, poor sleep and easy weight gain.¹³

So, we don’t really know everything that is going on. It might also be unhelpful for people to believe that their weight is caused by depression, anxiety, insecure attachment or trauma.¹⁴ In any event, focus on the underlying issues does not generally result in change, even though greater self-worth promotes better self-care.

I find myself enthused about an alternative and more compassionate way of looking at obesity that is emerging among obesity specialists. It’s called enhanced, or third wave, cognitive behavioural therapy (CBT), encompassing acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), cognitive defusion, flexibility training and compassionate brain training.

We avoid stigma by legitimising the desires of people who want to lose weight, showing them how the old methods cannot work, and seeking to help them in a different way, without causing stress. The new thinking is, to some extent, rooted in cognitive and behavioural strategies; after all, we cannot ignore the need to help someone to eat differently, to drink less alcohol and to move around more.

The principles of CBT help a person to remove problem foods from sight and to plan for times when temptation is high, but willpower is weak. Traditional CBT also targets the thinking that prompts unhelpful behaviour, such as telling yourself that you are fat and unattractive, or hopeless at dieting, and that people are thinking badly of you. The belief that ‘I will die without my treats’ can be scrambled by targeted Socratic enquiry.

However, third wave cognitive strategies don’t seek to change thinking, but rather to develop a different relationship to troublesome thoughts. For example, stepping aside from the argument between a needy inner child that wants some chocolate and a critical inner adult that says you should have an apple instead. The apple clearly doesn’t meet the same hunger. There is new alluring evidence¹⁵ that by upskilling a client and by promoting eudaimonia (meaning and purpose in life), an overweight person will feel willing and more able to resist the impulses of a hungry, inner child.

I welcome the new focus on resilience, replacing the old negative concentration on restrictive diets that make people feel infinitely worse, disempowered and distressed. Third wave CBT includes attention to poor mental health insofar as it acts as a barrier to change. But there is greater focus on wellbeing, flexibility and active strategies that boost self-esteem and a sense of: ‘Yes I can and I’m worth it!’

When we look back, we might realise that COVID-19 has allowed us to rethink obesity and the needs of the overweight person who wants and deserves weight change. The Government has a role to play, not in shoving us towards impossible behaviours, but in nudging us towards healthier choices, such as removing choccies from check-outs.

Obesity specialists

Where therapy is concerned, I think we now need a new class of obesity professional, with knowledge of nutrition, neuroscience, physiology, motivation and health psychology, as well as the range of enhanced cognitive therapies. These specialists will also compassionately understand the needs of the bariatric patient.

In-depth understanding of the treatment of eating disorders and poor body image is also helpful for the significant proportion of larger people whose compulsive eating pathology contributes to their problems. Among other things, binge-eaters are unaware of what drives some of their overeating. The loss of control around food arises, in part, from people installing a moral framework around forbidden foods, which leads to an overzealous aspiration for restraint that collapses when this food is intermittently available.¹⁶

If all this CPD feels like a big ask – it is. We can no longer deny that obesity is a specialism; nor can we try to persuade a larger client against wanting to be thinner. In the war on weight, one side declares that a person needs to lose weight, causing stigma. The other side argues that we should leave larger people alone and ditch all diets. We no longer need to take sides. The middle way non-judgmentally acknowledges some possible health risks of a high BMI, strengthens the person against stigma and offers a more compassionate way forward that has wellbeing at the centre of our work.