Food For Thought
Our weight obsessed society puts unrealistic pressure on people to lose weight and the NHS is exacerbating the situation by giving outdated information that fuels fat phobia, promotes low self-esteem and an unhealthy relationship with food.
93% of respondents to our Big Fat Weight Survey said they would like to weigh less.
This isn't a feeling that's going to disappear just because we tell them not to worry and whilst we do not advocate weight loss - we advocate activity and health - it's clear that people need constructive help now, to help them understand why weight loss groups don't work, what's really happening with their bodies when they try to lose weight and why current advice isn’t likely to work.
First things first, we were wondering about the need for words like obesity and BMI. When we asked our community how they felt about them the association was negative. We also learned that for over 85% of respondents, being told by their doctor that they were 'living with obesity', had a negative impact on their own feelings about themselves.
We asked one of our experts why the NHS was still using these terms and she explained that in order for those people who DO want to lose weight, to gain access to the help that is available, they had to be classified as obese. Unfortunately this obesity label also prevents access to many other services and treatments.
This is such a counterproductive way of delivering health care and we believe it illustrates the systemic fat phobia within our government and our health service.
1500 people from our community responded to our Big Fat Weight Survey - 92.7% said they would like to weigh less.
Whilst we acknowledge the issues people have around this terminology our advice and posts on this subject come directly from the NHS information and we think it’s important to use their terminology when we are challenging their content.
Extract from the NHS Obesity overview:
How to tell if you’re living with Obesity
“The most widely used method to check if you're a healthy weight is body mass index (BMI).
For most adults, if your BMI is:
- Below 18.5 – you're in the underweight range.
- 5 to 24.9 – you're in the healthy weight range.
- 25 to 29.9 – you're in the overweight range.
- 30 to 39.9 – you're in the obese range.
- 40 or above – you're in the severely obese range.”
Our Comment
We have issue with the terminology used by the NHS for a host of reasons but not least the idea that anyone who falls into the obesity category must be unhealthy and we feel that the NHS focus on weight rather than health is ineffective in creating a healthier and happier society.
The NHS categorisation of healthy weight, over weight and underweight don’t make sense when we take into consideration the latest scientific evidence about people and fat, furthermore this terminology causes weight stigma and undermines peoples relationship with their own bodies.
“Contrary to popular belief, obesity isn’t simply having a BMI above 30. BMI tells you about body size, but not a lot about health. Rather, obesity is carrying too much fat that it begins to impact your health. How much is too much? That will differ from person to person.”
Dr Giles Yeo 2021
Whilst the NHS website touches on the limitations of the BMI calculation and how other strategies should be used, it is still widely influential in the UK healthcare service. The BMI or body mass index was founded in the late 19th century and divides a person’s body weight by height to predict life expectancy and risk of ‘obesity-related diseases.’ The BMI calculation was originated by life insurance companies and was based on data gathered from a predominantly male population (Nuttall, 2015).
This outdated system is still being used in clinical practice to classify individuals and allow their access to specific services. For example, a BMI of over 29.9 is the criteria for the diagnosis of ‘metabolic syndrome’ (also called insulin resistance syndrome) which is a group of conditions that together raise your risk of coronary heart disease, diabetes, stroke, and other serious health problems. (Weir & Jan, 2022)
Research into the BMI calculation has highlighted its many drawbacks, including its inability to differentiate between fat and muscle, which types of fat are potentially more dangerous to our health than others and its use as a measure of health.
Our diagram shows two different types of fat that can not be measured by the BMI calculation:
You might be wondering what relevance fat types have, however there is a big difference between Visceral and Subcutaneous fat and they can have a big impact on your health.
Visceral fat is seen as a major risk factor for issues such as high blood pressure, type 2 diabetes, strokes, and cardiovascular disease (Mittal, 2019). It sits under the muscle and around the internal organs and is often found in men.
Subcutaneous fat sits under the skin and is usually found on the hips and bottom. It sees lower risks of inflammation and damage to a person’s internal organs (Mutsert & Despres, 2023) and is often associated with women who accumulate more as they go through puberty and then later, through menopause.
Every person is different, and we must consider the individual and their body before making any assumptions about them and their health. The strategies and systems of the NHS should reflect this and considerations should be made to the negative connotations of words like obese, stepping away from the fat phobic and blame like culture of the BMI calculation.
Other analysis tools such as the waist-to-height ratio, which looks at a person’s waist circumference in comparison to their height, can be used to distinguish between visceral and subcutaneous fat and give a better indication of the risks of cardiometabolic disease (Yoo, 2016). Tests can also look at the function of a person’s thyroid and liver to give more information on the inner workings of their body.
Most importantly we need to consider the variation in individuals’ lifestyles and demographics. For example, a recent study actually found that the current BMI calculation failed to identify nearly half of the reproductive-aged women classified as obese within more detailed testing. These results were exacerbated within the black and Hispanic communities (Rahman, 2010).
The BMI calculation is both failing to identify those not at risk and those who actually are.
Extract from the NHS Obesity overview:
CAUSES {of} OBESITY?
The NHS Obesity Overview website says:
“Obesity and overweight is caused when extra calories, particularly those from foods high in fat and sugar, are stored in the body as fat.”
“Lack of physical activity is another important factor related to obesity. Many people have jobs that involve sitting at a desk for most of the day. They also rely on their cars, rather than walking or cycling.”
“For relaxation, many people tend to watch TV, browse the internet or play computer games, and rarely take regular exercise.”
Our Comment
The factors which influence our weight are much more complex than this, but moreover this information reinforces weight stigma and fat phobia by suggesting that fat people are lazy and inactive.
Recent studies have found that your weight is 40-70% controlled by your genetics. For example, almost 200,000 UK citizens have been found to have mutations in a gene called MC4R, this is a really important gene that regulates a hormone called Leptin. Leptin is responsible for triggering the body to be hungry when energy stores are low. A person with a mutated MC4R gene would feel hungry even when they have eaten enough leading to a surplus of energy that would then be stored as fat. (Loos & Yeo, 2022)
This is only one example, there are an estimated 300 areas in your DNA that may be linked to weight gain. Even more studies have been done looking at the way our genes may lead to an increased preference for high-fat foods or even the way our taste buds differ – think the way some people find coriander tastes soapy and some of us can’t get enough (all down to the TAS2R38 gene)! (Melis et al. 2019)
In neglecting to give people who do want to lose weight accurate scientific information on the relevance of their genetics, the NHS is setting people up to fail. When surveyed less than 5% of respondents understood the importance of their genetics to their health and weight.
Almost everyone in our survey understood the importance of physical activity to their health and 84% reported having an active lifestyle, doing at least the recommended 150 minutes of activity per week, with 35% doing double that recommended by the NHS.
89% of our respondents consider themselves to be heavier than average and almost 64% have been told by a health professional that they are ‘living with obesity’.
94% of respondents understand what a healthy diet is and are aware of its importance to good health with 90% of people reporting that they see their diet to be healthy.
If inactivity and an unhealthy diet were the two major causes of weight gain, wouldn’t all of our survey respondents be thin? Our stats show that our community is active and eating healthily, with many people following the NHS advice and guidelines, yet the NHS would still classify them as unfit and overweight.
We would like to see the NHS switch focus to overall health rather than encouraging people to obsess about their weight. Simply understanding the other factors which influence your weight and health can help you to stop feeling like a diet and society failure and empower you to a more positive relationship with your body.
Further studies are being made around Leptin and MC4R regulation, while such trials are still in their infancy, it is clear that a one size fits all approach to health and weight does not work (Europe & Gunn, 2021).
More in-depth analysis of a person’s genetic background and medications must be considered within weight consultations and before more radical steps are taken. The study of epigenetics, which explores how our genes are influenced by our environment and behaviours, is a complex one but could provide further insight into how situations of the past, going even as early as our childhood environment, may influence our bodies in the future (Mahmoud, 2022). Whilst it is not possible for every UK citizen to have such an in-depth screening, a person who eats healthy and regularly exercises but is still classified as obese, should be raising red flags for healthcare professionals.
“Obesity is not a choice i.e., it’s a lot more complicated than we think it is, and we need to be kinder to people living with obesity.”
Sarah Le Brocq – Director of Obesity UK 2019
Extract from the NHS Obesity overview:
TREATMENT {of} OBESITY
The NHS Obesity Overview website says:
“If you're living with obesity, your GP can offer you for advice about improving your lifestyle and losing and managing your weight safely. Your GP can advise you about losing weight safely by eating a healthy diet and regular physical activity”
“Useful strategies could include:
local weight loss groups
avoiding situations where you know you may be tempted to overeat
monitoring your progress – for example, weigh yourself regularly and make a note of your weight in a diary”
“Managing a complex issue like obesity can be hard. Losing weight takes time and commitment.”
“Obesity is an increasingly common problem because the environment we live in makes it difficult for many people to eat healthily and do enough physical activity.”
“If as a nation we keep piling on the pounds around the waistline, we’ll be piling on the pounds in terms of future taxes needed just to keep the NHS afloat.” Chief Executive of NHS England 2014 Public Health England Conference.
Our Comment
Despite diet and nutrition playing a major part in our health; teaching on these subjects at medical school is reportedly only 10 hours and at best a couple of weeks respectively.
All too often we hear that our GP’s do not have the necessary training to be able to give constructive and helpful advice to people who want to lose weight and perhaps more importantly, this lack of knowledge and understanding is contributing to the systemic fat phobia we witness in our health service.
“If Doctors knew as little about asthma as they do about obesity they would be struck off.”
Dr Stephanie de Giorgio
Recommending useful strategies which have no scientific or statistical basis only serve to undermine the self-esteem of people and reinforce their feelings of failure.
46% of our community reported having joined a weight loss group like Slimming World or Weight Watchers but only 7% experienced lasting weight loss. This is in line with national statistics which show that the majority of people will gain at least as much weight as they lost, within 5 years.
The shame of weight regain after participation in any weight loss methods has been found to contribute to feelings of social isolation, disordered eating, and lack of motivation (Himmelstein et al. 2022).
Knowing the national statistics for weight loss and subsequent gain as well as the considerable damage these groups are doing to people we are surprised that weight loss groups are still being recommended by the NHS.
Telling people that losing weight is hard and takes commitment implies that not losing weight or gaining weight after loss means you are not working hard enough and not committed.
Recommendations to avoid situations where you may over eat amplify the fat phobic narrative that underlies the NHS advice and further reinforces the negative relationship we have with food. What constitutes over eating? Should we all avoid birthdays in case there is cake?
These ideas of avoiding oversized potions, reducing calorific intake and avoiding temptation are outdated and unmanageable and research has found that limiting calories only decreases your metabolic rate meaning that your body thinks it’s starving and therefore stores more energy as fat for later use (Benton & Young, 2017).
Advising people to get weighed regularly can encourage them to obsess about their weight which can fluctuate considerably throughout a day, week or month simply depending on our activity, what you eat and drink and your hormones.
Whilst the NHS recognise the environmental challenges that people face when trying to eat healthily and lead an active lifestyle, our Government has failed to put any meaningful processes into place to solve these issues.
59% of people said they did not feel they had enough time in the day to put focus on making the healthiest food choice.
There are thousands of exercise plans and strategies, some arguing that cardiovascular exercise is best (NHS) and others singing the praises of strength training or Pilates but the main issue with all plans is sustainability and research suggests that significant weight loss can only be maintained with high volume and continued exercise (Swift et al. 2014). For most of us the challenges to exercising regularly are simply too great.
The negative connotations around the word obese, damaging diet cultures, and stigmas surrounding weight loss medications and surgeries, all speak to an inherently fat phobic and blame like culture.
People are unique, as is their weight and their attitude to their body and to fat - opinions differ wildly but we all need to find something that works for us. Learning to be at peace with our body and to be kind to ourself is one of the things that many of us struggle with.
The focus should be placed on good habits and sustainable lifestyles choices such as:
Taking interest in the foods we eat and their nutritional content (not the calorific value) and trying to incorporate high amounts of protein and fibre into our diets = these are beneficial for gut health, hunger levels and lowering risks of cardiometabolic diseases (Yeo, 2023) are all good steps.
Staying away from fad diets and meal replacement shakes, which whilst effective initially are unsustainable and damaging. 80 – 95% of dieters gain all the weight that they lost after finishing such plans (Pogored, 2023).
Listening to our body’s signals constructively; we spoke earlier about how genetics can influence hungriness. The rhetoric of ‘not giving in to temptation’ is unsustainable. If you are a person who likes to snack don’t restrict yourself but do try to make this craving into a healthier one. For example, if you need a sweet pick me up at 3pm, grab one, but add some fresh fruit and veg and something high in protein to your plate. This will help you stay fuller for longer and provide you with the nutrients you need.
Activity doesn’t have to be a gruelling HIIT work out, a steady social bike ride (our favourite), a yoga class or even a run around with your children have all been found to improve mental health and positively influence our experience and motivation (Phillips, 2022).
The important thing is to be kind to yourself and to create plans which work with your lifestyle and your body. Our weight and our chance of developing depression are linked (Luppino et al. 2010) which is frankly no surprise when we consider the stigma and prejudices of our culture but people who do want to lose weight, are also less inclined to seek help and feel guilty even when they receive it. Dr Stephanie de Giorgio speaks openly about her journey with bariatric surgery (specifically a gastric sleeve) emphasising her use of ‘non-scale victories’ to celebrate her health in a positive way.
Making manageable changes that are focussed on your health, rather than your weight and considerate of your genetics, lifestyle and individual differences can help you to be healthy and happy, now and in the future.
“My hope for the next few years is that we can improve the knowledge regarding the science of obesity among healthcare professionals, and that we can work towards proper services both for the prevention of overweight and obesity.”
Dr Stephanie de Giorgio 2020
CAN WE MAKE SOCIETY HEALTHIER?
Food for thought
Over 82% of people want to see better education on the importance of an active lifestyle and improvements to our education system, making food and nutrition including cooking, part of the national curriculum.
Over 62% of people think that some of this could be funded by higher taxes on Big Food companies.
79% of people want to see an end to the targeting of children by Big Food and 55% would like to see restrictions preventing Big Food's marketing and sponsorship activities in general.
We'll continue adding helpful links and information to our page. If you have suggested resources please drop us an email
- You can find out more about the links between weight, mental health, and self-esteem in adolescents here
- Links to Dr Stephanie de Giorgio on Twitter
- Links to Dr Giles Yeo on Instagram
Finally, if you fancy joining our community of inclusive and positive people, challenging the stereotypes and supporting everyone on their journey towards better health check out our Community Forum and follow us on Instagram Twitter and Facebook
Research by Annabelle Russell
Links to research and information cited within this advice page:
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de Mutsert R, Després, JP (2023) Overall, abdominal, and visceral obesity in men and women: an introduction, Visceral and Ectopic Fat, Elsevier, Pages 3-18, ISBN 9780128221860, https://doi.org/10.1016/B978-0-12-822186-0.00017-1.
(https://www.sciencedirect.com/science/article/pii/B9780128221860000171)
Europe, D. and Gunn, S. (2021) Obesity drug cuts weight, D4 Pharma. Available at: https://d4-pharma.com/obesity-drug-cuts-weight/ (Accessed: 26 June 2023).
Himmelstein MS, Knepp KA, Phelan SM. The role of weight stigma in weight regain in bariatric surgery. Front Endocrinol (Lausanne). 2022 Dec 6;13:1076696. doi: 10.3389/fendo.2022.1076696. PMID: 36561565; PMCID: PMC9763922
Loos, R.J.F., Yeo, G.S.H. The genetics of obesity: from discovery to biology. Nat Rev Genet 23, 120–133 (2022). https://doi.org/10.1038/s41576-021-00414-z
Luppino FS, de Wit LM, Bouvy PF, et al. Overweight, Obesity, and Depression: A Systematic Review and Meta-analysis of Longitudinal Studies. Arch Gen Psychiatry. 2010;67(3):220–229. doi:10.1001/archgenpsychiatry.2010.2
Mahmoud AM. An Overview of Epigenetics in Obesity: The Role of Lifestyle and Therapeutic Interventions. Int J Mol Sci. 2022 Jan 25;23(3):1341. doi: 10.3390/ijms23031341. PMID: 35163268; PMCID: PMC8836029.
McArthur D, Dumas A, Woodend K, Beach S, Stacey D. Factors influencing adherence to regular exercise in middle-aged women: a qualitative study to inform clinical practice. BMC Womens Health. 2014 Mar 26;14:49. doi: 10.1186/1472-6874-14-49. PMID: 24666887; PMCID: PMC3975263.
Melis, M., Errigo, A., Crnjar, R. et al. TAS2R38 bitter taste receptor and attainment of exceptional longevity. Sci Rep 9, 18047 (2019). https://doi.org/10.1038/s41598-019-54604-1
Mittal B. Subcutaneous adipose tissue & visceral adipose tissue. Indian J Med Res. 2019 May;149(5):571-573. doi: 10.4103/ijmr.IJMR_1910_18. PMID: 31417024; PMCID: PMC6702693.
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Phillips, J. (2022) TRP study on how group ex dramatically increases retention, Les Mills. Available at: https://www.lesmills.com/uk/clubs-and-facilities/research-insights/acquisition-retention/trp-study-group-ex-is-key-retention-driver/ (Accessed: 26 June 2023).
Pogored (2023) Why people diet, lose weight and gain it all back, Cleveland Clinic. Available at: https://health.clevelandclinic.org/why-people-diet-lose-weight-and-gain-it-all-back/#:~:text=Experts%20think%20as%20many%20as,%3F%20(WHY%3F!%3F) (Accessed: 26 June 2023).
Rahman M, Berenson AB. Accuracy of current body mass index obesity classification for white, black, and Hispanic reproductive-age women. Obstet Gynecol. 2010 May;115(5):982-988. doi: 10.1097/AOG.0b013e3181da9423. PMID: 20410772; PMCID: PMC2886596.
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Weir CB, Jan A. BMI Classification Percentile And Cut Off Points. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541070/
Yeo, D.G. (2023) The 3 rules your diet needs to actually work, BBC Science Focus Magazine. Available at: https://www.sciencefocus.com/the-human-body/dieting-rules/ (Accessed: 26 June 2023).
Yoo EG. Waist-to-height ratio as a screening tool for obesity and cardiometabolic risk. Korean J Pediatr. 2016 Nov;59(11):425-431. doi: 10.3345/kjp.2016.59.11.425. Epub 2016 Nov 18. PMID: 27895689; PMCID: PMC5118501.