An Open Letter calling to change “Ob*sity Strategy” & Better Health Campaign

Co-authors: AnyBody UK, Anti Diet Riot Club, Nadia Craddock, Research Fellow, Centre for Appearance Research and Laura Thomas PhD, PGDip, RNutr, Director, London Centre for Intuitive Eating

Dear Boris Johnson & Matt Hancock,

We are a group of healthcare professionals, including medical doctors, registered nutritionists and dietitians, psychologists, researchers, academics, health advocates, and charity workers specialising in public health, weight bias, eating disorders, body image, and health equity. We are writing with regard to the UK government’s “Ob*sity Strategy” alongside PHE’s “Better Health” campaign announced on 27 July 2020.

Please note that we are placing an asterisk in the word ‘obesity’ throughout this open letter, as it is regarded as a stigmatising word.

We share your broad commitment to improving public health and we support actions that promote health and access to healthy living at a population level without shame. Specifically, we support moves to improve the food and advertising environment by restricting advertising and promotion of foods high in fat, sugar, or salt online and in store. We also support actions to increase access to physical activity though free online classes and apps. However, we have some deep concerns with the new strategy and invite you to consider important evidence that may have been overlooked concerning:

1. Weight stigma

2. The problem with weight-loss diets for health promotion

3. The role of social inequality

4. The harmful effects of an increased focus on calorie counting

The scientific evidence clearly demonstrates that any campaign which seeks to realise sustainable, equitable improvements in health at a population level must address the above concerns and avoid any harm, however inadvertent.

Weight Stigma

Our weight is influenced by over 100 different variables including our genetic makeup, our socioeconomic status, our geography, our physical and psychological health, the medications we take, as well as lifestyle choices, many of which are outside individual control.

The World Health Organisation (WHO) defines weight stigma as “negative attitudes towards, and beliefs about, others because of their weight. These negative attitudes are manifested by stereotypes and/or prejudice towards people with overweight and ob*sity”.

Decades of evidence demonstrates the deleterious impact of weight stigma on individual physical and mental health to include increased cortisol levels and higher blood pressure, depression, anxiety, disordered eating (including unhealthy weight control behaviours, extreme restriction, and binge eating), and avoidance of physical activity and movement (for fear of being fat shamed). Higher weight children have a higher risk of suicide due to weight based bullying and teasing and as adults are given less educational and employment opportunities, perpetuating the cycle of poverty, inequality and poor health outcomes. Further, higher weight individuals are more likely to receive compromised care in healthcare settings as the result of weight stigma and may also avoid healthcare settings due to anticipated or internalised weight stigma.

The harmful impact of weight stigma on health has been recognised by the WHO and some of this evidence has been presented to government during the Ob*sity Stigma Conference presented by the Ob*sity APPG earlier this year. More recently, PHE’s report examining “Excess Weight and COVID-19” acknowledged that weight stigma “may delay interaction with health care and may also contribute to increased risk of severe complications arising from COVID-19”.

Taken together, it’s clear reducing weight stigma is important in any public health campaign. This can be achieved by adopting a more holistic, weight-inclusive approach to health. In line with a Health At Every Size approach, this would involve (1) removing a focus on weight or BMI as sole metrics for health, (2) ceasing oversimplified associations between weight loss and ‘better health’ and (3) not framing weight as limited to individual responsibility and lifestyle choices.

The problem with weight-loss diets for health promotion

Central to the new strategy are steps for people of higher weights to engage in weight-loss diets and access weight management services. This is concerning for the following reasons:

1. Weight loss diets are ineffective and unsustainable for most people. Research shows that while some diets may initially result in short-term weight-loss of around 5–10%, for most people weight will be regained after five years. Studies show the extremely low probability of people with a BMI higher than 30 achieving a BMI that is considered ‘normal’. A comprehensive analysis of 31 long-term studies found “the majority of people regained all the weight, plus more. Sustained weight loss was found only in a small minority of participants, while complete weight regain was found in the majority.” Moreover, weight loss diets are a predictor of future weight gain which exacerbates weight cycling and yo-yo dieting behaviours.

2. Engaging in dieting is one of the most robust predictors for eating disorder onset. Evidence based on prospective studies indicate that dieting is a consistent predictor for eating disorder onset as well as disordered eating behaviours (see also Academy for Eating Disorders ‘Nine More Truths About Eating Disorders: Weight and Weight Stigma’). According to an analysis by PriceWaterhouseCoopers in 2015, eating disorders cost the UK economy an annual £15billion. Notably, eating disorder services have seen steep increases in demand in the wake of COVID-19.

3. Weight cycling is harmful to mental and physical health. Crucially, weight cycling (repeatedly losing and regaining weight via “yo-yo dieting”) has psychological consequences, harming individuals’ long term self-esteem and mental health. Evidence also suggests that weight cycling increases inflammation, the risk for heart disease, poorer blood glucose control and the onset of metabolic syndrome.

4. Improvements in health can be made independently of weight loss. By framing weight loss as a prerequisite for health, we are disincentivising people from engaging in self-caring and health promoting practices (such as nutrition and exercise) for their own sake. People who are only engaging in positive behaviours with the end goal of losing weight are more likely to give up those behaviours when weight loss slows, or indeed, weight is regained. The current approach also ignores the considerable scientific literature that suggests improvements in health can be made irrespective of weight loss.

5. The reliance on weight-loss diets and weight management strategies positions weight as a matter of individual responsibility. This leads to blame and further stigma for higher weight individuals when inevitably long-term weight loss is not achieved.

Calorie labels on restaurant menus

Calls and petitions to remove calorie labels on restaurant menus have already been made elsewhere. As detailed by others, this initiative is (inadvertently) harmful to those with eating disorders and disordered eating as it serves to increase anxiety around eating. In addition, this initiative reinforces the stigmatising message that people are higher weight because of lifestyle choices, overlooking the complex interacting factors that influence our weight.

The role of social inequality

As identified in PHE’s review on disparities in risks and outcomes of COVID-19, COVID-19 has highlighted the health inequalities present in the UK linked to factors, such as socioeconomic status, geography, and race. We argue that these inequalities ought to be prioritised that would embrace a ‘war on social inequality’ as a strategy to improve the health of the nation.

While we support actions to restrict the promotions of foods high in fat, sugar, and salt in principle, we must acknowledge that record numbers of people — including key workers — are depending on food banks and millions of Brits are living in ‘food deserts’ — areas poorly served by food stores. A recent report by the Social Market Foundation finds that food affordability, food prices, and access to stores selling healthy groceries at a good price are the biggest barriers to healthy eating in the UK. Consequently, we believe that improving access and affordability to a wide variety of foods must be the priority over restricting options that are currently affordable to people in need. Policy actions designed to specifically support those living in poverty and in socially deprived areas would also go a long way in improving public health related to nutrition.

Recommendations

We are encouraged to see the government’s investment in public health. However, in light of the aforementioned concerns, we are asking you to reconsider and amend the New Ob*sity Strategy to take action to sustainably improve public health without prompting shame for those of higher weight status and risking the many inadvertent consequences related to disordered eating.

1. Reduce weight stigma by removing the conflation of weight loss with automatic ‘better health’ in public health messaging.

2. Make healthy eating and daily activity easy, affordable and accessible for people across the weight spectrum by investing in communities, rather than initiatives that rely, and therefore put blame, on individual responsibility.

3. Address socioeconomic disparities in education, income, job opportunities and housing as a sustainable avenue of improving public health.

4. Commit to reducing advertisement of diet products that promote quick unsustainable weight loss and poor long term physical and mental health outcomes.

We welcome an opportunity to have an open dialogue with the Department of Health and Social Care to bring our collective expertise together to work to improve the health of the nation.

SIGNED:

AnyBody UK

Body Image Charity

Centre for Appearance Research (CAR)

University of the West of England (UWE Bristol)

Victoria Chetley

Photographer, AnyBody UK

Megan Jayne Crabbe

Author, Presenter, Body Acceptance Advocate

Nadia Craddock EdM

Research Fellow, Centre for Appearance Research (UWE)

Natasha Devon MBE

Campaigner, Author & Presenter, Mental Health Media Charter

Professor Phillippa Diedrichs, PhD

Professor in Psychology, Centre for Appearance Research (UWE)

Rebecca Gardiner

Body Acceptance Advocate and Campaigner for AnyBody UK

Dinah Gibbons

Director, BodyKind Festival

Sofie Hagen

Comedian, Author & Podcaster

Simone Harding, ANutr

University of the West of England

Sharon Haywood

Research Associate, Centre for Appearance Research (UWE) & Campaigner for AnyBody UK

Harri Rose Hill

Body Acceptance Coach, Author & Head of Community at Anti Diet Riot Club

Eliza Khinsoe, RD

Nutrition Counsellor, London Centre for Intuitive Eating

Hollie McNish

Poet

Zoe McNulty

Director, School of Strut

Dr Angela Meadows

Founder of the Annual International Weight Stigma Conference

Dr Roanna Mitchell

Lecturer, University of Kent

Susie Orbach

Consultant & Author, The Balint Consultancy

Vania Phitidis

Founder, Peaceful Eating

Vie Portland

VieNess Discover You Love You CIC

Isa Robinson, ANutr

Nutritional Therapist

Holli Rubin, MSW

Psychotherapist Specialising in Body Image

Nicola Salmon, MSc

Fat-Positive Fertility Coach

Laura Thomas, PhD, PGDip, RNutr

Director, London Centre for Intuitive Eating

Felicity Tyson

Psychotherapist, NHS East London and Association of Child Psychotherapists

Hope Virgo

Author and Mental Health Campaigner

Dr Joshua Woolrich, BSc (Hons), MBBS, MRCS

HAES-aligned NHS doctor

Rebecca Young

Founder, Anti Diet Riot Club