Unless you’ve been hiding under a rock (all power to you if you have been 💪🏻) or you’re not living in the UK, you’ll be aware that the government recently announced plans to get the nation to lose weight, because allegedly, being at a higher weight puts those who contract Covid-19 at greater risk of serious illness and death. We’ve had weight loss health messaging for years, but now, under cover of Covid-19, they’ve upped the ante. If you’re not in the UK, your country is likely to either follow suit, or already has similar health messaging, so this will be helpful for you too.
I’m not here to argue whether or not being at a higher weight does indeed confer greater risks when it comes to Covid-19 – making that kind of assessment is beyond my pay grade 😋. You can explore more about that in the resources below and learn from people who do have the skills and expertise to make that kind of judgement. What I am here to do is to critique the government’s approach and health messaging.
You’ll notice that I don’t use the BMI labels if I can possibly help it. When there’s no alternative, I’ll use them in quotation marks, with asterisks in place of some letters. I do this because those words pathologise body size, which is far too simplistic as well as stigmatising.
The point behind the drive for the nation to lose weight is because of the belief that this will improve our health. But is this true? Here are 5 ways I think our government could do better than harp on about weight, if what they really want is to improve the health of the nation.
1. Change the narrative
The narrative of weight loss as a panacea for good health is far too simplistic and fundamentally flawed – but it makes a good headline. It also shifts the responsibility of health entirely to the individual, rather than to look at health in a more comprehensive and nuanced way. This narrative makes some faulty assumptions:
- That being at a higher weight is unequivocally unhealthy.
- That weight loss is straightforward if you just put your mind to it.
- That it will result in better health.
Let’s test these assumptions:
Does being at a higher weight cause ill-health?
- Higher weights are correlated with higher risks of certain diseases. We do not know that higher weights cause the increased risk, like we know that smoking causes the increased risk of lung cancer. If we mistake correlation for causation, we could be missing large and important pieces of the health puzzle.
- Other variables could be causing both the ill health and the higher weight. For example, insulin resistance could be causing both the higher weight and the disease; lack of sufficient exercise could be driving both poorer health outcomes and higher weight.
- Reverse causation should also be considered whereby poor health may lead to circumstances that then increase a person’s body size.
- It’s also important to consider that weight cycling (repeated weight loss and weight regain) is an independent risk factor for some of the same conditions for which higher weights are often blamed: cardio-vascular disease, stroke, diabetes, immune function and early death.
How straightforward is weight loss?
- If you’re reading this, you’ll know from your own personal experience how difficult it is to lose weight and maintain the weight loss. You’ve probably blamed yourself and your lack of self-control, but what you may not know is that our ancient systems are built to fight for our survival in the face of food insecurity (which is still a real thing for far too many people on the planet). This means the body defends against weight loss and there are all sorts of internal mechanisms to do that, like increasing ghrelin (the hunger hormone) and deceasing leptin (the fullness hormone) in the face of calorie deficit, to name just one.
- The Australian National Health and Medical Research Council is so certain that any kind of lifestyle intervention in pursuit of weight loss (whether you call it a diet or not) will result in weight regain within 2-5 years, that they call it ‘Level A’ evidence. This is the same level of evidence for the statement that ‘smoking causes lung cancer.’ Let that sink in.
- And guess what? Up to two-thirds of dieters regain weight to a higher weight (thus dieting is a good predictor of weight gain). If being at a higher weight is actually causing ill health, then surely recommending weight loss is going to exacerbate the situation for many people?
- A review published in the American Journal of Public Health in 2015 of health records over a 9-year period of 76K+ men and 99K+ women showed that the probability of maintaining weight loss was ‘rare’ and the likelihood of achieving a ‘no**al’ weight was ‘extremely low.’
Does weight loss improve health?
- In order to know this, there would have to have been enough (or indeed any!) studies of people whose health markers or rates of disease have improved after sustained weight loss. The cohort needs to be people who used to be fat who are now significantly thinner and have stayed that way for more than 5 years. If you can’t get the health data from this specific cohort of people, then you cannot say that weight loss is what improves health. It’s no good looking at the health data of already smaller-bodied people and comparing these to the data of fat people, because in this case you’re not seeing the effect of the weight loss. These studies don’t exist as far as I’m aware, probably because there are not enough people who lose weight and keep it off for more than 5 years.
- What we do know about is a massive meta-analysis, undertaken by Katherine Flegal et al of the CDC (Center for Disease Control in the US) involving nearly 3 million people from around the world, looking at the correlation between BMI and risk of death (all-cause mortality). This study found that the group at highest risk of death was that in the ‘underw**ght’ category – but that’s not where we see the health messaging, is it?! Do we ever hear ‘don’t get too thin!? This study found that people in the 25 ≤ 30 BMI band (known as ‘o*’**weight’) had the lowest risk of mortality. People in the ‘n**rmal weight’ category had the same risk of death as people in the ‘ob*** 1’ category (BMI of 30 ≤ 35). Let that sink in…
- What we also know is that the correlation between BMI and risk of death becomes statistically irrelevant on a population level when health-promoting behaviours are consistently practised. These are: not smoking; drinking alcohol within recommended guidelines; eating 5 servings of fruit & veg a day and doing moderate exercise about 3 times a week.
- Some people do report an improvement in health markers after weight loss (though the weight loss is usually temporary). However, we don’t know that this is because of the weight loss itself. It could be because of a change in behaviour: increased intake of fruit and vegetables, a reduction in alcohol intake, more exercise and perhaps more and better quality sleep. One study of higher-weight patients that underwent radical liposuction, removing 28 – 44% of their fat tissue, found no change in metabolic and other health markers at 10-12 weeks post-op.
The ‘war on ‘ob**sity” has only increased weight stigma and done nothing to decrease body size.
Instead of pressing on with a harmful message that so far hasn’t worked and is counter-productive, the government would do well to change the narrative from weight loss to health gain. There are many ways that the health of the nation can be improved – but it’ll be harder for the government to achieve than sending out a simple message to lose weight (and then blame the individual when it fails).
In terms of how we might pursue health gain, it’s useful to understand a fuller picture of the factors that influence health. Take a look at this very comprehensive diagram which includes: genetics & biology, our physical environment, our individual behaviours (not limited to food intake and exercise by a long shot), medical care and the social circumstances we find ourselves in.
2. Focus on the social determinants of health
That our socio-economic situation impacts health outcomes is well established.
Poverty, poor housing conditions, over-crowding, poor air quality, unemployment, unequal access to opportunity, not enough rest (due to stress, long working hours etc.), no access to safe, clean spaces in which to exercise, little or no access to fresh, affordable fruit and vegetables, access to good education (note: postcode lottery), the time and energy to exercise and cook and good, safe transport links are just some of the ways our socio-economic status impacts on health.
I’m not saying it’s easy – but if the government is determined to improve the health of the nation, this is where a large part of the focus should be. In terms of Covid-19, it’s very well documented that people living in poorer communities are being hit the hardest.
3. Fund the NHS adequately
This is a no-brainer for a government seriously committed to population health. Yet this government has underfunded the NHS for more than a decade. I won’t indulge myself by getting into the ideological argument about privatising services within the NHS – because really that’s not relevant to the point that we need to do better. Much better. Staff need to be paid better and valued more (clapping is lovely, but that’s not it). Waiting times need to come down. Screening needs to improve. And more.
4. Increase funding for mental health provision
Mental health services through the NHS are woefully inadequate. Everything is connected. Our physical health is impacted by our mental health (and vice versa), both of which are impacted by the socio-economic circumstances we find ourselves in – all of which impact our capacity to practise behaviours that are known to protect or improve health. Mental health provision is such an important part of the whole picture and cannot be discounted.
5. Focus on behaviour
As far as individual responsibility goes, the government can encourage us to practise behaviours that do impact health positively. Most of this messaging already exists: don’t smoke; drink alcohol within guidelines; eat fruit and veg; exercise, practise safe sex, don’t carry guns or knives!!!, if you’re taking drugs, seek help – and – use clean apparatus and so on.
But this is rather pointless if the government doesn’t remove the socio-economic barriers that make these difficult or impossible. It’s no good telling people to eat more fruit and veg if they live in a food desert, or they work 14 hours a day and don’t have time to shop and cook. It’s no good telling people to get out and exercise if they live in unsafe neighbourhoods and have no open, clean and free spaces and air in which to move and breathe, never mind the time and energy required. Et cetera.
Here are some additional resources to explore the relationship between weight and health (and specifically to Covid-19).
Louise Adams (host), Fiona Willer and Jess Campbell came together for 2 conversations on the Untrapped podcast. They took a deep dive into the research on the relationship between size and Covid-19 that was extant at the time of the podcast (a few months ago now). It’s really worth listening to because it will help you understand more critically how the research is done, what it includes, what it leaves out, what assumptions are made etc.
Unpacking Weight Science podcast
Fiona Willer (dietitian, academic, researcher, about to receive her PhD) has her own podcast for subscribers. It’s well worth the Aus $5 per month if you’re interested in the science. About to be released in August is an update on the research regarding size and Covid-19.
Christy Harrison’s take on Covid-19 and weight
Jess is a nutritionist and student doctor in New Zealand. She has an amazing Instagram account which is super-informative.
And last but not least…
Dr Joshua Wolrich
also has an incredibly interesting and useful Instagram account, where he talks a lot about the social determinants of health, weight stigma and so much more.
And here’s a fascinating paper just published this year: An Evidence-Based Rationale for Adopting Weight-Inclusive Health Policy.
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