I am often asked how the healthcare system in the UK could be more proactive in helping people living with obesity to reduce their weight if they want to. The answers to this question are many, varied, and bewilderingly complex, which is presumably why we have yet to address it effectively.
The prevalence of people living with overweight or obesity in the UK is slightly higher than most other countries in Europe although largely comparable, and thankfully the rate of increase is now slowing. The underlying causes for this appear to be broadly similar to those seen elsewhere; the Foresight report published more than a decade ago remains relevant and suggests that obesity is a consequence of an elaborate interaction of myriad factors, and managing it requires changes at ‘personal, family, community and national’ levels. This is undoubtedly true.
However, when I talk with my patients and colleagues about the barriers that they perceive in this area, one of the main themes that emerges is that we do not like talking about it. Health care professionals feel awkward raising the subject of overweight, while patients often have a sense of shame or a negative previous experience in a healthcare setting that prevents them from even attempting to discuss it. I have two jobs: one as a traditional GP, and the other as a bariatric physician is a specialist weight management service, and I observe deeply contrasting attitudes to overweight and obesity between the two.
In my weight loss clinic, it’s relatively straightforward; from the moment that the patient arrives we both know why they are there, and it’s to get on with the business of weight loss, whatever that means for them. In my GP surgery, it is different. The very second that ‘weight’ is mentioned by either me or them, I see the patient visibly tense up and start to adopt a defensive stance. I can generally get around this and steer things in the direction of a constructive consultation, but it is not always easy. It seems to me that the main reason for this is that there is still a significant degree of social stigma associated with obesity, and this is something that we, as a society, would do well to change.
A wealth of evidence exists to suggest that people living with obesity experience significant weight stigma, both in society in general and in our healthcare settings, and that this leads to them receiving less effective management of their obesity or related health conditions, among other things. The prevailing narrative in our society is that obesity is the result of choices made by the individual, ultimately either gluttony or laziness, or a combination of both. As such, the treatment for obesity is thought to be ‘eat less and move more’ and all will be well. The scientific literature now confirms this to not be the case; the majority of factors contributing to weight gain are beyond the conscious control of the majority of people, which partly explains why overweight or obesity is highly prevalent.
We urgently need the narrative around the causes of obesity to change. People need to know that it’s not ‘their fault’, and that their healthcare provider also understands this and will support them without judgement or blame. Discussions around the subject of weight need to become as normal as those relating to blood pressure or cholesterol, with no hint of shame or embarrassment. Some people will not want to lose weight in the same way as some smokers don’t want to quit, but many will, and changing the conversation so that it catches up with the evidence can only help with this. Most of us are not policymakers or government advisors, but we can all make a difference by changing our own conversations – with ourselves, our patients if we have them, and our colleagues.
We have a robust weight management service in the UK. It has its problems in that it is chronically underfunded, not all patients have access to it and those who do get referred into the service face lengthy waits for treatment. It exists nevertheless and serves the population as best it can within those and other constraints, and most people who show up are glad they came. But every patient we see is there because either they or their healthcare provider had the courage to start a potentially difficult conversation. It’s good to talk; let’s make it easier.
For advice on how to sensitively discuss weight with patients, we recommend the following SCOPE E-Learning modules:
- Primary Care Weight Management: Shaping the Conversation
- Overcoming Perceived Barriers in Primary Care
- Weight Bias: A Hidden Harm
- Starting the Patient Dialogue (part of the Core Learning Path)