Katharine Palmer, a research assistant in Nutritional Psychology, and Millie Croal, a passionate fat positive writer, weigh in on the new Better Health campaign and find it wanting
CN: fatphobia, eating disorders
Following his stint in Intensive Care as a result of severe Covid-19 symptoms, the Prime Minister Boris Johnson has embarked on a mission to lose weight. And he wants the country to join him. As part of its new ‘obesity strategy’ (the Better Health campaign), the government will ban adverts for “unhealthy food” (defined as foods that are high in salt, sugar and fat), get rid of food deals containing unhealthy food and require calories to be displayed on restaurant menus. Public Health England (PHE) has also developed an app that offers a 12-week weight loss plan. BAME communities, who have been disproportionately affected by Covid-19, will be specifically targeted. Although the rates of those considered to have ‘overweight’ or ‘obesity’ differ between BAME groups, PHE’s July 2020 ‘Excess Weight and Covid-19’ report maintains that body mass differences may partially explain why BAME communities suffer more from Covid-19. However, they have also identified many other links between BAME communities and the risk of infection or poor outcomes, including existing health inequalities, housing conditions, working public-facing jobs and structural racism. As the full story becomes clear, the campaign is forging ahead.
In the past, Johnson has been opposed to such policies, arguing that advisory health labels on alcoholic drinks, for example – a proposal that the government is now considering – was “lunacy”. But it seems that the government is hoping that the Covid-19 pandemic will increase public acceptability for its bold campaign, as the aforementioned PHE report that has informed the development of the Better Health campaign has linked obesity with poor coronavirus outcomes (although it states that the risk of infection is unchanged). What Johnson hasn’t accounted for in his appraisal of public acceptability is the imperfect nature of BMI as a measure of health, worries about mental health and the impact of poverty on nutrition. Indeed, reactions to the campaign have been mixed.
BMI is often used by researchers to assess a population’s health because it is quick and easy to compute without special materials or medical training. As we know, however, it is only a proxy measure for body fat. Because muscle weighs more than fat, body builders and athletes are often misclassified as overweight. The cut-off points are also somewhat arbitrary: gaining a few pounds could be the difference between being defined as ‘overweight’ or ‘obese’, although the health risks will not dramatically escalate, contrary to the Health Secretary Matt Hancock’s assertion that everybody losing 5lbs would save the NHS money. The World Health Organisation also acknowledges that different cut-off points may be useful for different populations.
The link between BMI and health is much more complicated than it appears, and there is still much more to learn. Indeed, as Andrea Bombak points out in her article championing the Health at Every Size movement exercise produces health benefits even without weight loss, and weight loss is “a complex and dynamic process”. Meanwhile, the simplistic reasoning behind the government’s strategy is that lowering BMI can protect from severe Covid-19 outcomes. But even successful diets often result in weight regain and extreme or ‘fad diets’ can be dangerous.
The UK eating disorder charity Beat has reported an increase in demand during the pandemic. The situation looks to get worse with this government’s campaign, as the focus on calorie counting and pressure to track weight will undoubtably be triggering for people who have or are at risk of developing eating disorders. It’s also important to remember that it is possible to have an eating disorder, regardless of BMI, but this can often go undiagnosed in people at higher weights.
Food banks have also seen an increase in demand since lockdown began. Despite the fact that food choice in these outlets is exceptionally limited, the Better Health campaign focuses on individual choices as the gateway to good health and avoiding hospitalisation. The increasing number of people suffering from food insecurity and/or a lack of food choice is a reality that this campaign has conveniently forgotten, along with many other causes for weight gain. For example, between 2017 and 2018, 17% of adults in England had a prescription for antidepressants, many of which are known to cause weight gain. Medical conditions and quitting smoking can also cause people to gain or maintain additional weight. Unfortunately, however, the approach the government has taken does not demonstrate an understanding of the multiple causes of weight gain. The view that ‘excess’ weight is the result of a lack of control inevitably leads to judgmental, unhelpful attitudes and feelings of guilt when weight loss doesn’t work as planned.
PHE’s July 2020 ‘Excess Weight and Covid-19’ report does identify ‘deprivation’ (poverty) as a factor related to obesity and poor Covid-19 outcomes. However, it doesn’t attempt to further investigate deprivation, stating that it is “complex to address”. Instead, PHE is offering a simple solution to a multifaceted and complicated issue, possibly because individual choice is easier to understand than systemic failure. But the government risks alienating the very people they say they are trying to help, by peddling the narrative that people with a BMI of over 25 lack self-control and/or are nutritionally unaware. Even worse is the campaign’s explicit rationale: that losing weight can save the NHS money. This is dangerous, as it could lead to an increase in stigma and the framing of weight as a moral issue.
There is an increasing body of evidence (for example, these findings from Puhl and Heuer) that stigma is not just a bad feeling: it can increase psychological stress and depression, thereby leading to poor physical health, and perhaps even increased weight. An effort to improve a population’s health should avoid focusing on weight and shaming people for their choices, and instead provide more opportunities for everyone to live a healthy and happy life.
The focus on BMI is outdated and unsuitable in a world currently suffering poverty and unemployment, as well as anxiety and mass grief as a result of the pandemic. Many people are not back to their normal routine and are therefore not as active as they may have been before lockdown started. For those aware of the pitfalls of BMI and calorie counting, and those struggling with eating disorders, this approach is simply out of touch. Undoubtably, the Eat Out to Help Out scheme will enjoy a much higher uptake than the weight loss app thanks to actually reducing food costs and treating the user as a person with value, rather than a burden on the NHS. But, paradoxically, it will encourage people to eat out at the very fast food outlets the government wants us to avoid.
— Katherine Palmer
The government’s shambolic handling of the Covid-19 pandemic reached new heights last week when the Prime Minister announced his plans to wage a “war on obesity” in a bid to beat the virus. He cited evidence that nearly 8% of critically ill patients with Covid-19 in intensive care units have been morbidly obese, compared with 2.9% of the general population, a relationship that has not yet been proven to be a causal one.
Measures published by the Department of Health and Social Care, described by Katie above, have been framed as the proverbial killing of two birds with one stone: get the nation fit and healthy and protect the NHS. Yet just days before the announcement, MPs voted against an amendment to the Trade Bill that would have safeguarded the NHS against foreign control in post-Brexit trade deals.
This strategy, though not new to Whitehall, came following the Prime Minister’s brush with death after testing positive for Covid-19; he claimed that the severity of his condition was linked to him being overweight. This marks a significant departure from his libertarian, hands-off approach to social issues. But instead of intervening to make people’s lives easier and less expensive, the onus is being placed on individuals to make dramatic lifestyle choices at a time of crisis not seen since the Second World War and in a deeply unequal world.
The real scandal is that rather than taking responsibility for the UK’s numerous failures in containing the spread of the virus, such as the failure to make adequate PPE provisions, delays in implementing the nationwide lockdown, confusing messages around lockdown and social distancing rules and, most recently, the poor performance of the test and trace system, fat people have become the scapegoats for the government’s incompetence.
The measures the Prime Minister has proposed do nothing to address the very real public health issues that exist in this country, such as the shameless level of hunger – particularly among children and older people – in one of the richest countries in the world. The Food Foundation estimated, in evidence given to the Environmental Audit Committee, that 1.97 million people in the UK may be undernourished. They also told the Committee:
In a country such as the UK with a developed health and social care system and consistent food security, it should be feasible to achieve nearly undetectable levels of undernourishment.
The level of child hunger increased during the nationwide lockdown between March and July, as the parents of children who had been reliant on free breakfast clubs and school lunches now struggled to feed them. But rather than this resulting in “healthy food” becoming cheaper, “unhealthy food” is simply being made more expensive.
Meanwhile, punitive Conservative policies like the benefits freeze (which despite coming to an end in April of this year will not, according to the Resolution Foundation, leave households better off), while the five-week wait for and two-child limit on Universal Credit have pushed people further into poverty. It is unconscionable to ask individual households to simply “make better food choices” when hundreds of thousands of families are faced with the choice between eating and heating.
The government’s Better Health campaign is part of a neoliberal trend of blaming individuals for systemic issues and state failure. The Health Secretary Matt Hancock wrote in the Telegraph, “If everyone who is overweight lost five pounds it could save the NHS £100 million over the next five years.” This reinforces the Conservative narrative that it is individual patients who are to blame for the NHS funding crisis, as opposed to the real culprits: a decade of chronic underfunding under the Conservative Party and the undercover privatisation of NHS services.
One of the most dangerous potential consequences of this package of measures is that it will further encourage fatphobia in the medical community, discouraging fat people from using the NHS and/or leading medical professionals to misdiagnose their patients. This is an already worrying situation that puts fat patients at unacceptable risk of harm.
The campaign’s focus on the prohibition and restriction of certain foods will reinforce food moralisation, which is well known to be a trigger for disordered eating. Moreover, by failing to tackle 1) the double bind of working parents’ struggle to have the time and money to cook nutritious meals and 2) the diet-related impacts of our pitiful work-life balance, the campaign does little to change the UK’s food culture. Nor do these proposals do much to encourage us to be more active. For example, proposals for GPs to “prescribe bike rides” mean nothing when we have such a poor infrastructure for safe cycling. And, as well we know, exercise shouldn’t be framed as the conduit to weight loss, but rather an enjoyable part of everyday life (boy, how I wish this were true for me). What’s more, there is, of course, no acknowledgment of the shaming fat people face when they exercise in public.
Finally, a focus on weight as the ultimate health marker belies the need for a holistic approach to public health. From encouraging the joy of eating a variety of foods regardless of their nutritional value, as Ruby Tandoh so brilliantly writes about, to acknowledging the mental health benefits that would arise from eradicating poverty, fixing the housing crisis, improving working conditions and increasing pay, easing our multitude of 21st century stresses would, no doubt, allow people to lead happier, healthier and more fulfilled lives.
— Millie Croal
This shows a black woman with a black headscarf wearing a white protective face mask and looking to camera. She is wearing a grey jacket and the pink straps of her rucksack are visible. Her hands are in her pockets. She is standing in front of a city block and a large tree, both out of focus. The picture is taken from below.