The last 18 months have arguably been one of the most historically significant of my generation. I certainly don’t recall any other Pandemics catching us out like COVID-19 has. This disease has made it obvious that our wonderful and pioneering National Health Service (NHS) as brilliant as it is– pride of the British- its not ready for a Pandemic of any proportion. The NHS is struggling, in my 10 years of service, it’s always been struggling, which may explain in some ways why our healthcare system is failing those living with obesity.
Likely, the sad truth is that as a society we have already failed the battle with obesity because of a general misunderstanding. I’m sure you know someone, or perhaps you are someone with a higher BMI than is recommended for the stature, and what comes with this is a belief that the person is greedy, glutenous, lazy and choosing to be this way. Obesity is a disease, but because of this misconception it is not being treated as a medical condition in the same way that other diseases are.
If someone had any other medical condition, let’s say they have Diabetes, or a heart condition, we understand that there is an underlying physiological cause, obesity is no different. There is plenty of science that tells us that obesity is brought about by an impairment in the metabolic pathways- quite simply the metabolism is not working properly. The same way that a heart condition is when the heart is not working properly.
Studies have found more than 200 different gene variations that have an influence over the way our bodies regulate weight, and nearly all of these are related to appetite regulation. Those who are obese are being told by the chemical signals in their bodies that they are hungry, there is a lack of satiety or feeling of fullness. To clarify, obesity is not a lifestyle choice such as greed, but instead it is caused by genetic and environmental factors.
Despite the science supporting that being overweight is a serious condition, one that carries considerable risk factors for hundreds of other conditions and disease. Living with obesity is estimated to reduce life expectancy by 3 to 10 years and living with more severe forms of obesity can be seriously debilitating, such as feeling breathless, experiencing joint pain, feeling tired all the time, and poor mental health.
Still, even with knowing all of this, the widespread stereotyping exists and is so ingrained into our daily lives that it is rarely even challenged. The negative messaging from the media is so blindingly obvious, and even out own government perpetuates that message that shames and ridicules larger body sizes. They are considered undesirable, ugly, and creating low self-esteem. Even those living with obesity just assume it is all their fault, and why would they not feel that way when they are attacked by society, and where this stigma is encouraged.
What is most disappointing of all, is that this active bias exists in healthcare, the very same system that champions science. How will those living with obesity ever understand that this condition is out of their control, and instead it is related to the genetic makeup they were handed, when the healthcare education they are being given is to move more and eat less, even the attitudes and language used by professionals is enough to make me cringe. Interestingly, Weight is the most common form of discrimination in the UK, outweighing ethnicity, sexual orientation, and gender.
So then, why don’t they just eat less and exercise more, I hear you say. Let’s explore this…
Firstly, I want to explain the set point theory. Although still considered a “theory”, this is very well acknowledged in the scientific community. In adults our weight is generally maintained at a stable level, you may have experienced this yourself, I know I certainly have, I seem to always bounce back to roughly the same weight, this is where my body seems comfortable. Our hypothalamus in the brain is in control of this, it sets a preferred weight, and uses a feedback mechanism to maintain that certain level of fat within the body. When you suddenly start to eat less, your metabolism slows down, the chemicals in the brain reduce those feelings of fullness and signals the need to eat. This is evolutionary survival, to stop us from starving to death, our body responds in this way.
Most people living with obesity are able to lose weight, in fact they probably work harder at this and do very well with it, more than most of us are able. However, because of the body’s feedback mechanism to prevent starvation, they will only be able to temporarily alter their body weight, before the body fights to return it to its set point. Which means they often end up putting all the weight back on, and even more than before.
This weight cycling adds to the individuals feeling of failure, most will be living with low self-esteem. Which takes me to understanding the psychological implications connected with eating.
In several cases, labels will begin as early as childhood. Those suffering with mental health problems such as anxiety and depression, perhaps related to weight although this is not always the case, may find solace in food. Emotional eating can result in overeating, which then will impact on weight gain, and self-esteem. The cycle will continue. Food provides us with a natural reward and a feeling of pleasantness, it releases dopamine (our happy hormones) that activate pleasure centres within the brain. Science supports the link of mood, food, and obesity, but this is a complex process, and other factors such as cost, income, and availability will also influence food choices.
Many will feel they are unworthy and will not reach out for medical help, and when they do, they are met with the stigmas of the healthcare service, or when they do meet a caring and compassionate professional, they will struggle in getting access to appropriate treatment. Being offered weight loss surgery on the NHS is near impossible, because of this many individuals living with obesity is opting to go abroad or even privately within the UK to be operated on, people are willing to spend this money whether it is really within their affordability as it will inevitably change their lives.
The NHS takes a sensible approach to treating obesity, which is reasonable, it works on a TIER system that tries to apply the appropriate treatment to individual dependant on the severity of the condition. The makes sense, if I have diabetes, but it is well controlled, I would not be expecting a pancreas transplant anytime soon, so from this point of view it all sounds good and what we would expect from a public funded service, but when this is put into practice, the results are not so wonderful, mainly for 2 reasons:
Firstly, most will need treatment but can’t get access to it, as sadly some doctors have this misconception that you must go from TIER 1 to TIER 4 like climbing a ladder, which is simply not the case. The TIER most appropriate to that person will be based on the assessment of which category would fit their needs, for example if they have a higher body mass index and have been living with obesity for some time, it would be appropriate to refer them straight in at TIER 4, unfortunately because of this misconception they might instead be offered TIER 2, so by the time they reach TIER 4 they are getting the treatment far too late.
Could you imagine if this happened in any other condition where they did not receive the appropriate treatment for their stage of the condition? Take cancer as an example, and you went to see your doctor, and they have told you that your cancer is far spread and you need surgery, but they will not be providing you with the surgery until you have reached that stage of the ladder. There would be absolute outrage, but as cancer is innocent and obesity is full of blame, this is entirely acceptable within our society.
The other issue with access, is that the TIER 3-4 weight management services, which is where you may potentially access surgery, where you can be offered weight loss medications, and will receive an whole intense medical team approach; there will be nurses, psychologists, dieticians, doctors all working together within this service. Again, sounds great as a plan, but the reality is these services vary, depending on where you live in the country, in many areas a weight management service is simply not available or just does not exist, this is a prime example of health inequality, or simply put a game of “postcode lottery”, where you can just hope to land on Mayfair.
One positive impact the pandemic has brought about for those living with obesity, is that all sudden they are being given a focus, and this increase in attention is welcomed. I welcome the new policies that aim to help those living with this condition, this is very much needed. The problem is they haven’t improved any access to treatment, which I have just highlighted as needing change. What these polices are strongly focused on is prevention- which is again welcomed, prevention is better than cure after all. Even so, where does that leave the 35 million people living with obesity in the UK who many are already needing treatment?
Rather than focusing solely on individual responsibility to do something about obesity, there needs to be a systemic change, starting with how we view the disease. We need to change the narrative so those living with this condition feel supported to seek help. We need to ensure when they do seek help, they have somewhere they can access for what they need, when they need it
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Growing Nurses 