A couple of days ago, the National Institute of Health and Care Excellence released a draft of their new guidelines for the treatment of "overweight and obese adults". I am not going to talk about the guidelines in general - that is a whole other blog post and I've covered many of the points elsewhere; but I do want to focus on one of the recommendations from the guidelines that seems to have captured the attention of the press and that has been the focus of most of the news stories about the guidelines. What is it that's gotten everybody so excited? One phrase: that healthcare providers should "ensure the tone and content of all communications or dialogue is respectful and non-blaming." I'll let you ponder on that for a moment.
The Daily Mail ran the story as the main item on its front page with the headline: "Don't be nasty to fat people!" And it wasn't just the tabloids. The broadsheets also thought this was a newsworthy sentiment, with a remarkably similar "Don't be horrible to fat people" making the front page of the Times. How did we become a society where (a) doctors needed to be told to respect their patients, and (b) that the suggestions that fat people deserved respect became so shocking as to be front-page news? But the media were right - this is a story.
The scientific literature on the prevalence and impact of weight stigma is growing almost by the day. Not only are negative attitudes towards fat people endemic within society, but health care practitioners have been shown to have highly stigmatising opinions of their fat patients - everything from believing they are weak-willed, sloppy, greedy, lazy, and undisciplined, to actually disliking touching them or even wishing they didn't have to deal with them at all. And it's not just qualified doctors, nurses, bariatric specialists, dieticians, eating disorder specialists and exercise professionals. A recent UK study of 1130 medical, nursing, and allied health profession students reported that 16 of them managed a neutral or better opinion on the characteristics of fat people. Sixteen. So the problem seems unlikely to improve any time soon.
And it is a problem. It's not just about protecting people's feelings. There are real negative health consequences of being on the receiving end of stigma. Much of the scientific evidence on this comes from the racism, homophobia, and mental health stigma literature, but the findings are consistent, well known, and beginning to be shown to result from weight stigma also. The body's response to chronic stress can lead to numerous long-term health problems. Being the target of prejudice and discrimination, whether actual or perceived, is associated with significantly increased rates of chronic health conditions including depression, heart disease, hypertension, and diabetes. As these are all diseases usually associated with obesity, one can't help but wonder to what extent the weight itself is the problem and what role the 'War on Obesity' and widespread condemnation of fat people is to blame. This is a question that cannot really be answered, as it would be practically impossible to find a group of non-stigmatised fat people for comparison. But it is a question that any ethical body must at lease raise. And for this reason, whatever else is problematic about the NICE report, I commend them for listening to the evidence on this topic, for acknowledging that at least some of the harms associated with obesity can be traced back to stigma, discrimination and bullying, and for doing something about it.
And yet, many healthcare practitioners still hold the view that this is the wrong approach. As Dr Max Pemberton wrote in the Daily Mail following the release of the draft report, "If doctors like me are nice to fatties, they'll just get FATTER". He continued: "We doctors need to be a little less understanding, a little more judgmental, and realise that our oath -- 'Do no harm' -- must come before our desire to save the feelings of our patients."
The article has actually now been taken down. I'm not entirely sure why. At the time it was removed, most of Daily Mail commenters were in agreement with the piece, and lauding the doctor for standing up to what they called 'political correctness gone mad' - otherwise known as being frustrated that they are no longer allowed to be obnoxious to people they consider inferior without somebody saying something about it. But since neither the newspaper's readers, nor its editorial department found the article problematic, I can only assume the backlash came from elsewhere, hopefully from his colleagues or professional body.
Although the sentiment of the article is widely shared, perhaps it was the tone of the piece - the language used was indicative or Dr Pemberton's own disdain and disgust towards his fat patients. Whatever his personal views, words such as "guzzling" and "fatties" are disgraceful coming from a practicing health professional, even when writing in the popular press. Especially when writing in the popular press. For a licensed professional to derogate his patients in this manner would be inconceivable for any other condition. Imagine a psychiatrist referring to his patients as "loonies". Imagine a gynaecologist writing about his patient's "boobies". And yet this kind of language is often considered perfectly acceptable when directed at fat people.
Still, the idea that shaming is an effective tool in promoting behaviour change is not new, and nor is it dying out, despite all the scientific evidence suggesting that this approach is more likely to backfire and result in de-motivating people from engaging in health behaviours. Dr. Pemberton is not alone in holding this view, and some have even suggested that shaming may be an effective public health policy. As 'being nice' is clearly not enough of a reason for some professionals to treat their patients with respect, it is clearly necessary that organisations such as NICE educate their members on the medical benefits of such an approach.
What is more, people's feelings do actually matter. A recent study found that the worse people felt about themselves because of their weight, the worse both their mental and physical health impairment, even after taking into account their BMI, age, and existing health conditions like heart disease and diabetes. The shame alone made them sicker.
With the evidence of real damage caused by weight stigma, if doctors and other health professionals take their oath seriously, if they genuinely wish to do no harm, less judgment and more understanding would be a good start.