Use of the term 'obesity'
The importance of language when describing the problem, or developing
programs that attempt to tackle overweight and obesity, was highlighted
throughout the inquiry. Even the language used for this inquiry was questioned
as it potentially generates fear among individuals. These descriptions then
permeate to the level of the individual with negative connotations.
The committee deliberated on whether the term 'obesity' itself should be
used in any context. It is a medical term meaning excess weight that is likely
to be detrimental to health. The general usage of the term covers all aspects
of the condition from description, to prevention, to intervention. It is a term
understood and used universally among stakeholders.
However, the committee agreed that in certain circumstances the term is
not helpful. As discussed throughout this chapter, there is a high degree of
stigma associated with the term, which can cause those most in need of
assistance to shy away from accessing help, or being influenced by messaging
that contains it. The example cited below, of the Nepean Family Metabolic
Health Service changing its name from the Family Obesity Service, highlights the
difficulty the term creates. The same difficulties apply to public information
campaigns where the messaging needs to be focused on positive behavioural
change, with a focus on health rather than weight.
The committee therefore is of the view that the term should not be used
for intervention and prevention programs. These programs should emphasise
healthy weight; good nutrition; increased physical activity and appropriate
public and community infrastructure. This is discussed in the rest of this
However, in medical and high level policy settings, there is no current
alternative to the term. The efforts to tackle obesity are multipronged, and
require coordinated efforts from across all levels of government and public agencies.
Obesity is the single catch-all term that covers all elements that need to go
into prevention and intervention efforts, and as such, brings all of those
programs under one policy. The committee therefore accepts that until an
alternative is available, the term needs to remain attached to government
efforts and bodies charged with implementing change.
Focus on health, not weight
Food Fairness Illawarra recommended that programs to address the problem
should ensure that they do not attribute the blame for a person's weight solely
to the individual:
Education or campaign approaches need to demonstrate that
they will not have an unfavourable impact, such as stigmatisation, blaming and
misconceptions about the importance of physical activity and good diet as
protective factors for disease prevention irrespective of weight.
The National Centre for Epidemiology and Population Health (NCEPH),
Research School of Population Health at the Australian National University,
also pointed to evidence which suggests that the focus on body size, rather than
health, is detrimental to people's mental health:
Campaigns tend to target obesity using a bio-medical focus on
individual bodies and weight contributing to the stigmatization of fat people
and potentially contributing further to unhealthy food consumption practices
(Kinmonth 2016) and mental health issues. If the focus was shifted to directly
addressing chronic diseases such as Type 2 diabetes, hypertension,
cardio-vascular disease and cancers associated with obesity this might reduce
the obsession with body size.
As did the Royal Australian and New Zealand College of Psychiatrists in
Research has established an association between increased
body weight and mental health disorders, with increased odds for mood disorders
or anxiety disorders (Scott et al., 2008; Simon et al., 2006). People with
obesity are also at increased risk of exposure to bullying, social stigma and
weight bias in employment, education and health care. This can have a significant
impact on mental health, and exacerbate psychological issues around diet and
healthy eating. In addition, stigma can often form a barrier to seeking help.
It is important that these factors are considered when designing services to
meet the growing need for obesity-related interventions.
The focus on health rather than weight was raised by a number of
witnesses, including Ms Sarah Harry from Health at Every Size Australia:
It is taking the things that we know stigmatise like BMI and
weight, measuring those things in research and putting the focus on health and
wellbeing. I do keep coming back to This Girl Can because it worked so well...It
worked because it was stigma free, weight loss free and number free, and the
focus was entirely on getting out, having fun and being healthy.
The committee was also told of health services that no longer use the
term obesity, for fear of stigmatizing those who are most in need of treatment.
The Nepean Family Metabolic Health Service (formerly known as the 'Nepean Family
Obesity Service') changed its name to remove any barriers for people accessing
the service, particularly pregnant women:
We had several clients tell us that they had problems sitting
underneath the Nepean Family Obesity Service tag and they didn't like taking
referrals for various investigations saying 'obesity service'; they felt
judged. It's already hard enough for them to attend our clinic. In the first
clinic appointment they're usually very anxious and they don't want to be
there. It's our job to make them feel very comfortable, and we want to remove
every single barrier that there is. One area that we found particularly
difficult was the obstetrics services. Even midwives and other healthcare
professionals had problems referring pregnant mothers to our service because
they themselves felt uncomfortable with the concept of obesity and, indeed,
their own weight.
Psychological impact of stigma
The psychological impact of obesity on those affected can be profound.
The committee received evidence from the Nepean Family Obesity Service,
whose region has one of the highest levels of childhood overweight and obesity
in Australia, explaining how children in particular are affected by obesity:
The typical paediatric patient engaging with our tertiary
service tends to live a stressful life. One or both parents of this child are
obese, often living on minimal incomes, and have high stress and/or medical
co-morbidities. Children suffer psychological illness due to bullying and
weight stigma and feel excluded from school and peer interactions. These
children can also have multiple medical conditions including diabetes, sleep
disorders and joint and mobility limitations.
The International Health Economics Association's Economics of Obesity
Special Interest Group echoed findings citing the psychological effects of
obesity on children:
Children with obesity suffer from weight stigma and bullying.
After accounting for confounding and selection bias, compared to healthy weight
children, obesity among 6 to 13 year olds in Australia causes substantially
more emotional problems (both genders) and peer problems (especially
for boys). Similar findings have been reported in the United States.
The committee also heard that one of the reasons previous measures to
tackle childhood obesity have failed is because they have focused on weight,
rather than health, and this results in stigmatization which has many
There is strong evidence that weight focused anti-obesity
interventions have significant unintended harmful consequences through
stigmatization of people of higher weight. This causes psychological harm
including anxiety, depression, body dissatisfaction and disordered eating; that
promotes adolescent dieting which predisposes and leads to eating disorders and
weight gain. Weight focus and stigmatization result in reduced participation in
health related physical activities.
This view was shared by Professor Susan Sawyer from the Centre for
Adolescent Health at The Royal Children's Hospital Melbourne:
This is where it's also important to recognise the
intersection between obesity and eating disorders... I'm just highlighting that
we need to be very careful, particularly with children and adolescents. We
know, absolutely, from the studies that at the age of three and five they are
already highly aware of the stigma of being overweight. That then leads to the
risk of very abnormal behaviours and the entry into anorexia nervosa and
The real life effects of this stigma on a child's life choices were
illustrated by the Clinical Dietician from the Nepean Family Metabolic Health
Service, Ms Sally Badorrek, who explained:
They find every opportunity to get out of sport at school.
They will choose to do art at high school instead of sport because often there
are art classes that can be used as sport. That's an issue. Or they'll say that
they're unwell, and they're often unwell, and they'll go and sit in the sick
bay to miss out on sport. Often they feel a lot of stigma. They're not going to
be chosen to be on a team sport, and that makes them feel even worse about
themselves. So they grow to hate sport.
The committee heard that stigmatisation has far-reaching health
consequences beyond any conditions related to weight. Health at Every Size
Australia provided the take up of pap smears as an example:
We see time and time again that people in bigger bodies
aren't presenting to primary care until it's way too late. They're putting off
pap smears. They're putting off treatment and they're coming in with illnesses
way too late, because they're afraid of the stigma that's associated with
weight when they come to primary care. 
Stigma in the medical profession
This sensitivity of treating obesity and weight-related conditions among
health professionals was also evident for doctors. Dr Alexander, Staff
Specialist and Head of Weight Management Services at The Children's Hospital
Westmead, told the committee that there is a reluctance by general practitioners
(GPs) to raise the issue, particularly in the case of children:
Because it's such a sensitive thing, particularly general
practitioners don't want to raise it because they think it's going to upset the
family. Whereas the research suggests that, in fact, parents want you to raise
any health issues, including weight management, but many GPs won't raise it
because of their own barriers of feeling uncomfortable about raising it.
This is an issue which is widely recognised in the medical profession
and health sector. Professor Boyle, Deputy Director and Obstetrician from the
Monash Centre for Health Research and Implementation, told the committee of the
training for health professionals to overcome the stigma attached to the issue:
There are a number of difficulties that health providers
experience. One is time—training people to undertake these sorts of brief
interventions in a short time, and understanding that it can be delivered by a
health promotion officer; it doesn't actually have to be the doctor or the
midwife. I think that a lot of health providers worry about talking to women
about their weight. There is the stigma. How do they go about it? We need to
train people at undergraduate and postgraduate levels about how to do that.
Mr Ahmad Aly, a bariatric surgeon, told of the stigma and prejudice
around surgical treatment to treat obesity, which includes from hospital
Obesity has this stigma and prejudice. Further than that,
surgery has a stigma as well, because people say: 'No, you should be able to do
it yourself. You shouldn't need surgery; that's too drastic.' So that has a
stigma as well...So, yes, prejudice is part of it. That probably is what
happens at a local hospital level. If a surgeon went to their administrators
and said, 'We'd like to start a bariatric surgical service,' one of the main
reasons that that may not go ahead is that concept of stigma and perception.
A fundamental and highly damaging feature of the obesity problem is the
stigma associated with weight, and weight-related health conditions. The stigma
is endemic, in that it impacts all aspects of how society thinks about
overweight and obesity, how is describes it, how it attributes blame for the condition,
and how it is treated.
The committee unsurprisingly received extensive evidence on the impact
of stigma, and importantly and pertinently, how to avoid stigmatising the issue
further, even to the point of the naming this inquiry differently. The
overwhelming message in the evidence is that this goes far beyond a simple
How program and treatments are named impacts on how people will access
them, which in turn impacts on their effectiveness. The psychological impacts
from childhood onward have significant tangible effects, and exacerbate the
health impacts of overweight and obesity. The attitude and understanding of the
condition, and treatment options by health professionals, including
doctors, and health administrators, again impacts hugely on clinical and
The committee heard useful suggestions on how to best address stigma at
all junctures. Care should be taken in naming programs and treatments, and
funding for programs should be conditional on them being appropriately named.
Health professionals at all levels should receive adequate training on how to
ensure that recipients of care and treatment are best identified and encouraged
to access services.
As discussed at the start of this chapter, the committee supports a move
away from using the term 'obesity' in all prevention and intervention programs
and public information campaigns, and move the focus from weight on to health. However
the committee accepts that in medical and overarching policy settings, there is
no current agreed alternative to the term, and as such it will continue to be
The committee recommends that Commonwealth funding for overweight and
obesity prevention efforts and treatment programs should be contingent on the
appropriate use of language to avoid stigma and blame in all aspects of public
health campaigns, program design and delivery.
The committee recommends that the Commonwealth Department of Health work
with organisations responsible for training medical and allied health
professionals to incorporate modules specifically aimed at increasing the
understanding and awareness of stigma and blame in medical, psychological and
public health interventions of overweight and obesity.
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