Health & Wellbeing Queensland
Response to Queensland Obesity Prevention Strategy (2023-2032) and Strengthen (2023-2025) Action Plan (working title)
Eating Disorder Queensland (EDQ) would like to take this opportunity to elaborate further on our online survey responses on Queensland’s planned O* Prevention Strategy. In writing this feedback, we consulted with lived experience activist Nic McDermid to ensure that personal experience of the issues being discussed is incorporated. O* and eating disorders are interrelated, with many individuals moving between the conditions over time or both conditions co-occurring for an individual.[i]
EDQ is a state-wide, community-based not-for-profit organisation. We support both individuals who are living with an eating disorder and their carers, loved ones, and key support people.
Support options include therapeutic and psychosocial support for individuals, coaching, and community connection for carers. EDQ also provides early intervention opportunities with community education events focusing on creating healthy relationships with food and our bodies.
We are passionate about eradicating weight stigma and diet culture.
It’s all in the name:
We want to start our feedback with the ‘working title’ of the strategy, which will set the tone for the plan and its actions; language is powerful and, whether intended or not, will be a driver for positive or negative outcomes.[ii]
The word ‘obesity’ carries vast amounts of stigmatising connotations;[iii] the term has been used to shame, marginalise, insult, and discriminate against individuals living in larger bodies.
The Senate’s Select Committee into the Obesity Epidemic in Australia[iv] acknowledges that “a high degree of stigma is associated with the term ‘obesity’. As a result, the committee supports a move away from using the term ‘obesity’ in prevention and intervention programs and public information campaigns and move the focus from weight to health” (p. XV).
The current term will be used with the caveat since no contemporary agreed-upon alternative exists. The Senate Select Committee acknowledged that addressing weight stigma “goes far beyond a simple language issue” (p. 16).
Language holds power; this word is far from a ‘simple language issue’; it forms the basis of a deep-seated, inherent, and systemic social injustice.
Dr Carolynne White[v] from the Swinburne University of Technology states, “Weight stigma is a social justice issue. [vi]Therefore, reducing stigma is a societal responsibility requiring education and cultural change. Choosing the appropriate language is an important first step. For example, ‘obese’ and ‘overweight’ are unhelpful. While some researchers and organisations have argued for person-first language (e.g., a person with obesity), fat activists prefer the term ‘fat’, which they have reclaimed as a neutral descriptor of their body size. A useful compromise[vii] is to recognise and respect the person’s wishes.”
Additionally, an intersectional approach to understanding weight stigma is essential. The impacts of O* Campaigns and strategies don’t exist in a vacuum; weight stigma is often experienced alongside multiple marginalisations. The effects of weight stigma and discrimination may be more pronounced in marginalised groups at the intersection of gender, sexuality, race, and class.[viii],[ix],[x]
Now is the time to change harmful language, do the work through lived experience consultation, and find an alternative.
The Vision and Goal set the tone:
We note the weight-centric focus in both the Mission and Goal, referencing ‘healthy weight’ and changing a system that is not ‘supportive of healthy weight’. We currently have a system geared towards ‘thinness = health’. A system that advocates ‘clean eating’, ‘detoxing’, and ‘fitspo’, to mention only a few of these non-evidence-based diet cultures that cause significant harm and can lead to body image issues and severe eating disorders.[xi],[xii] A goal to “change the systems that are not supportive of a healthy weight” only gives the system more ammunition to discriminate against people in larger bodies by legitimising and condoning this discrimination through a ‘prevention’ strategy.[xiii]
(Intended or not).
“Weight stigma is also often unintentionally reinforced in public health campaigns, the media, and through social media discourses, which oversimplify the relationships between weight and health through associating specific body shapes and sizes with risk and disease while idealising others. In addition, emphasising an individual’s responsibility to maintain a ‘healthy’ weight causes fear of weight gain, fuels body dissatisfaction and encourages blame while ignoring the broader social, cultural, environmental, and commercial determinants of health”, states Dr White.[xiv]
‘Healthy Weight’ messaging is problematic, as it medicalises body size based on Body Mass Index (BMI), an outdated measure. As the Butterfly Foundation highlights, “this simple formula, designed before calculators and computers, fails to consider several important factors. Firstly, BMI does not acknowledge the differences between muscle mass and fat distribution. As such, athletic people with a high muscle mass could be classified as ‘overweight’ or ‘obese’, despite them being ‘healthy’. BMI also does not consider age, sex, or bone structure. Researchers say the lack of information can introduce misclassification problems that may result in important bias in estimating the effects related to ‘obesity’.[xv] Others highlight that as the BMI formula originated from data of European men, it lacks effectiveness for people of other races and ethnicities.”[xvi]
For a plan to pivot to a weight-centric Vision and Goal, we run the risk of further stigmatising people, creating a healthcare approach that ignores the bigger picture. A 2021 parliamentary enquiry into body image in the UK reported that people with a higher BMI… felt it was difficult to access quality healthcare as health complaints were automatically diagnosed as weight-related and not properly investigated” (p. 18).[xvii] “Further research demonstrates that adults with a higher BMI are nearly three times as likely as a person with a ‘normal’ BMI to say that they have been denied access to appropriate medical care, leading many to avoid seeking treatment because of the discomfort of stigma.”[xviii],[xix] As lived experience activist Nic McDermid says, “the further you are towards the proximity of fatness, the harder it is to access care and support that isn’t laden with weight stigma.”
The medicalising of body weights and sizes in health messaging and healthcare also has counterproductive impacts on health. As highlighted by the recently released Management of eating disorders for people with higher weight: clinical practice guideline, “eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated.” According to Nic McDermid, “folks in larger bodies are seen as unreliable sources of information about their own experiences – when we are seen as the sum of our body size, instead of being treated like human beings, we’re infantilised and treated as though we cannot be trusted.”[xx]
Placing emphasis on weight control/reduction in health messaging has been shown to promote disordered eating behaviours, reduce physical activity, and discourage health behaviours.
This is important to note as many health indicators have been shown to be improved through positive changes in health behaviours, regardless of if body weight is reduced.[xxi] As such, weight-focused strategies and public health messaging may be more detrimental than beneficial to health.[xxii]
To incorporate Health at Every Size (HAES) principles[xxiii] in the Vision and Goals in place of a weight-centric focus. HAES is an approach to health policy and care that supports people of all sizes to take care of their health and well-being without weight stigma or a focus on reducing body size.[xxiv] A HAES approach has been demonstrated to “achieve health outcomes more successfully than weight loss treatment and without the contraindications associated with a weight focus” (p. 1).[xxv] Evidence from numerous controlled clinical trials also indicates that a HAES approach is associated with improvements in physiological measures (e.g. blood pressure), health behaviours (e.g. eating and activity habits) and psychosocial outcomes (e.g. body image and self-esteem). [xxvi],[xxvii]
The HAES principles include:
Weight inclusivity: Accept and respect the inherent diversity of body shapes and sizes and reject the idealising or pathologising of specific weights.
Health Enhancement: Support health policies that improve and equalise access to information and services and personal practices that enhance human well-being, including attention to individual physical, economic, social, spiritual, emotional, and other needs.
Respectful Care: Acknowledge our biases, and work to end weight discrimination, weight stigma, and weight bias. Provide information and services from an understanding that socio-economic status, race, gender, sexual orientation, age, and other identities impact weight stigma and support environments that address these inequities.
Eating for Well-being: Promote flexible, individualised eating based on hunger, satiety, nutritional needs, and pleasure rather than any externally regulated eating plan focused on weight control.
Life-Enhancing Movement: Support physical activities that allow people of all sizes, abilities, and interests to engage in the enjoyable movement to the degree they choose.
EDQ wholly support and stand by Butterfly Foundations’ statement that “the simple fact is that treating someone as a human being worthy of respect and appropriate medical care, and not just as a number on a scale, works.” [xxviii]
Let’s not create an overarching strategy that inadvertently undermines this.
The targeting of ‘obesity’ in children and adolescents is very concerning, especially as we have seen a significant rise in eating disorders in children as young as two. The presentation of children with eating disorders to the Children’s Health Queensland Hospital and Health Service (CHQ) alone has been alarming. Emergency department presentations to the Queensland Children’s Hospital for children with eating disorders almost doubled between 2019 and 2020.[xxix]
The recent increase (since COVID in 2020), in addition to the longstanding (years) trend upwards, in the number of young people presenting with eating disorders to CHQ, has led to significant challenges for these young people and their families in accessing appropriate, timely treatment across the service continuum.[xxx] One measurable outcome of this has been a 130% increase in the need for hospital admission for acute management during the 2020/21 financial year.[xxxi] The reason for the higher presentations is multifactorial and complex, which cautions for an approach that does NOT take into consideration all these factors.
The Victorian Centre of Excellence in Eating Disorders (CEED) submitted a report[xxxii] to the Select Committee into The O* Epidemic in Australia, with the insights 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 stigmatisation which has many unintended consequences. There is strong evidence that weight-focused anti-obesity interventions have significant unintended harmful consequences through stigmatising people of higher weight. This causes psychological harm, including anxiety, depression, body dissatisfaction and disordered eating, which promotes adolescent dieting and predisposes and leads to eating disorders and weight gain.”[xxxiii] Experiences of weight-based teasing and bullying from family and peers during childhood have been associated with disordered eating behaviours in adulthood. [xxxiv] Weight-based teasing and bullying result from ongoing weight stigmatisation in society, which is only perpetuated by weight-focused public health and government initiatives.
The National Eating Disorder Collaboration warn that children targeted by weight-focused strategies and “their parents may misinterpret awareness-raising initiatives that focus on the consequences of childhood obesity without appropriate information and support for an effective lifestyle change. They may misinterpret such initiatives as cues to engage in dieting, such as fad or restrictive dieting. This is unsuitable for growing children and may have detrimental consequences for health and physical growth.”[xxxv] Dieting is also the most common risk factor for developing an eating disorder during adolescence.[xxxvi] Adolescents who engage in moderate dieting are five times more likely to develop an eating disorder, and those who engage in severe dieting are 18 times more likely.[xxxvii]
“Weight focus and stigmatisation result in reduced participation in health-related physical activities.” This information was shared by Professor Susan Sawyer from the Centre for Adolescent Health at The Royal Children’s Hospital Melbourne during the Senate Select Committee into the Obesity Epidemic in Australia. “This is where it’s also important to recognise the intersection between obesity and eating disorders… I’m just highlighting that we must be cautious, 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 entry into anorexia nervosa and bulimia nervosa.”[xxxviii]
We recommend the approach of the Satter Division of Responsibility in Feeding (sDOR) from birth.[xxxix]
“Flag the child’s medical record for periodic assessment of fdSatter/sDOR adherence and ongoing, consistent growth. As outlined in a related issue of Family Meals Focus, detect early growth acceleration or faltering and intervene by identifying and correcting factors that disrupt feeding dynamics, the child’s energy balance, and the child’s growth trajectory. Avoid direct or indirect attempts to get the child to lose weight. Such attempts interfere with children’s natural slimming and with weight maintenance throughout life.” [xl]
Supporting parents around approaches to feeding and food that are less stressful for the family. For example, research indicates that mindful parenting is associated with lower levels of parenting stress and more adaptive parental-child feeding practices, such as less use of food as a reward, pressure to eat, and monitoring, which in turn is associated with less disordered eating behaviours in children and adolescents.[xli]
We acknowledge that HWQld has been undertaking a broad engagement process, including hearing from people with lived experience of higher body weight. We would further recommend that HWQld seek consultation with people with lived experience of both higher body weight and eating disorders.
In conclusion, the Guiding Principle of Equity in the strategy will be undermined by a weight-centric approach that causes stigma, marginalisation and discrimination.
“Social justice for people who are fat and stigmatised based on their weight cannot be fully realised when their advocates on the scientific front lines believe they should (and can) be thin. It is essential that scholars campaign for formal legislation to protect against weight stigma and discrimination.”
“We encourage weight-stigma scholars (and in this case, state government) to engage more directly and openly with non-stigmatising models for health and well-being, instead of promoting a stigmatising treatment (weight loss) for an already stigmatised group (people who are fat)” (p. 19).[xlii]
There are empirically supported models and approaches for health promotion that do not rely on weight loss and weight control as markers of success or misalign weight loss with health.
Weight-neutral approaches have emerged in recent years as a response to weight-normative (or weight-centred) approaches to health and recognise the debilitating stigma associated with being fat and the failure to procure weight loss.[xliii]
References are listed below.
[i] Bullivant, B., Denham, A. R., Stephens, C., Olson., R. E., Mitchison, D., Gill, T., Maguire, S., Latner, J. D., Hay, P., Rodgers, B., Stevenson, R. J., Touyz, S., & Mond, J. M. (2019). Elucidating knowledge and beliefs about obesity and eating disorders among key stakeholders: Paving the way for an integrated approach to health promotion. BMC Public Health, 19, Article 1681. https://doi.org/10.1186/s12889-019-7971-y
[ii] Vartanian, L. R. (2010). “Obese people” vs “fat people”: Impact of group label on weight bias. Eating and Weight Disorders; 15(3), e195-e198. https://doi.org/10.1007/BF03325299
[iii] Vartanian, L. R. (2010). “Obese people” vs “fat people”: Impact of group label on weight bias. Eating and Weight Disorders; 15(3), e195-e198. https://doi.org/10.1007/BF03325299
[iv] The Senate Select Committee into the Obesity Epidemic in Australia. (2018). Select Committee into the Obesity Epidemic in Australia: Final Report. Commonwealth of Australia.
[v] White, C. (2019). Weight Stigma 101. Medium. https://medium.com/@carolynnewhite/weight-stigma-101-6bceb7f209c5
[vi] Calogero, R. M., Tylka, T. L., & Mensinger, J. L. (2016). Scientific weightism: A view of mainstream weight stigma research through a feminist lens. In T.-A. Roberts, N. Curtin, L. E. Duncan, & L. M. Cortina (Eds.), Feminist perspectives on building a better psychological science of gender (pp. 9–28). Springer International Publishing/Springer Nature. https://doi.org/10.1007/978-3-319-32141-7_2
[vii] Meadows, A. & Daníelsdóttir, S. (2016). What’s in a word? On weight stigma and terminology. Frontiers in Psychology, 7, Article 1527. https://doi.org/10.3389/fpsyg.2016.01527
[viii] Paine, E. A. (2021). “Fat broken arm syndrome”: Negotiating risk, stigma, and weight bias in LGBTQ healthcare. Social Science & Medicine, 270, Article 113609. https://doi.org/10.1016/j.socscimed.2020.113609
[ix] Ciciurkaite, G., & Perry, B. L. (2017). Body weight, perceived weight stigma and mental health among women at the intersection of race/ethnicity and socioeconomic status: Insights from the modified labelling approach. Sociology of Health & Illness, 40(1), 18-37. https://doi.org/10.1111/1467-9566.12619
[x] Puhl, R. M., Heuer, C. A. (2009). The stigma of obesity: A review and update. Obesity, 17(5), 941-964. https://doi.org/10.1038/oby.2008.636
[xi] Rohde, P., & Stice, E. (2014). Development and predictive effects of eating disorder risk factors during adolescence: Implications for prevention efforts. International Journal of Eating Disorders, 48(2), 187-198. https://doi.org/10.1002/eat.22270
[xii] Cataldo, I., De Luca, I., Giorgetti, V., Cicconcelli, D., Bersani, F. S., Imperatori, C., Abdi, S., Negri, A., Esposito, G., & Corazza, O. (2021). Fitspiration on social media: Body-image and other psychopathological risks among young adults. A narrative review. Emerging Trends in Drugs, Additions, and Health, 1, Article 100010. https://doi.org/10.1016/j.etdah.2021.100010
[xiii] Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harm health. BMC Medicine, 16, Article 123. https://doi.org/10.1186/s12916-018-1116-5
[xiv] White, C. (2019). Weight Stigma 101. Medium. https://medium.com/@carolynnewhite/weight-stigma-101-6bceb7f209c5
[xv] Rothman, K. J. (2008). BMI-related errors in the measurement of obesity. International Journal of Obesity, 32(S3), S56-S59. https://doi.org/10.1038/ijo.2008.87
[xvi] The Butterfly Foundation. (2021). Why you shouldn’t let BMI define your health. https://butterfly.org.au/why-you-shouldnt-let-bmi-define-your-health/
[xvii] Women and Equalities Committee. (2021). Changing the perfect picture: An inquiry into body image. House of Commons. https://committees.parliament.uk/publications/5357/documents/53751/default/
[xviii] The Butterfly Foundation. (2021). Why you shouldn’t let BMI define your health. https://butterfly.org.au/why-you-shouldnt-let-bmi-define-your-health/
[xix] Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16, Article 123. https://doi.org/10.1186/s12916-018-1116-5
[xx] Ralph, A. F., Brennan, L., Byrne, S., Caldwell, B., Farmer, J., Hart, L. M., Heruc, G. A., Maguire, S., Piya, M. K., Quin, J., Trobe, S. K., Wallis, A., Williams-Tchen, A., & Hay, P. (2022). Management of eating disorders for people with a higher weight: Clinical practice guideline. Journal of Eating Disorders, 10, Article 121. https://doi.org/10.1186/s40337-022-00622-w
[xxi] Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10(1), 9. https://doi.org/10.1186/1475-2891-10-9
[xxii] Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10(1), 9. https://doi.org/10.1186/1475-2891-10-9
[xxiii] Health at Every Size (HAES) Australia. https://www.haesaustralia.org.au/
[xxiv] Health at Every Size (HAES) Australia. https://www.haesaustralia.org.au/
[xxv] Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10(1), 9. https://doi.org/10.1186/1475-2891-10-9
[xxvi] Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10(1), 9. https://doi.org/10.1186/1475-2891-10-9
[xxvii] The Butterfly Foundation. (2021). Why you shouldn’t let BMI define your health. https://butterfly.org.au/why-you-shouldnt-let-bmi-define-your-health/
[xxviii] The Butterfly Foundation. (2021). Why you shouldn’t let BMI define your health. https://butterfly.org.au/why-you-shouldnt-let-bmi-define-your-health/
[xxix] Tedja, A. M., Shanmugam, M. R., Stathis, S., & Middeldorp, C. M. (2022). Short research article: COVID-19 and its impact on child and youth mental health service demand in the community and emergency department. Child and Adolescent Mental Health. https://doi.org/10.1111/camh.12593
[xxx] Children’s Health Queensland Hospital and Health Service. (2022). Children’s Health Queensland – Submission to the Mental Health Select Committee. Queensland Government. https://documents.parliament.qld.gov.au/com/MHSC-1B43/IQ-5DEF/220218-QTON-CHQ.pdf
[xxxi] Children’s Healthcare Australia. (2021). Children’s Health Care Australia Annual Report 2020-2021. https://children.wcha.asn.au/wp-content/uploads/sites/2/2022/03/cha_annual_report_20-21_final.pdf
[xxxii] The Victorian Centre of Excellence in Eating Disorders (CEED). (2018). The Victorian Centre of Excellence in Eating Disorders (CEED) – Submission to the Australian Senate Select Committee into the Obesity Epidemic in Australia. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Obesity_epidemic_in_Australia/Obesity/Submissions
[xxxiii] The Senate Select Committee into the Obesity Epidemic in Australia. (2018). Select Committee into the Obesity Epidemic in Australia: Final Report. Commonwealth of Australia.
[xxxiv] Puhl, R. M., Wall, M. M., Chen, C., Austin, S. B., Eisenberg, M. E., & Neumark-Sztainer. (2017). Experiences of weight teasing in adolescence and weight-related outcomes in adulthood: A 15-year longitudinal study. Preventive Medicine, 100, 173-179. https://doi.org/10.1016/j.ypmed.2017.04.023
[xxxv] National Eating Disorders Collaboration. (2011). Evaluating the Risk of Harm of Weight-Related Public Health Messages. https://www.nedc.com.au/assets/NEDC-Publications/Evaluating-the-Risk-of-Harm-final.pdf
[xxxvi] Patton, G. C., Seltzer, R., Coffey, C., Carlin, J. B., & Wolfe, R. (1999). Onset of adolescent eating disorders: Population based cohort study over 3 years. British Medical Journal, 318(7186), 765-768. https://doi.org/10.1136/bmj.318.7186.765
[xxxvii] Patton, G. C., Seltzer, R., Coffey, C., Carlin, J. B., & Wolfe, R. (1999). Onset of adolescent eating disorders: Population based cohort study over 3 years. British Medical Journal, 318(7186), 765-768. https://doi.org/10.1136/bmj.318.7186.765
[xxxviii] The Senate Select Committee into the Obesity Epidemic in Australia. (2018). Select Committee into the Obesity Epidemic in Australia: Final Report. Commonwealth of Australia.
[xxxix] Satter, E. (2005). Child’s Weight: Helping Without Harming. Your Child’s Weight: Helping Without Harming (pp. 23-62). Kelcy Press.
[xl] Satter, E. (2022). Children and Weight: Are Current Guidelines Helpful? Do They Do Harm? Ellyn Satter Institute. https://www.ellynsatterinstitute.org/family-meals-focus/6-children-and-weight-guidelines/
[xli] Gouveia, M. J., Canavarro, M.C., & Moreira, H. (2019). How can mindful parenting be related to emotional eating and overeating in childhood and adolescence? The mediating role of parenting stress and parental child-feeding practices. Appetite, 138, 102-114. https://doi.org/10.1016/j.appet.2019.03.021
[xlii] Calogero, R. M., Tylka, T. L., & Mensinger, J. L. (2016). Scientific weightism: A view of mainstream weight stigma research through a feminist lens. In T.-A. Roberts, N. Curtin, L. E. Duncan, & L. M. Cortina (Eds.), Feminist perspectives on building a better psychological science of gender (pp. 9–28). Springer International Publishing/Springer Nature. https://doi.org/10.1007/978-3-319-32141-7_2
[xliii] Calogero, R. M., Tylka, T. L., & Mensinger, J. L. (2016). Scientific weightism: A view of mainstream weight stigma research through a feminist lens. In T.-A. Roberts, N. Curtin, L. E. Duncan, & L. M. Cortina (Eds.), Feminist perspectives on building a better psychological science of gender (pp. 9–28). Springer International Publishing/Springer Nature. https://doi.org/10.1007/978-3-319-32141-7_2