Health professionals weigh in on fat issue

http://www.guardian.co.uk/society/2013/jan/25/health-professionals-weigh-in-obesity

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The week started with the Conservative MP Anna Soubry claiming that people got fat because they were poor, and ended with NHS campaigner Dr Eoin Clarke unearthing the most magnificent graph of the causes of obesity, which I can summarise for you as "everything in the world".

And underneath all these fireworks, both figuratively and literally (yes, I'm afraid this is an unnecessarily long way of saying we were in a basement), some real health professionals and academics were at a conference discussing the real reasons people got fat and stayed fat.

"It's funny to hear you use the word 'fat'," said Jo Wallace of St George's Mental Health NHS Trust's eating disorder service to Professor David Haslam, who said it about 500 times. "Working with anorexia for so long, we almost wince at it. We'd say 'fear of fatness'. We'd never describe anyone as fat." She laughed ruefully. There's something about knowing what they're talking about that gives people lovely manners.

Soubry's view was scotched almost as soon as she said it, by some Department of Health statistic showing no obvious correlation between income and weight, with the thinnest people being women in the richest fifth and men in the poorest. The conventional narrative – that obesity is a combination of personal failure and societal booby-trapping, where we're nudged towards unhealthy eating and inactivity, and don't put up much of a fight – remains the starting point.

In a presentation so droll that the people who came after him kicked off with "We're not going to be as enjoyable as that, I'm afraid", Haslam emphasised activity, more activity, sustainable activity – best of all, routine activity, that is built into your life and carries on regardless of the weather, or whether you've broken your arm. I was a little sceptical about his graph of the ideal routine, which included the item "after-dinner walk" (who does that?), but otherwise, it was unarguable. "Five minutes of vigorous masturbation," he pointed out, "takes up 300 calories. It can replace a light meal." In the words of the meal-replacement industry, he continued: "Shake for breakfast, shake for lunch and a sensible dinner."

But there is a school of thought running alongside calories-in-calories-out, which in some ways poses larger questions even than "how can five minutes of masturbation possibly use more calories than half an hour of cycling?"

Julia Buckroyd, emeritus professor of counselling at the University of Hertfordshire, says: "For a substantial number of people who are obese, perhaps half, there is an emotional component to their eating." Jane Dalgliesh did an MA on whether the cognitive models used to treat anorexia would also work on obese patients, and went on to try this out on patients. Her funding was cut after three months so the data is only partial, yet she had plenty of time to notice: "We used the Stirling Eating Disorder Scales, and when we looked at the scales for an obese client, we could have been looking at patients with anorexia or bulimia. The psychopathology was very similar."

Wallace points out the differences in the way we treat undereating and overeating – someone starving themselves to death would be deemed not to have mental capacity and be force-fed; someone eating themselves to death could never be sectioned, never mind starved, on that basis. We perceive undereating and overeating as opposites, when in fact we might understand them better if we saw their similarities.

The implications of this are massive: people with a strong emotional element to their overeating typically, Buckroyd says, "have a history of poor attachment. It could be abuse, trauma, neglect." (Dalgliesh mentions some research that found a third of obese women had been sexually abused.) "They haven't learned how to self-soothe, how to talk themselves down," says Buckroyd. A simple "eat less, exercise more" will never work on someone who is comfort eating for reasons that they haven't articulated.

"The government spent millions on that obesity campaign, then wondered why it didn't work. But I don't think there is an information deficit," adds Buckroyd. Obese people know very well the mathematical discrepancies of their calorie usage. "But so many people are puzzled by their own behaviour."

A course of cognitive therapy or transactional analysis will work; the behavioural tactics that are taught to people with anorexia will work. The flipside, of course, is that in the absence of an understanding, psychological approach, the negative emotional component is simply magnified – by the stigma of being fat, the lack of empathy from others and society in general, the subtext (or sometimes surtext) of blame. If childhood trauma made you fat, it is people like Anna Soubry that keep you fat.

The co-morbidity of obesity and depression (around 50% of obese people are depressed) is often attributed to the fact that people become less mobile as they gain weight, and activity wards off depression.

This newer school of thought, though, raises the possibility that the depression caused the obesity, rather than vice versa.

Another brilliant fact, before you find a way to burn off that Mars bar: obesity costs £5.1bn to the NHS. Malnutrition costs £7.3bn.