Anne Milton, MP, who is minister for public health in the coalition government, spoke to the BBC on the subject of overweight people:
GPs and other health professionals should tell people they are fat rather than obese, England’s public health minister says.
Anne Milton told the BBC the term fat was more likely to motivate them into losing weight.
She said it was important people took “personal responsibility” for their lifestyles.
This seems to me to be a strikingly stupid thing to say.
Firstly, the words obese and fat are not synonyms. The word fat applies to (and is commonly used to describe) people who range from could-do-with-losing-half-a-stone overweight all the way up to call-out-the-specially-strengthened-ambulance overweight. Obese is a more precise term – it describes people who are sufficiently overweight that it impacts on their health. If I see my GP and she tells me I’m fat, I might come away with the impression that I’m in the could-do-with-losing-half-a-stone camp when she meant me to understand that I was a couple of bags of cheese-and-onion away from needing the special ambulance. If she describes me as obese – and explains what it means in detail, rather than assuming I know – then I know exactly where I stand.
Secondly, the word fat is insulting. Not offensive – insulting. It’s regularly used in this way: bullies in the school playground use it to attack their victims. If the NHS is to go down the road of using insults to describe patients then presumably someone who’s short-sighted will be officially re-classified as a specky four-eyes, while a person with learning disabilities will be officially known as a retard. The NHS’ ethnic monitoring forms will be a revelation – though how many people will be happy to tick boxes marked Paki and Honky I’m not sure.
It only takes a moment’s thought, of course, to realise that a person who believes themselves to have been insulted by their GP is highly unlikely to respond positively to whatever comes next from their mouth – assuming they haven’t walked straight out of the consultation, that is. In the immediate aftermath of a personal insult, I’m not especially likely to accept a referral to a dietician, or pay much attention to a trite little homily about putting down the Hob Nobs and picking up the running shoes. In fact, pretty much any consultation in which the doctor insists on bandying round insults is gong to rapidly degenerate into a confrontation. I would have thought that this would not be especially useful from a clinical perspective, although it seems that Professor Steve Field, head of the Royal College of GPs, may not agree. He is quoted by the BBC as saying
I think the term obese medicalises the state. It makes it a third person issue. I think we need to sometimes be more brutal and honest.
You can be popular by saying the things people want to hear and in the NHS we too often do that when we should be spelling things out clearly.
Inappropriate medicalisation is, of course, a buzz topic at the moment – hell, I’ve sounded off on this blog about the tendency to medicalise normal human emotion as depression often enough – but I’m not sure it’s legitimate to raise it in this case. I mean, obesity is a medical issue – that’s the whole point. The whole reason doctors get involved in discussing weight with their patients is that it’s not just an aesthetic matter, or a question of being discriminated against and bullied – it’s also, sometimes, a matter of chronic physiological ill-health: potentially, even, of life and death.
The ‘third person issue’ Professor Field raises is also a complete red-herring – a doctor who says “You’re obese” is speaking in the second person just as much as a doctor who says “You’re fat”, and she’s being just as honest, too. The only difference is that, in the latter case, a precise clinical term has been exchanged for an imprecise insult. I also have to question the extent to which ‘people want to hear’ that they’re obese, or that doctors who make a point of telling patients that they’re obese are ‘popular’. I wonder if there’s a chance that Professor Field might have failed to recognise the difference between a patient reacting strongly to being insulted and a patient reacting strongly to an unpalatable truth about themselves which they hadn’t previously recognised.
It often seems as though the teams involved in the development of public health policy towards overweight people think that they don’t realise they’re overweight. This is why, for those patients who don’t take slim-fit jeans, every GP consultation, whatever it’s for, has to include a discussion of weight. The fact is, though, it’s literally impossible to be overweight in our culture and not know it. You’re reminded of it every time you want to buy clothes and realise that there’s virtually nothing available in your size. You’re reminded about the difference between your body-type and the ‘ideal’ every time you pick up a magazine, or watch a film or a TV show or an advert. Every overweight patient a GP sees already knows they’re overweight. The fact they’re still overweight, despite knowing all about it, means either that they don’t care, or they don’t know what to do about it, or they know what to do but are finding it hard to follow through.
None of these people are going to be helped if their doctors insult them. At best it will irritate them, but at worst, for those patients who have body-image issues, it will reinforce every negative opinion they have of themselves. In this context, it’s genuinely shocking to realise that the reason that Anne Milton wants the NHS to use the word fat is not because she thinks the use of such a direct word will act as a wake-up call to people who are deluding themselves (which seems to be, from what I can tell, Professor Field’s position). She seems to want the NHS to use it because she actually wants to encourage negative body-image in overweight people:
If I look in the mirror and think I am obese I think I am less worried [than] if I think I am fat.
This, clearly, will be massively counter-productive in those people who already suffer from body dysmorphia, and also has the potential to push people who are on the threshold of the disorder into full-blown illness, but it’s wrong-headed even so far as it applies to the mainstream population. The physical appearance of being overweight is the part that doesn’t matter – it doesn’t matter what I look like to myself, or to other people, and a sizeable proportion of overweight people will automatically (and quite reasonably) dismiss such appearance-based criticism. The part of being overweight that matters is the probable impact on health, the fact that someone who’s overweight is at a statistically greater risk of developing type II diabetes, and heart disease, and stroke, and certain types of cancer.
None of these parts of being overweight show up in the mirror. Certainly, they correlate with physical appearance, but, so far as public health is concerned, the focus should be on the invisible risks, not the fact that some people might find a particular body shape unattractive. Quite apart from anything else, appearance is affected by so much more than weight – someone with a barrel chest is always going to look stocky, even if they restrict their diet to the point of near starvation.