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Is Cancer Research UK’s obesity campaign ‘fat shaming’?

Two leading GPs debate whether critics are right to say the charity’s new campaign publicising the link between obesity and cancer is ‘body shaming’.  

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Picture: Cancer Research UK

Cancer Research UK has generated controversy with a new publicity campaign that explicitly links obesity with cancer. Does the campaign – including posters evoking public health warnings and cigarette packets containing chips – amount to ‘fat-shaming’ as critics say? Two GPs debate the issue for Pulse.

Dr Jonny Tomlinson

Yes. This only serves to stigmatise obesity further

It is a commonly held moral trope that fatness is a punishment for the twin sins of gluttony and sloth. Punishment for the aesthetic crime of publicly displaying a fat body is that of mockery, shaming and disgust. Now that fatness has been medicalised as obesity, people who are obese are additionally guilty of being a burden on the NHS and the economy.

When this public stigma is internalised and the moral opprobrium is internalised, the consequence is shame. Shame is an inner voice that says, ‘I’m disgusting’, ‘this is my fault’, ‘I deserve this because of who and what I am’. This contrasts with guilt, in which it is possible to separate the deed from the person.

Common sources of shame in patients who confront medical professionals include mental illnesses, incontinence, disfiguring conditions, poverty, ignorance and dependency. For someone who has been obese since childhood, who sought or seeks comfort in food, because the rest of their life is so insecure, any sense of agency is severely impaired. The ineffectiveness of weight loss interventions and the links between shame, stigma and weight gain prove this.

If the Cancer Research UK (CRUK) adverts are intended simply to state a fact – ‘you’re fat and you’re going to die from cancer’ – but not to provoke action, then it will have achieved nothing. So we should assume it is intended to provoke change; either to encourage obese people to get tested for cancer or to encourage obese people to lose weight.

Shaming people has been shown to make them do more self-harming behaviour

But the charity should know better than anyone that telling smokers they were going to die didn’t work – it was legislation that cut smoking rates. And obesity is far more complex than smoking – you can’t put a ban on eating.

Shaming people has been shown to make them do more self-harming behaviour to compensate for the distress. Indeed, behaviours in children and adults that have experienced significant adversity are often compensating for, or dissociating from, feelings of shame and fear. They include obsessive-compulsive rituals, sexual proclivity, drug and alcohol abuse, social isolation, self-harm and eating disorders such as comfort eating. The first study to show the long-term effects of childhood adversity was in an obesity clinic and found strong links between childhood sexual abuse and severe obesity. These links, while widely researched, are not part of medical education, which partly explains why doctors’ stigma and bias towards overweight patients is as prevalent as it is among the general population.

What then should CRUK do? Rather than shaming people, which we know risks causing them to eat more and withdraw from care, the charity should seek to empower them. It should shift the focus of attention onto the obesogenic environment, rather than obese people. And it should put more effort into informing and educating policy makers and the public about the links between inequality, lifestyle and cancer.

The current approach is simply reinforcing stigma and risks doing more harm than good.

Dr Jonathon Tomlinson is a GP trainer in east London

Further reading

Vartanian, L and Porter, A. Weight stigma and eating behaviour - a review of the literature. Appetite; 2012: 102: 3–14  

Tomlinson, J. Shame. A Better NHS; 2012

Tomlinson, J. Doctors, patients and obesity. A Better NHS; 2011  

Scrambler, G. Weaponising stigma. Author's blog; 2018 http://www.grahamscambler.com/weaponising-stigma/

Stevens, JE. How the adverse childhood experiences study began in an obesity clinic. Aces Too High; 2011  

On being a fat medical student, at the start of our metabolism module. Raspberry Stethoscope; 2017 

Sample, I. Fat to fit: how Finland did it. Guardian; 2005 

 

Dr Ellie Cannon - online

No. The public deserves to know the truth

Fat shaming and size discrimination is devastating and hugely damaging to people. I have patients who have been overlooked at work because of their size, abused by partners for being overweight and openly discriminated against in social circles for being too large.

So why am I not upset or offended by the most recent Cancer Research UK (CRUK) campaign highlighting obesity as a major cause of cancer?

Because, quite simply, this is not fat-shaming, but fact stating. This is not a charity’s pejorative judgment of body idylls and aesthetics. We mustn’t let the perennial desire to be offended get in the way of awareness-raising and good health education.

In data published by CRUK, only 15% of people knew obesity to be one of the major causes of cancer; yet it is the second biggest cause after smoking. The correlation has been evident since the 1970s but at that point cause and effect was not definitively established.

Has it ever been offensive to point out smoking is dangerous? 

Now a huge body of high quality data has established that obesity is a cause of some 13 cancers, and revealed a dose-response relationship between the degree of obesity and level of risk. The data are high quality, with confounding factors accounted for: as you would expect from our leading cancer charity. The current national advertising campaign was piloted two years ago with its value verified before it was nationally rolled out.

Once CRUK had this body of optimal scientific evidence should they have hidden it from the public to save offending people? As a GP, a patient, a parent and a journalist I feel the ‘fat-shaming’ allegation against CRUK is a case of ‘political correctness gone mad’.

I am involved in the current Be Clear on Cancer campaign talking about breast cancer risk in the over-70s. Is that ageist? After all, women don’t choose to get old. Are the adverts targeted at BME groups regarding prostate cancer racist? Of course they’re not – they raise awareness among specific populations who deserve to be educated by truth.

Importantly, the aim is not just to educate individuals but also government, industry and policy makers. Publicising this factual message, enforces appropriate lobbying power and influences strategy, adding pressure on companies to lessen obesity in children through sugar reduction policy and responsible marketing.

An argument levelled against the CRUK campaign is that people don’t choose obesity and pointing it out somehow blames the individual. I agree, but similarly people do not ‘choose’ smoking – they became smokers through experience, cultural influence, trauma, their social environment and many other factors. Has it ever been offensive to point out smoking is dangerous? No, of course not, it is merely factual health education.

What do we want our leading cancer charity to do? Raise some money and say ‘there, there’? No, this is what our cancer charities should be doing. Putting tough messages into the public domain to inform, drive awareness and save lives. I am proud as a British doctor that CRUK runs campaigns like this to help individuals, government and stakeholders beat cancer.

Dr Ellie Cannon is a portfolio NHS GP in London and broadcast media doctor

 

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Readers' comments (8)

  • Dear All,
    Absolutely right, the only way to deal with obesity is to ostracise it in the same way that other societal harms are handled. Obesity is as damaging to society as smoking and alcohol and should be managed in the same way. People are heavily detered from from smoking, 100% because of its health impacts, the same should apply to obesity which is equally damaging , not only to the individual but to their support circles and society in general.
    Ostracise Obesity!
    Regards
    Paul C

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  • Dear All,
    Dr Tomlinson is clearly not an evidence based practitioner; "And it should put more effort into informing and educating policy makers and the public about the links between inequality, lifestyle and cancer." Err that's been obesity policy for teh last several decades, its not worked. What were the public health interventions that resulted in fewer smokers, few MIs, fewer Ca lung, fewer road deaths etc? The evidence is clear, the empathic its not your fault approach does not work.
    If you find it difficult to deal with these issues with your patients, then let society do it for you. lets have weight based airline pricing, lets have checkouts that analyse your purchase and show a red, amber, green light when you pay your bill, lets ban certain sales to the under 13s, lets regulate portion size. it can all be done, we just need the guts to do it.
    Regards
    Paul C

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  • Money talks and BS walks.
    The biggest factor in smoking reduction has been steep price rises. And look at what 5p for a plastic bag has done.
    If HMG can shrug off the pernicious influence of the Food Lobby they can introduce a straight forward traffic light “fat tax” - 20% on for red, 0% amber, minus 20% green. Shopping baskets would change overnight, and a “fat tax” would have far more influence on spiralling obesity rates than the failed public health information strategies of the last few decades.

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  • With respect to Dr Cundy, I think he needs to read Dr Tomlinson’s piece again. Nobody’s really arguing with the evidence that obesity is a part of the aetiology of some cancers. What he is saying, and I agree with him, is that ‘ostracism’, which Dr Cundy is apparently backing (but how do you ‘ostracise’ obesity?- you can only ostracise those ‘guilty’ of it...) never did anything positive. The smoking comparison isn’t ideal- you can stop smoking, hard though it may be, and obese people don’t do anyone direct harm (unless, I suppose, they fall on them). Now, here’s a suggestion: if we want to save money for the NHS, let’s stop people marrying anyone who is going to be obnoxious to them and make them miserable. Millions wiped off the MH services budget at a stroke. Easy! It is not as simple as there being two sides, the ‘get a grip, porky’ hawks and the ‘it’s safe to be obese, poppet’ doves. We as doctors really should grasp this even if the general public mostly don’t. The dimmer sections of the general public might like to have a scapegoat to be horrible to, and just slot obese people into the slot more often filled by ‘migrants’; we ought to be better-educated that that, even of not kinder. If you re-read the article, you’d see that Dr (‘dove’) Tomlinson is advocating just what you’re suggesting, taxing obesogenic foods. He’s also, I suspect, in favour of a society in which being an arse to those who have different weaknesses from our own isn’t seen as a magic solution to complex problems. (If we had a remotely adequate mental health service and employment/social care services, that would be helpful too, but I dare say that is past praying for.)

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  • ‘Even *if* not kinder’, sorry.
    I am sure CRUK didn’t intend their campaign to trigger yet more fat-shaming, but they were being a bit naïve in failing to realise it would. Have got tired of trying to put straight my many online acquaintances who take it as a go-ahead to be obnoxious. The truth, as dear Oscar said, is rarely pure and never simple.

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  • The evidence suggests that once a person is obese, the chances of them successfully losing a significant amount of weight permanently through "lifestyle changes" is around 5% . Even with intense multidisciplinary input . NHS provision for treatment of the long term chronic Ds sense that is obesity is woeful. It is woeful because of the moral judgments made by those in charge about fat people. They "deserve it", they "just don't get hard enough", they are "weak". The lack of evidenxe based scientific rigour that doctors use when they say lifestyle measures are the way forward is laughable and would NEVER be considered acceptable for any other condition. It's like telling a depressed person to cheer up.

    For a charity like CRUK to have a campaign like this , without backing it up with a call for the NHS to provide proper obesity services, including but not exclusively massively increased provision of the one successful evidence based treatment available , bariatric surgery, is short-sighted and fat-shaming and shows a massive lack of thought.
    I can guarantee that almost no fat person will see that poster and think oh gosh, I must try harder. They will think, great, another thing bashing me without anyone being able to offer decent help.
    This is why the smoking comparison is laughable. There are good services and no one has to pick up a fag, everyone has to eat. It is a very different thing.

    Yes obesity contributes to cancer. So let's treat it seriously. With evidence based treatment like every other condition. Not tel

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  • I think with a lot of medicine we are guilty of over reaching. Obesity is not really a medical problem but an environmental / personal one, over which doctors have very little control.

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  • Agree Motdoc, except that it becomes a medical problem, and consumes vast resources to no evident benefit.When I started in GP in 1981, Type 2 diabetes was an unusual disease, entirely managed by hospitals.
    Its all about self respect and personalresponsibility.Hiding behind the comfort blanket of "being shamed" helps no-one.

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