When it comes to talking about obesity, it is often tarred by stigma and negative connotations.
According to The Obesity Collective, which advocates for better understanding for the overweight and obese community, there is a common misconception that obesity is the result of laziness and lack of self-control.
Obesity it is not a lifestyle choice and doesn’t come down to a lack of willpower — rather it is a serious and complex health issue that can stem from genetic, biological and societal factors.
In 2018, it was estimated that around 70 per cent of WA adults live with overweight or obesity, while one in four WA children were overweight or obese. The rate of adult obesity in WA has seen a steady rise from 21 per cent in 2002 to 32 per cent in 2018. If the overweight and obese population continues to climb at current levels, the predicted costs to the WA health system will jump by 80 per cent in the decade between 2016 and 2026 from $338.7million to $610.1million.  But when it comes to the challenges faced by people living with overweight or obesity, it is far more complex than just the health costs that can arise from carrying excess weight.
Living with overweight and obesity: what are the biggest challenges?
Weight stigma is a form of discrimination, where a person feels judged, ashamed, guilty and blamed for their size or weight.
Sadly, weight stigma – sometimes known as ‘fat shaming’ – is widespread and more often than not, people don’t realise they’re doing it.
La Trobe University Associate Professor in Psychology Dr Leah Brennan says the prevalence of weight stigma is rising just as fast as the rates of overweight and obesity.
“We know weight stigma is very prevalent,” Dr Brennan says.
“You might think that rates of overweight and obesity are increasing, but the stigma might be decreasing, but actually it’s the opposite. At the same time as weight has increased across the population, the experience of weight stigma has also increased.
“I think it’s really tricky because I think on the one hand, we do have that message that obesity is the result of complex factors and the vast majority of those factors are out of the control of the individual.
“That message is starting to spread more broadly, but it does conflict with the other messages that we get about taking personal responsibility for our weight so I think even our public health system hasn’t quite worked out how we’re going to balance those two messages, so I think it’s hard for the general public to make sense of that as well.”
“So I think that it’s a contradiction that people are trying to navigate.”
Dr Brennan adds that people with overweight and obesity experience weight stigma in various facets of their lives.
“We know that it occurs in medical settings, educational settings, employment settings, and even amongst family and friends, as well as out in the general public,” she says.
“It’s also really easy to see examples of stigmatising situations on TV shows, in advertising – so we are bombarded with stigmatising messages about weight all the time, to the point where we don’t even notice it much anymore, because it’s become so normal.”
When it comes to public health campaigns that focus on tackling obesity using the confronting and graphic scare tactics often used in ‘quit smoking’ campaigns, Dr Brennan believes a softer approach is far more effective.
“While people may feel like stigmatising someone will motivate them to change their behaviour and lose weight, research shows the opposite to be true,” she says.
“People who have been stigmatised are much less likely to be able to make healthy changes in their life.
“Making people feel bad about themselves and about their bodies is not a healthy way to sustain healthy behaviours.”
When it comes to taking a person-centred solution to tackle the rising rates of obesity, Health Consumers’ Council WA Engagement Manager Clare Mullen says that developing
a supportive approach that understands where the individual is coming from is pivotal.
“It’s important for people to be active participants in discussions about what’s going to work for the individual, and how different peoples’ experiences might be,” Ms Mullen says.
“It’s also recognising the really important fact that, we’re in an obesogenic environment, and so it’s about trying to support people who want to take action but also recognising how challenging that can be when their environment makes it very difficult.”
In 2018, Ms Mullen led a consumer engagement project, Is weight a weight on your mind?, which included a survey and call out for personal stories, which sought to explore peoples’ experiences with taking action to lose weight, and how they could be better supported by the health system to achieve their weight loss goals.
Results from the anonymous online survey – which received around 800 responses – showed that 66 per cent of participants had taken action to lose weight more than twice in the past year, with more than 40 per cent making five or more attempts.
The survey results also suggested that there are a lack of affordable weight loss options and services available, which became a barrier for people to lose weight.
“I wasn’t surprised by some of the feedback we received about weight stigma,” Ms Mullen says.
“I do think that it’s an important part of how we move forward, because I think that stigma can act as a barrier to accessing health in the first place
and also to continuing to access the right support.
“I think that overweight and obesity is something that is really misunderstood at a community level, despite the fact that it impacts so many of us in the community.
“One of the strongest insights we took away (from the engagement project) is that this is very individual. What I was really struck by is that it’s very complex with a whole range of factors.
“I know there are some conversations happening about how there can be training for health professionals in approaching the topic of weight, and I guess we’ve heard, anecdotally, about a whole range of experiences.
“Some people say ‘I’m really overweight and no one has ever mentioned it to me’, and other people might say that a health professional tells them they need to lose weight, but then they’re not able to offer them practical support on how the person might do that.”
In the State Government’s Sustainable Health Review (SHR) — released in 2019 — one of the key recommendations is to halt the rise of obesity in WA by July 2024 and strive for the highest percentage of population with a healthy weight in Australia by July 2029.
Diabetes WA Senior Manager Sophie McGough says to achieve that goal, people living with overweight or obesity need to be supported to make an informed choice about the evidence-based options available and should have access to all forms of support for weight loss.
“People who are overweight and obese are currently advised to eat according to the Australian Guide to Healthy Eating, and increase physical activity to achieve slow, sustainable changes to their weight,” Ms McGough says.
“While this may work for some people, there is a proportion of people who find this approach inadequate, but when they turn to the public health system for support from health professionals to assist with the complexity of their obesity, access is limited and often comes with a dose of judgement.
“We can’t ignore the psychosocial needs and social determinants of health that impact people who are overweight or obese nor the need to provide multiple strategies to achieve long term weight maintenance.”
Ms McGough adds that one of the viable weight loss options that is not currently available for people with overweight and obesity within the WA health system is the supported total meal replacement approach.
“To halt the rise of obesity, the WA health system must provide options that meet consumer needs, not assume they are a ‘one size fits all’,” she says.
Clinical trials have shown that total meal replacement diets produce twice the amount of fat and weight loss in half the time than diets based on healthy eating.
Despite achieving rapid weight loss of around 10 to 30kg between six weeks and four months, total meal replacement diets have developed a reputation as being easy to follow initially, partly due to the fact that it can be effective in controlling hunger. But the addition of behavioural support strategies as part of a supported total meal replacement approach has been shown to better sustain the achieved weight loss between one to three years later compared to food-based diets.
“Very low calorie diets (meal replacements) have been used by many individuals to successfully lose weight,” Diabetes WA Dietitian Sheryl Moore says.
“This is because, put simply, total meal replacements are designed to be a straightforward exchange for the meal that a person would normally choose. This is a simple swap which can be relatively easy to do so for a short period of time.”
The Education and Health Standing Committee’s The Food Fix Report also highlights recent evidence from DiRECT (Diabetes Remission Clinical Trial) in the UK for very low calorie diets (VLCD) using total meal replacement (TMR) products to support significant weight loss in people with type 2 diabetes.
Looking at this evidence, the Committee recommended that the State Government looked to the results of the UK’s National Health Service (NHS) subsidised meal replacement program for people at risk of type 2 diabetes, and also believes this approach should be formally offered to Western Australians as an option to manage their type 2 diabetes.
Offering a person-centred solution for people living with overweight and obesity
Earlier this year, Diabetes WA received funding from the WA Primary Health Alliance (WAPHA) and the WA Department of Health to pilot an obesity intervention program that pilots a supported total meal replacement program in the primary care setting.
Three GP practices will recruit 50 Western Australians who live in ‘obesity hotspots’ with a BMI greater than 30 or, if they have an existing health-related condition, a BMI greater than 27.
During the pilot program, participants will follow the total meal replacement regime for eight weeks, while being provided with support via telehealth with a multidisciplinary team of Diabetes WA health professionals who will listen to their stories, provide clinical support and cheer them on for six months.
They will also be given access to a locally developed behavioural and weight maintenance app, WINK and virtual peer support options.
Drawing on Diabetes WA’s expertise in self-management education and behavioural science, the pilot will be developed by the organisation’s team of DESMOND trainers, dietitians and exercise physiologists in collaboration with leading obesity researcher Professor Amanda Salis.
The program intervention will also be designed with input from consumers through collaboration with the Health Consumers’ Council WA.
In line with the SHR recommendation to halt the rise of obesity, the project is also guided by recommendations in the WA Healthy Weight Action Plan 2019-2024 which aims to address the challenges faced by people at risk of or living with obesity through “taking action in the early intervention and management space” by working collaboratively with consumers, non-government agencies, private providers and professionals from across the WA health system.
WAPHA Chief Executive Learne Durrington says the initiative carries exciting potential to be part of a longer term solution to overweight and obesity embedded in general practice.
“We are delighted to co-fund this promising pilot, partnering with Diabetes WA and the Department of Health as part of the WA Healthy Weight Action Plan implementation,” she says.
“Being overweight or obese has a profound impact on a person’s physical and mental wellbeing, as well as being a significant cost to our health system. This problem requires us to explore a variety of measures to ensure people can find a solution that works for them.
“For most people, their GP is the medical professional they trust and interact with the most, so having them embedded in any approach to weight management makes sense and increases the likelihood of positive, sustainable outcomes.
“This pilot will support a number of general practices and focuses on quality improvement and better patient outcomes, to build skills, capacity and confidence to help the target group achieve a healthy weight.”
Ms Mullen says the pilot is a great opportunity to bring consumers and health professionals together to explore the best options for achieving weight loss.
“I think person-centred is not just a buzz word, it really does mean understanding the things that make up that person both in their upbringing but also in their day-to-day life in their family situation, their housing situation,” Ms Mullen says.
“Research that involves consumers as partners adds value to the discussions about what might work in some circumstances. But I think that it is important to make sure that, across the health system, all health professionals have an understanding that different things work for different people, even though taking the time to build a relationship between the consumer and the health professional can be challenging.”
During the obesity intervention program, Diabetes WA will work with three GP practices to recruit participants from high-risk communities located in obesity hotspots.
The health professionals involved in the project will also be trained to expand their confidence and knowledge in having respectful and empowering conversations about weight, identifying people for who the total meal replacement diet is a viable weight loss option and the medical management required during total meal replacement to give people the best chance of success. Ms Moore adds that the pilot aims to highlight how health professionals can play a big role in supporting a person’s weight loss journey.
“We are hopeful that we can enable individuals to achieve the same successful weight loss as has been previously achieved, however, we aim to ‘value add’ to the individual’s experience,” she says. “With a focus on self-management and support, we will provide the opportunity for each individual to identify subtle changes they can make in their world to achieve lasting benefits, not only for their weight but ultimately their ongoing health.
“Through regular interactions with trained health professionals as well as the use of an app surrounding their use of the meal replacements, individuals will gain knowledge, skills and insights to assist them long after the use of the total meal replacements have finished.”
Creator of the WINK app Professor Salis, who is an obesity scientist and Senior Research Fellow at the University of WA, has experienced the challenges of living with obesity firsthand, having lost close to 30kg more than 20 years ago.
Professor Salis understands the challenges that people with overweight and obesity face when it comes to weight loss and has dedicated her life’s work to finding the most effective, scientifically proven ways to lose weight – and keep it off.
“My research at UWA involves using diets that are severely energy-restricted, meal replacement diets,” she explains.
“These diets restrict the daily kilojoule requirement to around 3000KJ per day – instead of eating food, it involves eating formulated meal replacement products, so things like powders that can be made into a shake, or a bar or a soup.”
Professor Salis is blown away by what she’s uncovered in her research so far.
“I started this research into these diets to find out just how bad they were and the results really showed the opposite, in fact,” she says.
“Despite being severely energy restricted, it results in this paradoxical suppression of hunger while people are on the diet. So normally when someone is losing weight there is an increase in hunger….but during these severely energy restricted diets, there is often a decrease in hunger from how people feel before the diet.”
Needless to say, when Professor Salis was approached to be apart of Diabetes WA’s obesity intervention project, she was keen to jump onboard.
“I think it’s a fantastic approach and a fantastic initiative of Diabetes WA to be doing this,” she says.
“It’s not only using the meal replacement diet, but it’s also combining that with telecoaching, which means this diet (eventually) becomes accessible to people who are all over the State, so it’s not limited to being in a particular location or clinic.”
Professor Salis says her WINK app aims to support people in maintaining their weight once they’ve completed the diet.
“The main thing with the WINK app is helping people to maintain their weight after the total meal replacement diet,” she says.
“So it involves listening to hunger signals and eating according to hunger signals and also eating a reasonably healthy diet but without needing to count calories.
“It’s about managing weight in a way that doesn’t involve special foods, but just fruit and veggies and it can be any kind, frozen, tinned or fresh.
“It’s also about combining that with physical activity, which is encouraged in the app as well.”
She adds that regaining the weight is one of the biggest challenges participants may face after following the total meal replacement diet for eight weeks.
“There will likely be some weight regain, and this can feel so discouraging that you may want to abandon the program, including any efforts to eat healthy foods or be physically active,” Professor Salis says.
“It’s important to recognise that weight regain is a normal part of any weight loss regime, and that regaining weight does not mean you have failed at weight loss: it just means that your body is good at protecting you from wasting away in a famine.
“It’s also…really important to keep drawing on the support offered in the trial program, like telehealth meetings with the pilot team, as the team can help you find do-able strategies that work for you to help offset weight regain.”
Echoing the recommendations in the Food Fix Report, Education and Health Standing Committee Chair Janine Freeman strongly believes that dietary interventions like the very low calorie diet should be offered to Western Australians as an option for the management and treatment of type 2 diabetes.
“One of our key recommendations was looking at the (very low calorie diet) and saying that we need to do something quite radical in this space,” Ms Freeman says.
“It’s that whole aspect of saying stop just thinking this is business as usual and start thinking there is actually something we can do to be able to take control of this disease that has really dire consequences.
“The Committee found that diabetes is a major issue in our community, it has major health consequences and those are far reaching in terms of all the complications with type 2 diabetes, and that it is growing at a rate that, unless we address it, it’s a huge burden on the State budget but it’s also a huge personal burden.”
While Ms Freeman commended Diabetes WA for landing funding for the obesity intervention project, she says more work needs to be done in the type 2 diabetes space.
“I think it is really great that Diabetes WA has taken a lead in this,” she says. “I just think the problem with institutions within health is that they don’t give primary focus on the prevention and treatment of type 2 diabetes.
“There are 28 people diagnosed with type 2 diabetes daily – and that’s adding to the 100,000 in WA already.
“This is a critical area that needs a focus in and of itself, in addition to obesity.”
Diabetes WA Clinical Services Manager Carly Luff, who is providing input into the design of the intervention program and is assisting with recruitment of clinical staff, is hopeful that the pilot will show the benefits of providing support when tackling weight
loss options like the total meal replacement diet.
“Many people have tried total meal replacement diets before without the support of their GP and other health professionals,” she says.
“This pilot allows them to have ongoing support, goal setting and a clear plan to follow through the program.”
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