Obesity: 'We have been sold the idea that it is all about personal responsibility'

Some one million people in Ireland live with obesity.  Dietitian Aoife Hearne joins a growing scientific consensus, which says  we need to move beyond the 'eat less and move more' mantra and explore the complexity of weight gain 

Pic: iStock

Anyone who struggles with obesity will also know all about the extra burden of judgment, the blaming and shaming for being lazy or not having enough willpower. 

However, in recent years, there has been a change in thinking around obesity, with a growing scientific consensus that it is not due to a personal failing or lack of control and is instead a complex and chronic condition that deserves a compassionate and supportive response.

Government health agencies around the world now view obesity as a chronic disease similar to diabetes or high blood pressure, and as a leading cause of those illnesses, along with other conditions including heart disease, stroke, and cancer, the impact on those who live with it cannot be underestimated.

In October, Ireland became the first country in Europe to introduce new clinical practice guidelines for obesity treatment based on the work of Obesity Canada, seen as the international benchmark for obesity treatment. 

Published in Ireland by the Association for the Study of Obesity on the Island of Ireland (ASOI) with the backing of the HSE, doctors and patient groups, these guidelines redefine care for the more than one million people in Ireland who live with obesity.

According to consultant endocrinologist Professor Donal O’Shea, HSE clinical lead for obesity, the guidelines represent a ‘turning point’ in the management of obesity, providing the framework for patients to have access to a broad range of care, including medical nutrition therapy, physical activity and physical rehabilitation interventions, psychological interventions, pharmacotherapy and bariatric surgery. 

Calling on more resources to be made available, he said obesity should be put on the same footing as diabetes, heart disease and chronic lung disease in general practices.

This thinking is backed up by high-profile dietitian Aoife Hearne, who runs a clinic in Waterford and also lectures in SETU Waterford. She agrees that obesity is a complex condition often requiring a multi-pronged approach beyond the ‘eat less, move more’ mantra. 

However, she says there is still a widespread reluctance to accept the reclassification of obesity as a chronic disease.

“I’m passionate about people eating well, that’s never going to change. But I do think we need to have compassion for people who have a chronic disease. 

For so long, we have been sold the idea that it is all about personal responsibility. 

"Where the science is going — and it is evolving — is that it is not only about personal responsibility. Of course, there is some element of that but once somebody has met the clinical criteria for obesity [BMI is 30.0 or higher], how we treat that now, depending on the severity, is different from what we knew maybe ten or 15 years ago. 

"It is unfair to sell the idea that eating less and moving more is the only treatment for this chronic disease.”

Aoife Hearne: If eating less and moving more worked, we wouldn’t still be talking about it. There has to be something more to it.

New medications

According to Hearne, medications should be offered to people with obesity, just as they would be to those with chronic conditions.

“We know now that some of these newer treatments, specifically medication, help support those who want to lose weight. It just helps make things easier on them and have more success long-term.”

With weight-loss medications such as Ozempic and Saxenda growing in popularity, however, she cautions that they should only be used in conjunction with medical advice.

“I have seen some of the headlines about celebrities using them. Best practice is that when someone meets a certain criteria, they should be afforded a conversation with their doctor to see if this medication is suitable for them, just like you would do for cholesterol, type 2 diabetes or hypertension.”

According to Hearne, we are psychologically and biologically “hard-wired” to maintain weight because from an evolutionary perspective, if you lost weight, your brain interpreted it as a threat to mortality.

“It is difficult to see people taking on that responsibility when we know more now about chronic disease.”

She says that people need honesty and support when it comes to tackling their weight issues.

“Many people don’t want that support, they say, ‘I can do it myself’. That is why I think there is a lot of work to be done on educating the public around that to try and help people understand this complicated and multi-faceted chronic disease. It is going to take time for us all to understand it a little bit better. I am learning too as it is so complex and it is evolving.”

Societal factors

There are also many societal factors which factor into obesity, not least our growing reliance on processed and ultra-processed foods. Hearne says we need to accept that these foods are part of our lives and learn how to incorporate them in moderation.

"Parents need support on what is the best approach to teaching children how to have a healthy relationship with food.”

“We are bombarded with processed foods, everywhere. I think we need to give up on this idea of never eating these foods at all. We need to train ourselves and our children how to eat these foods in moderation.

"The only way we can do that is to enjoy a little bit at times. That is not easy. Especially through Covid, it was really hard for people who were working from home, and those with kids, that constant asking for snacks and treats. 

"Parents need support on what is the best approach to teaching children how to have a healthy relationship with food.”

Hearne says it is important to remain open to the evolving science on obesity but acknowledges that it will take time for others to see it as a chronic condition which cannot be solved by dieting alone.

“When we think about obesity as a chronic disease, it means that we cannot cure it. 

"It is going to take time for health professionals and the general population to get to grips with what that reclassification actually means. I can see people struggling with it in the work I do.

“I’ve been a dietitian for 20 years and I see people in my clinic losing weight and then regaining it. 

"I don’t think I necessarily have all the answers either. 

I would say if eating less and moving more worked, we wouldn’t still be talking about it. There has to be something more to it.

“When people come to me, they want a diet plan. And when I say that’s not the best approach, that’s a difficult conversation; they’re quite disappointed that I’m not going to give them what they feel they need. As a nation, it is trying to change our mindset.

“I’m teaching that to my students so hopefully they will have a better understanding that it is far more complex than we ever imagined.”

Aoife Hearne's mindful eating advice

• It is not always about the weight, it is more that people feel they are out of control with their eating. Try to shift your perspective from that idea of being in control — you want to be in charge of your food choices, not in control.
• Have that chocolate, cake, a few drinks on a night out or whatever but you need to consciously make the choice. What happens is that people don’t think about what they are doing and then feel huge shame about eating more than they intended to. Then that sets off a whole cascade of deprivation, craving and bingeing.
• Think about why you want to make a change, is it about having more energy, sleeping better — what is the why? Then really start to think about the choices you make around food. For many people, that will be not letting yourself get hungry because when we do that, we tend to overeat. Then you need to eat every few hours. That might mean then you have to pack snacks with me or have dinner ready to go when you get home.
• Focusing on behaviours is far more effective in allowing yourself to be in control of what you are eating and actually eat in a more mindful way. It is not easy, it takes time to work out a mindful eating practice. With that comes compassion.
• Try to take the emotion out of it. It is not easy when we live against a backdrop of ‘go on a diet to lose weight’. Surround yourself with like-minded people so you are hearing positive messages.