by Lily O’Hara, Section Head for Health Promotion, Health Authority – Abu Dhabi
The dominant health paradigm governing public health action from government departments and health care organisations is the weight centered health paradigm, where body weight is positioned as the single biggest problem in health today. But is this paradigm consistent with the values and principles of modern health promotion?(good rhetorical questions) Shouldn’t government departments and health care organisations be engaging in the most up to date practices? Would we accept other forms of health care that were based on outdated knowledge and beliefs? As our scientific and other forms of knowledge grow, sometimes exponentially, health care practices change and develop to take account of the new knowledge. This is what happens in most of the health care world EXCEPT in the area of weight.
Modern health promotion is the process of enabling people to increase control over the determinants of health. Research over the last 100 years has taught us that the determinants of health are extensive, multilayered and interconnected. Determinants are biological (such as genes and age), cognitive or psychological (such as knowledge, attitudes and beliefs), behavioral (including physical, mental, social and spiritual practices), and environmental (social, cultural, economic, political, natural and built environments). These determinants operate at the individual, family, group, community, population and global levels. In ecological science, these levels are referred to as nested hierarchies and the interconnections are referred to as feedback loops. So we know that health is complex.
But that’s not the message we hear from our public health authorities. In fact, it’s just the opposite. Health is simple – it’s about how fat you are. And the answer is simple – eat less bad/wrong/unhealthy food, eat more good/right/healthy food, and move more and you will lose weight and therefore be healthier. Unfortunately for the authorities that is Just. Not. True. And saying it is will not make it so.
Clearly body weight casts such a long dark shadow over the practice of modern health care that it has effectively created an enormous blind spot. Otherwise thoughtful and evidence based health practitioners still uncritically buy into the fat=bad story and act accordingly.
In my own field of health promotion, the big picture story since 1978 at least, when the World Health Organisation adopted the goal of Health for All by the Year 2000, has been the need to address systemic health inequities within and between countries by focusing on the environmental determinants of health – commonly referred to as the social determinants of health – which are basically all of those factors beyond the control of the individual. Major conferences have been devoted to the social determinants of health, and there was even a World Health Organisation Commission addressing them. When it became clear we would not achieve health for all by 2000, the goal became Health for All by the 21st Century.
Although criticized for being unrealistic, this aspirational goal has sought to focus our attention on reducing health inequities through addressing the structural determinants of health. As a result you’d think that modern health promotion practice would be focused on addressing poverty, reducing income inequity, creating peace, improving social relations, social security and social justice, empowering women, respecting human rights, and creating healthier, sustainable environments in which we live, work, play, learn and love. These are the health determinants that all countries participating in the World Health Assembly made a legal commitment to address through health promotion programs.
But they are not living up to this commitment. A significant chunk of the global, national, state and local health promotion effort is still directed towards trying to change behaviors, and a narrow range of behaviors at that – what people eat and drink, how much they move and what drugs they use. These are the holy trinity of health promotion that you will find on the agenda of pretty much every health promotion government department, conference or journal.
Many practitioners that are vociferous and outspoken advocates for programs that address the social determinants of health can somehow also engage in ‘obesity prevention’ practice. In the past few years ‘obesity prevention’ at a public health level has broadened to address the ‘obesogenic environment’. The rationale is that by altering the environment then the behaviors that ‘create obesity’ will be altered. So what sounds on the surface like a more sophisticated argument about the role of the environment in creating health, basically boils down to the same simplistic beliefs about body weight.
It doesn’t seem possible that the same articulate and passionate health promotion practitioners that advocate for a socio-ecological approach to reducing structural inequities in health are the same people arming up in the ‘war on obesity’. The dissonance between the two approaches seems so obvious to me and everyone else using the HAESSM approach, but it’s a great big blind spot for them. I guess you just can’t see what you can’t see.
The Health at Every Size® principles advocate practices that are known to enhance the health of people of ALL sizes (In addition the HAESSM approach opposes practices that perpetuate body size oppression. This means any form of oppression including bias, exploitation, marginalisation, discrimination, powerlessness, cultural imperialism, harassment or violence against people based on their body image, body size or weight. Furthermore, the HAESSM approach opposes any approach to health, eating or exercise, the provision of products, services or amenities which focuses on body weight or perpetuates body size oppression.
Body size oppression is a social determinant of poor health. Public health authorities are supposed to improve the social determinants of health, not make them worse. They are meant to be working towards health for ALL people. Governments have signed up to this through a succession of charters at the World Health Assembly. It’s time we held them accountable and demand the adoption of modern health promotion practice that is enhances health for all.