Member Blog: There Is No Health Without Mental Health
19 June 2023
At the Royal College of Psychiatrists we constantly emphasise that
There is no health without mental health.
Mental health is woven into every level of public health
Our mental, physiological, environmental and social contexts shape our health. Every day, we are inundated with promotions and adverts for over-processed food and drink, which take advantage of the evolutionary drive to eat that humans developed when resources were few. Our daily lives are stressful and chaotic, with less opportunity for physical activity and regularly scheduled meals, and often the food that most conveniently fits with our busy schedules is highly processed and high in fat, sugar, and salt. Increased food prices mean that not everyone can access options that are not over-processed and high in sugar, fat, or salt. And a culture where we are pressured to drink more than we otherwise would exposes us to ‘empty’ calories, and binge drinking is often paired with consumption of highly processed foods.
Clearly, solutions need to create an environment that promotes our health: restricting marketing, promoting active travel and creating environments that encourage physical activity, and ensuring that everyone in Scotland can access healthy, nourishing food regardless of where they live or how much money they have. Mental health is woven into these solutions at every level: reducing stress and managing emotions, access to restorative environments and fulfilling activities, and enjoyment of our food and the way it makes us feel are key to healthy lives.
The ‘individual choice’ mindset damages health
We can’t expect individual responsibility for weight management within imposed lifestyles that work against healthy habits. And when the conversation about obesity moves away from our environments to focus too narrowly on individual factors, this greatly harms mental health. Obesity in our society is stigmatised to a damaging extent. One disturbing study (Schwartz, 2006) found nearly half of us would sacrifice a year of life rather than be obese; 15% would sacrifice 10 years. Overweight participants thought poorly of themselves, and 10% would rather their child were anorexic than obese.
Focusing on individual factors not only fails to address the contextual causes of obesity, it also often makes health outcomes worse. Shame, which is seen as motivation to change (Callahan, 2013), would be cruel even if effective. However, in experimental settings, when people experience weight stigma, their eating increases, self-regulation decreases, cortisol (an ‘obesogenic’ hormone) levels rise, and they avoid exercise. Self-reported weight stigma predicts future weight gain, and people who report weight-based discrimination are more than twice as likely to experience mood or anxiety disorders (Phelan, 2015).
To truly prioritise health, we need to see the whole picture, and we cannot do this without considering mental health. If we want to see what ‘health’ looks like without mental health, we need look no further than body image obsession masquerading as health concern. In today’s social media-conscious, body image-conscious environment, more people try to lose weight to improve their appearance than for health reasons. Health professionals may condone this under the false impression that it motivates change. People plaster their fridge doors with ‘fat pictures’ of themselves to discourage overeating. Many turn to drugs like semaglutide, which can be a treatment for people with severe obesity but also might allow commercial interests to exploit people who are experiencing weight stigma.
In addition to interfering with metabolic health, these desperate weight loss attempts can trigger eating disorders – which are more common in overweight people. We’re seeing increasing rates of eating disorders in our clinics, with many more untreated in the community. Sufferers turn to ways to lose weight regardless of potential dangers and waste their precious lives preoccupied by how they look and how others perceive them.
It’s no wonder, then, that well-meaning approaches to combatting obesity and poor metabolic health aren’t working. If we take a fragmented view of health that focuses on individual rather than environmental factors and physical rather than holistic health, we will more likely see a Scotland reliant on drugs and the ‘diet’ industry than a Scotland where everyone can thrive.
Changing national guidelines could encourage a holistic approach
To better support holistic solutions, healthcare and public health initiatives need to integrate mental health into their work, and the government needs to take the lead in providing guidance and support.
First, clinicians need more support on how to talk about obesity. Common anti-obesity efforts, such as standard medical advice for weight loss, unintentionally contribute to weight stigma by focusing on individual responsibility and willpower. These programs need to be designed with mental health at the heart – for better mental and physical health outcomes.
Recognising mental mechanisms at work in obesity stigma means reconsidering the words - and numbers - we use. Terms such as ‘excess weight’, ‘adiposity’, and ‘higher than average weight’ have all been suggested. Clinicians need to be supported in having a dialogue with their patients to find the most compassionate, least stigmatising way to discuss these sensitive issues.
It would be kinder to step back from our obsession with numbers too. Weight and body mass index (BMI) are not accurate predictions of weight-related pathology. They’re a convenient rule of thumb for public health surveys, but they don’t reflect the complexities of what body weight signifies for individuals. Even when using BMI, we shouldn’t ask the Scottish population to conform to a BMI range of 18.5 to 25. US research suggested ‘weight trajectory’ is more relevant (Zheng, 2013). It could be more helpful to plot individual ‘growth charts’ throughout the life span so our weight trajectory can be considered in terms of its own norms and trends, and in the context of other health indices such as blood pressure, and blood glucose. Redefining how we approach weight and health can reduce stigma and shame, improving health outcomes for all.
Next, clinicians need support in creating a welcoming, non-judgmental environment. Higher-weight patients say they feel unwelcome and disparaged in clinical settings, and so avoid them. It may seem paradoxical, but as part of efforts to reduce obesity, we need to actively welcome people with weight concerns into health settings and even invoke legal protections against weight-based discrimination.
While public health interventions re-shape environments, clinicians need individualised, psychological understanding of people’s experience of overweight. It is helpful to acknowledge the emotional forces that combine with chemical influences when we eat. We may be using food to ‘self-medicate’. Mental disorders and side effects of their treatments can bring weight gain. People with eating disorders may turn to bingeing for comfort and sedation, to self-induced vomiting for a neurologically-induced sense of relief, or to prolonged starvation to induce a sense of power. Professionals at all levels – doctors, teachers, therapists, and more – need to be equipped with the knowledge and skills to recognise and address the mental health causes of obesity.
Mental health needs to be considered at every level of intervention – from public health to clinical provider – and one way to encourage this is to update the obesity guidance that national health bodies provide, such as the SIGN (Scottish Intercollegiate Guidelines Network) Guidelines on Obesity and NICE (National Institute for Health and Care). The recent SIGN eating disorders (2022) recommended that psychological and cognitive aspects of weight management should be incorporated into addressing obesity.
Scotland will tackle obesity better by putting human values at the centre, addressing the need for compassion, and when we consider mental health as an integral part of health and wellbeing.
Member Blog from Royal College of Psychiatrists.
Twitter: @rcpsych
Website https://www.rcpsych.ac.uk/home
REFERENCES
Callahan, D. (2013). Obesity: Chasing an elusive epidemic. Hastings Center Report, 43(1), 34-40.
Health Improvement Scotland/Scottish Intercollegiate Guidelines Network (2022) SIGN 164: Eating Disorders A national clinical guideline
Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319–26.
Schwartz, M. B., Vartanian, L. R., Nosek, B. A., & Brownell, K. D. (2006). The influence of one's own body weight on implicit and explicit anti‐fat bias. Obesity, 14(3), 440-447.
Tomiyama, A., Carr, D., Granberg, E. et al. (2018) How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Med 16, 123.
Zheng, H., Tumin, D., & Qian, Z. (2013). Obesity and mortality risk: new findings from body mass index trajectories. American journal of epidemiology, 178(11), 1591-1599.