We’re living through a global obesity crisis, and nobody has the answers. In the UK, 63.8% of people are overweight or obese, with the figure rising to 73.6% in America. And by 2035, 51% of the world’s population is forecast to be overweight or obese, putting billions at elevated risk of heart disease, diabetes, cancer, musculoskeletal disorders and premature death. How do we tackle this unfolding health disaster?

Professor Jane Ogden, a professor of health psychology at the University of Surrey, has been researching eating behaviour and weight management for over 30 years, and has written several informative books, including “The Psychology of Dieting”. Though impressed by the exciting potential of new weight-loss drugs like Wegovy, and the ethical values of body positivity movements like Health At Every Size, she is increasingly worried that we are losing sight of the central importance of human psychology within the obesity debate, from the power of individual responsibility to the potential for positive behaviour change. She tells Unfiltered why our personal behaviour and choices will always be central to our long-term health.

Where does responsibility for a person’s obesity lie? With the individual, with their genes or with the unhealthy environment around us?

All of the above. Your genetics play a part. Some people are more predisposed to eat more, or to store food as fat. Our environment plays a big role because it is feeding us food the whole time. But the individual still has a role to play in terms of how they respond to that environment. So if you go to the cinema, there’s the popcorn, but – and this is whether you believe in freedom of choice or not – do you buy the bucket of popcorn or not? Or do you buy the huge bags of chocolate or not? The food is there but the individual makes those choices.

So it’s all of it. It’s the individual: their choices, responsibility, behaviour, learning, emotions and childhood. It’s also their brain chemicals, gut hormones and genetics. And it’s also the environment around us.

But the big problem here is then the issue of blame… If you say to somebody, ‘There is a level of responsibility about how you interact with the world,’ the flip side of that is automatically blame. And that’s where a lot of people don’t want to go. And that’s why it becomes difficult to talk about choice and individual decision-making at those moments of interfacing with our obesogenic, toxic environment. Fair enough. But then you have to decide: does the person still have the choice? And that’s where it becomes a difficult conversation to have.

Weight loss can be hard and diets often fail. Why is changing our eating behaviour such a challenge?

Firstly, we eat because of the schemas in our head. And secondly, we eat because of triggers in the world outside. The schemas in our heads come from childhood and they are extremely difficult to change.

They are the habits we learned very early on. We’re feeling fed up, so mum gives us a piece of cake. We’re tired, so we watch a film on the sofa and we manage our wellbeing through food. So food functions in our lives for emotional regulation. We use it when we’re bored or fed up or upset. And it’s used for social interaction. We go out for dinner, we have treats, we have birthday celebrations. And it’s also used for communication. Who am I? I’m the person who eats a lot. I’m the person who’s picky… It is a huge part of our identity. It is in our heads and that’s difficult to change because it’s incredibly ingrained.

And the second thing is that the world out there certainly does not help us. We have a food industry which gives us bigger portions, buy-one-get-one-free and meal deals, and puts food everywhere we go. We have a cup of tea somewhere and we can get a muffin. Or you watch a film at home and you buy a takeaway pizza. And now we’ve got every food delivery service under the sun that can bring you whatever food you like, at a couple of presses on your phone. And that world out there constantly triggers us to want to eat – and then gives us high-calorie, high-fat foods.

So that combination of the things in our heads and in the world out there means it’s very difficult to change what we do. So people do need help. And if drugs come along which help that process, that is absolutely brilliant. But so far there hasn’t been the magic wonder-drug that means we don’t have to think about our behaviour too.

My biggest concern is that this is all part of the medicalisation of obesity: the desperate search for a medical solution, something which will magically take the control out of the individual and not require individual behaviour change

Professor Jane Ogden

New weight-loss drugs like Wegovy are now here. What are your hopes and worries?

I’ve been working in the area for about 30 years, and each time a new drug is launched on the market, there’s a big hurrah, everyone’s very excited, people seem to lose weight and then usually about six months later, it gets taken off the market, very quietly, because it has side effects. And the side effects of previous drugs have included heart attacks and suicide – serious side effects. So when this one was launched, you think this could be ‘it’, this is what everybody needs, but there’s a little bit of scepticism and waiting to see what actually happens. So far, it hasn’t been taken off the market for side effects. And so that’s a good thing.

The way I see it is that people who are living with obesity need a toolkit to help them lose weight, manage their weight and increase their health. And this is one part of that toolkit. We’ve got surgery. We’ve got medication. And we’ve got behaviour change. And if we have a drug that adds to that toolkit, that’s a good thing.

My concern is that you need to actually take it in order to lose weight, and as soon as you stop taking it you put the weight back on. At the moment, you can only take it for two years. So people are just going to lose weight and put it back on, which is what they do anyway. They do that with behaviour change and other medications. And some of them also do that with obesity surgery. So this isn’t going to be necessarily a long-term solution. And adherence rates are not always great for medication.

But my biggest concern as a psychologist is that this is all part of the medicalisation of obesity: the desperate search for a medical solution, something which will magically take the control out of the individual and not require individual behaviour change, (instead) allowing the person to be able to magically lose the weight. And this kind of fans the flames of that optimism that that will actually happen. And in the meantime, at least, it becomes less related to what we eat and how active we are. And I worry that if the emphasis on medicalisation increases, we will move away from thinking: maybe people should eat well and be more active.

Could these drugs at least serve as a psychological springboard for kickstarting a person’s weight-loss journey?

Absolutely. Over the years, we’ve had super-low-calorie diets, which can give people a jumpstart, we’ve had other drugs and we’ve had surgery which can give you a massive jumpstart. My emphasis would always be on behaviour change because I’m a psychologist. When you ask somebody with a BMI of 35 plus to lose two pounds a week, by changing your diet and being more active, for the next 15 years, it is a huge ask, with that slow degree of reward.

But if you can say: take this medication and you will lose 5% of your body weight within a year, that’s going to make someone feel better about themselves, they’re going to be able to fit into clothes that they couldn’t fit into before, they’re going to be able to be more active, that self-esteem is going to then spiral up, so they are going to eat more healthfully, they’re going to feel happier about themselves, and they are going to do more exercise that will then cause more weight loss.

So it gives people a kickstart. The problem is that in order to sustain those changes, you have to have sustained behaviour change. So you’ve got to learn from the way you live when you’re on the drug and transfer that into the future when you’re not on the drug – and that’s what’s difficult. I think that’s why we get weight regain when people come off the drug now, because they haven’t actually changed their behaviour.

If we medicalise obesity with drugs, might individuals believe positive healthy lifestyle change doesn’t really matter?

If you’re on the jab, and you get psychological support and dietitian input, you could whilst you’re on the drug learn to change the way that you eat, and to increasingly be more active. That would be what you’d want. And then you give people the support when they come off the drug to carry on those behaviours.

But we need to get the message across that because there’s a medical solution to obesity, or because there’s a surgical solution, it doesn’t mean that behaviour is not involved. And I think that’s the problem if we think: ‘Here’s a drug that can solve the problem of obesity. Obesity has nothing to do with how we behave. It’s all in the brain. It’s all in the gut.’ The psychological process and the behavioural process always go hand in hand.

The pharmaceutical companies or the people with a more medical perspective tend to focus on the medical aspects of obesity, but we still have to behave in healthy ways to maintain our weight in the long term.

The danger of calling obesity a ‘disease’ is that it’s no longer seen to be preventable… it’s seen as something that you just ‘get’

Professor Jane Ogden

Is obesity a lifestyle disorder or a disease?

I think it depends on what you want to do with the word. Some people say, ‘Let’s call it a disease,’ because that will give you greater access to medical and surgical interventions, and it’ll be taken more seriously by policymakers, politicians and the NHS. It could mean less blaming of the individual – and that’s great.

But the danger of calling it a ‘disease’ is that it’s no longer seen to be preventable. Because it’s seen as something that you just ‘get’. And there’s two totally different parts of understanding obesity. One is the management of people who are living with obesity now. And then there’s future generations who haven’t developed it yet. We need a message which is good for people who are living with obesity today. And maybe calling it a ‘disease’ helps because they get access to services.

But my worry is if you call it a disease people no longer think it’s preventable. And then we can’t get the message out to younger people, who haven’t gone through that process yet: eat well, be active, because it is to do with you, and your lifestyle can help prevent this problem. When you call something a disease, it becomes a little bit more out of your control, and therefore a bit more inevitable, as though it’s just a consequence of your genetics. My worry is that it’s a good term for the here and now. But it’s not necessarily a good term for future generations.

Based on your decades of experience, what are the best evidence-based approaches to the psychology of weight-loss?

First of all, choose your time. There’s a moment when you’re more open to change. It can be a teachable moment or an epiphany, but something can happen to you. Maybe you feel breathless going up the stairs.
Maybe you have a health scare. Or maybe someone in your family has a health scare. Maybe you’re in a new relationship or you get divorced or you come back from holiday or you’re going on holiday. Sometimes life throws us opportunities. And at those crossroads, those are the times to make a change…

But we also need rewards. We need some kind of feedback. The problem is that weight is a long-term goal. And avoiding a heart attack and diabetes is a really long-term goal. So you need to set yourselves short-term goals that bring the benefits into the here and now. So don’t say: I will do this for the next 20 years because then I won’t get diabetes. Say: I’m going to do this this morning, and then by lunchtime if I have walked to the shops and back, or eaten some vegetables, or had a salad with my sandwich, I will feel good about myself. I achieved that. Today.

Human beings do an awful lot of future-discounting. We’re rubbish at thinking into the future, and we’re very good about living in the here and now. So any benefits have to be now.

Body positivity movements like Health At Every Size fight weight stigma and encourage health for all body sizes, but they also downplay the very value of weight-loss, encouraging a more holistic view of health. Is this a positive or dangerous trend?

I think in a world which since the 1960s has encouraged women, particularly, but increasingly men to have unrealistically thin bodies, which has brought with it not only eating disorders, but general body dissatisfaction and dieting when people don’t need to lose weight, and a preoccupation with food, and low self-esteem, being positive about your body has to be a good thing. Regardless of what size you are, absolutely feel good about yourself. And absolutely push for wellbeing, positivity, a celebration of who you are and good health…

But being healthy – low and behold – involves eating well and being active. The evidence on the importance of being active, in particular, is huge. It is absolutely overwhelming how being physical active is fabulous for health…

But I think it’s disingenuous to say that being overweight isn’t detrimental to your health. So celebrate being healthy, and encourage people to be healthy, but weight is a proxy measure for health. The evidence is that excess body fat is not good for your health. And that’s where the argument gets problematic. I don’t think you can deny that evidence.

The message ‘eat well and be active’ should be out there regardless of obesity. It is what we should all be doing

Professor Jane Ogden

In your work, how do you navigate between the known psychological harms of weight-based stigma and the known physical harms of obesity?

How do you say to somebody that you can change, without saying it’s your fault you got to where you are? With smoking cessation, you say lung cancer is caused by smoking, so if you smoke you’re probably going to get lung cancer. So stop it now. And that seems to be an easier conversation than the one around obesity.

When the smoking bans came in, people flinched about it, saying it was their right to smoke and people were very vocal against it. But among the next generation, that seems to have sorted itself out.

But we haven’t got there with obesity yet. It is about how to encourage people to take control and have a sense that they can make better choices, without blaming people. And bearing in mind always that whatever you say now is having an impact on future generations. The message ‘eat well and be active’ should be out there regardless of obesity. It is what we should all be doing. And maybe that is the way to navigate obesity. This is about health. And it’s what we should all be doing.