Obesity was a growing problem even before the pandemic, but the links between being overweight and poorer outcomes from a Covid-19 infection have made tackling the nation’s waistline even more of a priority. Nic Paton listened in to a recent webinar that outlined strategies and approaches for both occupational health practitioners and healthcare professionals more widely.
After prime minister Boris Johnson had recovered from his serious bout of Covid-19 in April last year, which required a spell in intensive care, he admitted that one of the reasons it had been so severe was because he had been “way overweight” at the time.
The links between obesity and poorer Covid-19 outcomes are increasingly well recognised, and was one of the reasons why Johnson launched a “Better Health” campaign designed to encourage people to be more active and work to lose weight. The fact that the think-tank The Social Market Foundation in December, however, concluded this campaign had been ineffective and largely unsuccessful only serves to illustrate just what a tough public health nut this is to crack.
Of course, rising levels of adult and childhood obesity were a growing worry well before the pandemic, with all the accompanying long-term and chronic health conditions this can bring, including diabetes, coronary heart disease, musculoskeletal issues, high blood pressure, stroke and some forms of cancer. These, in turn, can have an impact on an individual’s ability to work, to function effectively, and even to remain in work, not to mention the mental health and psychological issues that can accompany long-term obesity.
People living with obesity can also often find themselves subject to stigma, barriers to progression at work and discrimination, as a recent report by the Institute for Employment Studies (IES) has concluded. The report, Obesity stigma at work: improving inclusion and productivity, has set out a range of actions employers, individuals, healthcare professionals and the media can all put in place to help tackle these issues. Importantly, too, it has highlighted the role occupational health practitioners can potentially play, especially around early intervention and more effective liaison and co-ordination with primary care (and see the end of the article for more on this).
Personal perspective from Dame Carol Black
The launch of the report in December was accompanied by a webinar where the highlight was a very personal presentation by Professor Dame Carol Black, author of the 2008 report Working for a healthier tomorrow, and expert advisor on health and work to NHS England and Public Health England.
Dame Carol, first, made the case for the government to step up and go further than it already has on this issue. “Given the current prevalence of obesity and future trends, and the potential scale of its costs, both to government and individuals, the government should consider the in-work aspects of obesity more fully. So we recommend that government undertake other research to investigate the impact of obesity on the working population,” she said. Childhood obesity also needed to be a part of this, “because childhood obesity leads to adult obesity, with all that means going into the workplace,” she pointed out.
“I believe employers can make a huge difference, especially if they have an encouraging and compassionate approach. We might like to think, too, about the power of leadership. If a CEO talks about their mental health and their issues, and we know that a lot do have their own depression or stress, and how they have overcome it and look where they are in their careers, then employees can feel relieved and empowered and able to disclose and discuss their own issues. It is very powerful and I wonder if a similar approach would help for obesity,” she said.
“I think it is also crucial that employers provide the right, healthy environment, whether it be food choices and availability or encouraging support to be more active; the number of workplace canteens or restaurants I have been to where the first thing you see is really the unhealthy food. I think it would be helpful if employers could do the link-up between what the workplace can do, and what is happening outside in organisations like Weight Watchers. I think that could be a really supportive, joined-up approach,” Dame Carol added.
Dame Carol then highlighted how this issue was intensely close to her own heart because of her own private battle with obesity as a child and a young adult, something she admitted she had rarely, if ever, spoken about before in public.
“I was a fat child; I looked like a little Michelin man. I was fed on bread and dripping, jam sandwiches and cake; we were a very working class family and we didn’t have much else,” she outlined.
“I simply hated being fat, and it affected my schooling. I didn’t want to go to the games field or in the gym; I didn’t want to go to the parties and so on. It was a form of stigma in the context of an educational setting.
“I did then have a lightbulb moment. It was at a party in the sixth form and I found myself in a turquoise party dress, but bulging out of it. And there was no one who wanted to dance with me. Something happened; something broke inside of me. I was just determined to lose weight, which I did achieve. But still, to this day, when I look in the mirror I see a fat person, a fat child.
“So this makes me passionately keen to see childhood obesity taken very seriously and to do whatever we can in the workplace to make sure that people are treated with respect and supported and helped,” she added.
Obesity and discrimination
Earlier in the event, Sarah Le Brocq, director of Obesity UK, had emphasised the direct and indirect discrimination that is still often associated with obesity. “Why do we think it is OK for us to comment on someone’s appearance or the way they look as an indicator of how good they are at doing their job or how good they are at doing something?” she pointed out.
“What I really want to change is, we don’t think somebody who has brown hair can do something better than someone who has blonde hair. Or someone who has blue eyes or someone with a certain colour skin or certain gender.
“However, when it comes to people who live with obesity and people in larger bodies, we still think it is acceptable to have this perception that they are not as good at their job; they’re incapable; they’re not as intelligent. And this absolutely needs to stop. Just become someone lives in a larger body does not mean they are a lesser person,” she added.
Dr Abd Tahrani, senior lecturer in metabolic endocrinology and obesity medicine at the University of Birmingham, highlighted how obesity is not just a physical health challenge. Obesity stigma, negative attitudes and obesity discrimination can also bring with it lots of impacts around mental ill health too.
“Having obesity does not mean laziness or lack of abilities. In fact, many highly successful professionals and leaders in their fields, from all walks of life, have obesity. Discrimination against people living with obesity in terms of employment and income should not be acceptable or tolerated, especially given the links between obesity and social deprivation and inequalities,” he explained.
Early retirement and ill health departure from work
And report authors Dr Zofia Bajorek and Stephen Bevan emphasised how obesity and obesity stigma can lead to early, ill health-based departure or retirement from the workplace and the importance of ‘good’, supportive work in this context.
“Those living with obesity may be at a higher risk of developing other physical or comorbid conditions. These may require an element of treatment, but may also have an impact on employment,” pointed out Dr Bajorek.
“The most common of these co-morbidities include type 2 diabetes, some forms of cancer, osteo-arthritis and heart disease,” she said, highlighting that by 2050 it is estimated some 60% of men and 50% of women in the UK will be living with obesity. “It is important that we look beyond ‘eat less, do more’ rhetoric. Employees living with obesity may not experience ‘good’ work, and quite surprisingly and upsettingly, weight-based stigma occurs at every stage of the employment cycle,” she added.
“Particularly for women, and particularly if you control for age and other factors, stigma discrimination seems to play a really important part in determining whether women are leaving the labour market early, and that is a troubling sign,” said Bevan.
“In some service sector jobs, things like style, image grooming and appearance are seen as a way of enhancing the customer experience, and that particularly affects women in service sector customer facing roles. We have seen examples from the hotel and airline industry that made fairly unsubtle demands about particularly women working in those sectors, and particularly their look and their appearance, and making requests of them to look a certain way. I think that is one of the things we are seeing, certainly as we have shifted towards being much more of a service-based economy,” he added.
“We need to think a bit more about how work can be regarded as a clinical outcome of care, and healthcare professionals play a part in that,” he said.
“There is some worrying evidence that, even now, there are some healthcare professionals who – still – use stigmatising language or take a view of ‘eat less, move more’ whereas we ought to be encouraging people living with obesity to play a stronger part in the management of their condition.
“Also we need healthcare professionals to think beyond the physical symptoms. The biopsychosocial model of care is really important here; thinking about how you are treating the whole person, their physical and their psychological health as well, is a really important part of this. It is a complex issue; it doesn’t have simple causes and therefore it doesn’t have simple solutions,” Bevan added.
Occupational health’s role in tackling obesity
The IES report has highlighted the value of early intervention when it comes to supporting an employee struggling with weight issues within the workplace.
As it argues: “Employers should always take action sooner rather than later to support an employee whose health may affect their attendance and performance at work because caution and delay can only make matters worse.
“Employers who behave compassionately and make decisions on rehabilitation and workplace adjustments based on evidence and on expert opinion, find that delivering early interventions can benefit the employee and the employer,” it adds.
And this is an area where a proactive approach by occupational health can potentially make a difference, it contends. As it says: “In practice, this [early intervention] means early involvement of occupational health (OH) expertise.
“In addition, vocational rehabilitation, carefully organised and tailored to the individual, can make a real difference to the success and sustainability of return-to-work plans, productivity, morale and performance,” it adds.
The report also highlights how better co-ordination and collaboration between primary care and OH could make a big difference. The government, it recommends, should “help make GPs more effective in handling occupational health issues related to obesity and related health conditions.”
This will “require an input into GP training, through the General Medical Council, and medical training at all levels from undergraduate to continuing professional development would benefit from inclusion of health and work issues” it adds.
Beyond this specific OH-related advice, the report in its recommendations for healthcare professionals emphasises the importance of prioritising return to work, the effective use of fit notes (so, again, meaning good liaison with GPs) and recognising the role, and value, of work and return to work as a positive health outcome.
Part of this is needing to think beyond physical symptoms and taking a biopsychosocial, whole-person approach. “Bring to bear your understanding of the biopsychosocial model and the limitations of the biomedical model in your diagnosis of the patient and – most importantly – your assessment of the role that their job might play in helping them stay active and avoid isolation,” the report recommends.
For employers, the advice, in a nutshell is to be proactive around including obesity and overweight explicitly in any equality, diversity and inclusion policies. There should be a focus on capacity rather than incapacity, fostering a safe and supportive working environment, considering how work is designed to assist job retention, and the value of, again, intervening early and with being compassionate and supportive.
For employees, the report emphasises the value of self-management of any health conditions associated with obesity so as to minimise its impact on their ability to function and perform at work and their general wellbeing. “It is important to find an advocate or supporter to help navigate through organisational policies and employment law,” it adds.
For government, the report argues that clearer guidance to employers on the legal status of obesity discrimination in employment would be helpful, if obesity is to remain outside the protected characteristics under the Equalities Act. “Better measures are needed to assess the social, economic and work impact of obesity to allow NICE guidelines to take these more explicitly into account when evaluating treatments and therapies,” it adds.
Practical OH obesity support within the workplace
The Royal College of Nursing in its guidance around obesity points out that the World Health Organization’s definition of obesity is a body mass index (BMI) greater than or equal to 30, and the NHS has an online healthy weight calculator.
Common health problems associated with morbid obesity may include:
- heart disease,
- raised cholesterol levels,
- type 2 diabetes,
- respiratory problems,
- gastroesophageal reflux,
- urinary stress incontinence,
- degenerative arthritis,
- skin infections,
- sleep disturbance, and
Practical ways that OH can help include providing leadership and guidance to employers on things such as healthier canteen and food choices (especially for those working shifts or unsociable hours).
OH practitioners may also be able to take a lead on ways in which an employer can encourage and support employees to be more active during their working day, something that may be especially challenging at the moment given the numbers likely to be working from home.
In more ‘normal’ working times, however, this can include communicating and promoting the benefits of more active commuting, physical infrastructure changes such secure parking for bicycles or showering and changing facilities, and improving stairwell areas and signage to encourage more use of the stairs during the working day.
Adjustments such as sit-stand desks, standing meetings or even walking meetings (with outside meetings, when the weather allows it, likely to become more popular post pandemic). However, it is also important to take account of any mobility issues employees may have and whether there is a risk of employees living with obesity feeling disadvantaged or even stigmatised by such changes.
Employers also need to consider – and be open to advice and guidance on – how their policies and procedures can better support obese employees and reduce the risk of discrimination occurring, even though obesity is not yet a protected characteristic under UK legislation.
Within this, an employer may want to consider whether its anti-harassment or bullying policies take into account behaviours and language around obesity, and any impact this might have. This may need to extend to social media policies, too.
Implementing regular wellbeing, weight, BMI and waist measurement, blood pressure, cholesterol, blood sugar and body composition checks can also all help, but must of course be conducted in a sensitive and positive manner. However, these may of course not be viable at the moment.
Don’t forget too, the connections between obesity and mental health, especially between obesity and depression, and the potential knock-on effect on productivity and absence from work that may result.
Coronavirus: Boris Johnson says he was ‘too fat’ as he launches obesity crackdown
Sky News, July 2020, https://news.sky.com/story/pm-targets-checkout-sweets-and-buy-one-get-one-free-deals-in-national-obesity-plan-12037000
Mahase E (2020). “Covid-19: Why are age and obesity risk factors for serious disease?”, BMJ 2020;371:m4130. Available online at: https://www.bmj.com/content/371/bmj.m4130
“New obesity strategy unveiled as country urged to lose weight to beat coronavirus (COVID-19) and protect the NHS”, Department of Health and Social Care, July 2020, https://www.gov.uk/government/news/new-obesity-strategy-unveiled-as-country-urged-to-lose-weight-to-beat-coronavirus-covid-19-and-protect-the-nhs
“Government’s obesity strategy not working”, Occupational Health & Wellbeing, December 2020, https://www.personneltoday.com/?p=262070
“Statistics on Obesity, Physical Activity and Diet, England, 2020”, NHS Digital May 2020, https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/england-2020/part-3-adult-obesity-copy
“Obesity: overview”, NHS, https://www.nhs.uk/conditions/obesity/
“Obesity stigma at work: improving inclusion and productivity”, Institute for Employment Studies, December 2020, https://www.employment-studies.co.uk/system/files/resources/files/Obesity%20Stigma%20at%20Work%20-%20Improving%20Inclusion%20and%20Productivity_0.pdf
“Working for a healthier tomorrow: work and health in Britain”, Department for Work and Pensions, 2008, https://www.gov.uk/government/publications/working-for-a-healthier-tomorrow-work-and-health-in-britain
“Obesity”, Royal College of Nursing, https://www.rcn.org.uk/clinical-topics/public-health/obesity
“Obesity”, National Institute for Health and Care Excellence, https://www.nice.org.uk/guidance/conditions-and-diseases/diabetes-and-other-endocrinal–nutritional-and-metabolic-conditions/obesity
“Obesity and overweight”, World Health Organization, https://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight
“BMI healthy weight calculator”, NHS, https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/