29 February 2024

Jo Hollington is a Principal Dietitian and the Dietetic Lead for Tier 2,3 & 4 at Guy’s and St Thomas’ NHS Foundation Trust. The tier services that she leads are part of the Guy's and St Thomas' NHS FT weight management services and each tier represents a different level of support for patients. We spoke to Jo to see what she has learnt about living with obesity that people don't often realise.    

How does language impact people living with obesity?  

When someone has cancer, we do not say they are cancerous; having cancer does not make someone cancerous. Saying somebody is obese has been equated to calling somebody cancerous: it takes the condition and applies it to the person. We should be saying a person ‘living with cancer’ or a person ‘living with obesity’. It's not that you're an obese person, that label is really stigmatising.  

In my consultations I ask for the patient’s permission to talk about weight first, even though they're in a weight management clinic. People living with obesity know the position they’re in but sometimes they're not ready to have that conversation. It depends on the setting, but for GP's, healthcare providers and nurses it's worth asking for permission to talk about it.  

Stigmatising language, especially when used in a consultation to encourage weight loss, has been proven to have the opposite effect. Oxford University found in a study that when positive language was used by GPs in patient consultations, it resulted in better behaviour changes than when negative or neutral language was used. Words can be triggering so I don’t think it's too far-fetched to ask patients what sort of language they would prefer. As opposed to focusing on someone’s weight and weight loss, instead, we should focus on changing unhealthy behaviours. If you can change the behaviours that are fundamental to weight gain and promote the mental and physical health benefits of changing these behaviours then weight loss will always follow.  

How does your service support patients? 

I describe living with obesity to my patients as a maze. When people realise how they got into the maze they start to create a blueprint of how to get out. This analogy also helps people to understand the complexity of what they’re going through because every maze is unique to the individual. 

The principals of weight maintenance and weight loss are the same for most individuals, but we need to account for personal circumstances when deciding what type of support they might need and to what degree. We have a multidisciplinary team with access to psychology, physio and dietetics and this helps us to address a wide range of patient concerns.  

For example, if someone got into the maze through mental health difficulties, we would consider providing additional support through our in-house psychologist or connect the patient with local talking therapies. Once we know how they gained the weight, we can start to apply the right support.  

Is BMI the best tool for assessing a person’s health? 

BMI is problematic at its core because it does not explore body composition - we know that. BMI is used in the NHS as a guide but it's just one piece of the puzzle. We also look at comorbidities and ethnicity as this helps us to capture a more accurate picture of an individual’s metabolic risk.  

I once had a patient who was referred to our medical obesity clinic with a BMI of about 38, but once I saw her in person, I knew she was not overweight. She was sent to us by a fertility clinic because they had seen her BMI and they had not seen her in person. This lady was a semi-professional weight lifter! She was fit, healthy and active and by no means an eligible candidate for bariatric surgery. The fertility clinic had seen the high BMI and referred her to us to help her lose weight so she could reach the criteria for fertility treatment, but it was not an appropriate triage. This is why it’s important that we don't look at just that number. 

What societal trends need to change so we can make a difference? 

There are some fundamental lifestyle patterns that we see in our Tier 3 and Tier 4 services that we know contribute to weight gain. These are some of the areas that we need to address as a society to give people a better chance of living longer lives: 

When we eat 

Erratic eating patterns – long periods of not eating followed by very large meals - dysregulates hunger and makes people more likely to overeat at the end of the day. We see irregular eating patterns from people who don't perceivably have time so they snack on ultra processed and sugary foods throughout the day. Prof Tim Spector and Dr Sarah Berry from the King’s College London Faculty of Life Sciences & Medicine stressed how ultra-processed food can impact on long-term health in BBC One’s Panorama in July last year. 

When we sleep 

We see a lot of people who work night shifts through no fault of their own other than the career they're in. This is also where finances come into it - we see people who have to work night shifts so they can look after their kids during the day which means they’re always on duty. Shift pattern, broken sleep and insomnia can cause weight gain because it disturbs your hunger and satiety hormones. It also creates a taste preference for sweet and faster energy foods. We need to work with patients to find solutions so they can get the sleep they need.  

What we eat 

There is a lot of emerging research about the issues with ultra-processed foods in our diets. We’re not talking about all food processing, such as pasteurising milk for safety. Here, we are talking about layering in thickeners, artificial flavours, artificial colours, gums, binders and emulsifiers. We’re starting to see connections with ultra-processed food and weight gain: focusing on diet quality has never been more important. We should be focusing on eating foods the way they appear in nature. Eating fresh (or frozen) fruits and vegetables, lean protein, wholegrains, healthy fats, nuts and seeds. We also need to support people to reduce their consumption of processed meat and actually meat as a whole. It is beneficial for health (and environment and animal welfare) to go meat free on at least one day a week.   

We should make it easier for people to eat with the seasons. When something is in season, it is at it’s peak nutrition. For example, when it’sblackberry season, this is the time when the berries have the highest polyphenol and vitamin C content. A really nice way to eat with the seasons is through fruit and veg boxes that feature seasonal fruit and veg, some boxes even rescue wonky fruit. 

How we eat 

Some cultures have such a brilliant way in which they eat. They sit down, socialise, eat slower, have smaller portions and share plates. It’s not the biggest factor but it has a significant role to play in food intake and diet quality. We live in a culture, particularly in London, where we're always on the go. We eat convenience foods daily, we grab food on the go, like meal-deals, packaged foods and high calorie snacks. We need to encourage people to enjoy what we eat and how they eat it. Taking the time to appreciate the food we eat and slow down when we eat, we actually recognise our hunger and satiety hormones a lot better and we can recognise more easily when we are full.  

What’s something that people not living with obesity might not realise about the condition?  

Obesity is complex. When people decide they want to lose weight they are often targeted by products that sell the dream of fast weight loss but if it’s not done safely, erratic changes in weight can contribute to weight gain longer term. We need to help people stay away from dramatic (and sometimes dangerous) fad diets.  

The fundamentals of healthy eating are relatively simple, but it's working out how to apply that to your lifestyle, your finances, your family, and your culture that may require some thought. What we eat, why, and how is so ingrained in our society. We are so easily influenced by food marketing because we are fundamentally hormone driven as humans and if we didn't eat, we wouldn't survive. We have to try to manage the real complexities of living in what we call an obesogenic environment where the food industry is not our friend, they are there to make money. The food industry has taken advantage of the way humans live and make food choices.  

If you are living with obesity and want to make a change, a proven way to lose weight is to find your tribe. You can turn to friends, family or you can join clubs or group programs because knowing that you're not doing it on your own does help and that is evidence based. GPs can also provide evidence-based support.

King’s Health Partners Diabetes, Endocrinology and Obesity is focused on delivering improved health and wellbeing outcomes for people living with obesity and addressing the inequalities gap within the diverse communities we serve.