Once again, Cancer Research UK is plastering the nation with billboards encouraging people to “know” that obesity causes cancer. A lot of the time I think I should be grateful to CRUK, as I’m sure they’ve been behind a whole lot of my treatment, but even before I got ill, there were a couple of things that caused me concern:

1. The campaign ‘Research shows that vaping is far less harmful than smoking’. Maybe, but is that saying it’s “healthy”? CRUK Statement
2. When I cancelled all my charitable direct debits on my cancer diagnosis, most other charities said ‘sorry to hear that, and hope treatment goes well’, but CRUK sent a very standard email and didn’t acknowledge the reason at all.

Last year, CRUK created a campaign focused on ‘Obesity‘, which I found really problematic, and this was echoed by a number of public or medical figures, including GP Margaret McCartney, who noted that CRUK defined ‘success’ as raising awareness of the association between cancer/obesity, and that this only increased by 2% in their pilot campaign. ‘Raising awareness’ without any associated behavioural change doesn’t seem particularly helpful to me, and if CRUK are going to get involved in such campaigns, as their own research demonstrated ‘combining the effect of eating more fruit and vegetables and less processed meat, for example, would easily outweigh the risk carried by obesity’.

I was shortlisted for a patient involvement role at CRUK, and they asked me to talk about the 2018 obesity campaign - should they have taken such a ‘bold step’? and here’s some of the kind of things I said:

• The way that ‘obesity’ features in the news is not helpfully framed (all headless figures, and individual-blaming, rather than structural issues - e.g. poverty, food access, smoking, genetic pre-disposition).
  • It’s a very visible thing, and it becomes very easy for others to point fingers, rather than provide sympathetic support
  • It 1) assumes that people choose to be fat 2) could do something about it but won’t
• I don’t have the research expertise to necessarily counteract the statement itself (although correlation/causation is a question), but I do have much with the way the message has been created/marketed. Bearing in mind that my PhD was on government campaigns during the Second World War, so including looking at persuasion theory, and behavioural change…
  • This included a chapter on VD posters (now STI) - the government was more keen to encourage treatment than to shame users (although there was both a medical and a moral message in the posters).
• People who are fat do typically know they are fat, and will ‘know’ that there is a whole load of advice that says this is not healthy. The ‘Health at Every Size’ movement is less funded as it doesn’t really have a product to sell.
  • There needs to be more research into why people are fat, assuming this is a problem…
• For those of us in Beyond Chocolate, we have tried diets (all the diets), and have typically ended up heavier, and also much unhealthier mentally
  • We define ‘success’ by re-finding an enjoyable relationship with food that is not about rules/punishment, about finding ways of ‘moving’ that are about enjoyment, and more about understanding yourself/having compassion on yourself (as per the counseling I’m having at the Christie).
  • 95-97% of diets fail long-term, and often lead to disordered eating. There is a lot of concern about ‘weight-cycling‘ leading to a higher ‘weight set point’, and that many of the poor ‘life chances’ could be attributed to this rather than the being overweight.
  • This seems to be the way that some areas of culture are going - see the iWeigh campaign - we are more than we weigh
• There is increasing research that focusing on calories in/out is not helpful, nor is ‘all or nothing thinking’ helpful.
  • E.g. There’s been the focus on the ‘sugar tax’, replacing natural sugars with aspartame (which I would think is more cancer-causing!)
• I favour the carrot over the stick. Any campaign that can be more positive, rather than exclusionary and ‘victim-blaming’. The #thisgirlcan campaign is a benchmark for how this can be done:
  • People were recognised as holistic beings in a way that was ‘fit for purpose’
  • Featured ‘real’ people of all shapes/sizes (less about using ‘influencers’ and more about a community of women)
  • Noted to people that whatever they did, they ‘lapped everyone on the couch’
  • Encouraged people to ‘try new things’
  • Had a celebratory rather than a condemnatory tone to the campaign - embodied the whole spirit
  • Created a cross-platform campaign with shareable assets that users can show their friends, or organisations can use
• I want to share positive content, and after looking at the campaign, it wasn’t clear what CRUK wanted us to DO having seen their campaign, e.g. they could have said:
  • Eating a diet rich in fruit and veg can cut the risk of cancer
  • Increasing activity can boost the body’s cancer fighting abilities
• How many would only have seen the poster (overly simplistic), and not looked any further? And how many who are not overweight would then think that cancer is therefore not a potential problem for them? Is it clear what else CRUK are doing to change wider policy?
• The BMI is hugely problematic (see some info on this, and in 1998 thousands of people became ‘overweight’ overnight)
  • There is an assumption that exercise must be about weight loss, rather than other forms of wellbeing (I have a clearer head, write better, breathe better, etc. when I exercise - just wish I could do more at the moment).
• Neoliberal ideologies put the responsibility on the individual to make changes, whereas much research on obesity shows larger societal issues.
• Cancer diagnoses are typically put down to multifactorial reasons … and most oncologists will say it’s bad luck (for breast cancer being a woman and getting older are the main factors - and for those who are pre-menopausal being (somewhat?) overweight is actually a positive).
• Sofie Hagen had a lot to say - how the campaign is causing shame, ridicule, abuse and fear - ‘others fat people’ - legitimises fatphobia - which weirdly when fat people are seen going to the gym or buying vegetables = stigmatises.
• Blaming individuals indicates that weight is easily controllable = not helpful. Raises question of are we in an obesity epidemic that nobody can control, or is it a personal issue we can manage.
• A friend who saw this poster countless times within a 1 mile walk (yes, walk) - felt rubbish, powerless, and when posted about this on Twitter was trolled and told she ‘deserved cancer’.
• Talking to friends, illnesses have led to weight gain; those who have gone on extreme diets have ended up with gallstones; fatigue, etc. means that people can’t do the exercise they may wish to - we need more exercise plans like PARIS and ABCDiagnosis.
• The Twitter account @AtYourCervix was recently set up in recognition that going for a smear test is not ‘easy’, and offering help to people wanting to attempt it anyway.
• Think about individuality/personalisation (especially as digital tech improves) - e.g the 10k steps per day was created by a marketing agency - it’s too high for some people (e.g. shortly after chemo I can just about manage 1k).
• This campaign adds guilt/distress to patients that they have ’caused’ their own cancer. Indicates that they are lazy/lacking willpower (rather than using food as a coping mechanism, which just saying to ‘stop’ doesn’t help); the shock factor gets PR, but what damage is done in the process? Also, cancer drugs such as tamoxifen make many put weight on.
• Can this campaign shape the bigger debate? And does bold mean helpful? The campaign scares more than it helps… timely treatment can be put off as patients will except to be blamed for their weight, and often GPs don’t look past the weight for an explanation…
• Are there questions about the fact that CRUK runs events with alcohol, etc. then runs this kind of content?
• It would be interesting to see who stopped/reallocated donations as a result of this campaign…

And now there’s a new campaign - has it just been written to get the PR coverage, and ‘fat people’ are just collateral damage?

I am particularly concerned about the link with Slimming World … an organisation that helped me lose 3+ stone, and then gain 7+, which is how I got involved with anti-diet groups, which have more of a focus on healthy habits, and learning the reasons that cause you to eat, rather than fixed ‘plans’ that are guaranteed to backfire, or take over your life with their rules and regulations. Since being involved with Beyond Chocolate I have stopped putting weight on (including during 2 rounds of chemotherapy + hormonal therapy), although I’ve not lost any - but if I look back at what I’ve been dealing with over the past 10 years or so … there’s a lot to turn one to comfort eating!

Part of the reason for my concern has been written by Natasha Devon, in that overweight people (and this is something that is very visible) end up being blamed for e.g. the problems in the NHS (a complex, multifactorial problem, especially the reduced budgets given by the government):

Not only does it add more gravitas to a burgeoning multi-billion pound diet industry with a 95 per cent failure rate, it fuels eating disorders and encourages the public to consider themselves ‘visual doctors’, firing casual micro-aggressions in the direction of fat people under the guise of ‘concern’ for their ‘health’.

Within cancer groups there has been a whole lot of debate as to whether this campaign is a) necessary b) helpful. I don’t think anyone is arguing if the research shows a definitive link then CRUK shouldn’t be running a campaign in this area, but a) causation hasn’t been proven b) this kind of message doesn’t help with behavioural change.

• Another friend with secondary cancer, who has never been overweight, thinks not only is a poor type of message, but she thinks that maximum 5.5% of cancers have any identified potential link to weight, and that CRUK could use it’s finances better.
• There’s a question of how it’s in the interests of pharmaceutical companies to define ‘obesity’ as a disease (although I’m a little wary about adding to any ‘big pharma has the cure for cancer’ nonsense).
• Others think the policy is clear/a step in the right direction as they believe people are unaware of the link. Think there is frustration from healthcare professionals because of significant (perceived) consequences. Some viewers feel challenged to ‘look after themselves more’.

A great response:

The best comment I’ve seen on @CR_UK ‘obesity’ campaign so far … pic.twitter.com/ZdMXIdhqyR

— Dr Bex Lewis (@drbexl) July 5, 2019

Then:

Five reasons why @CR_UK‘s #obesity campaign is flawed:
1 Smoking is a behaviour and bodyweight is a physical outcome
2 Linking obesity to smoking frames it as a lifestyle choice
3 Genetics have a big influence on whether or not someone has obesity
1/2

— NIHR CLAHRC West (@CLAHRC_West) July 3, 2019

Also:

 

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WEIGHT STIGMA CAUSES SHAME, NOT HEALTH// ?? CW: fat-phobia, anti-fat bias, weight stigma, ‘obesity’ ? I’m sure you all remember @cr_uk infamous OB_S_ _Y campaign from last year which compared body weight to smoking - it came under fire for painting an overly simplistic relationship between weight and cancer, using causative language (when we can only ascertain associations) and placing blame on individuals which increases stigmatising attitudes and can cause physical and psychological harm. ? Well, today CRUK launched the updated 2019 version of their campaign, which, to all intents and purposes - is exactly the same (swipe to see a picture) ? Before we go any further, I just want to make it clear that this is a critique of this particular campaign, not of the overall work that CRUK are doing to raise research funds + support those affected by this devastating disease. That work is important and appreciated. ? But this campaign, is a total shit show. ? This is currently a bit of a brain dump + I’m working with colleagues to actually *do* something. We will need your help though, so stay tuned. ? But for now, let’s start with what CRUK were *intending* to do with this campaign, and then we’ll look at how it misses the mark. 1?? Raise the awareness of ‘obesity being a cause of cancer’ (their words here, not mine), similar to smoking. 2?? Influence policy makers So let’s look at these a little closer. · First up, comparing body weight to smoking is entirely unjustifiable; smoking is a behaviour (+ shouldn’t be shamed either!), whereas weight is an outcome of many, complex, intersecting variables (many of which we don’t have control over) - our genetics, socioeconomic status and trauma, just to name a few. People can’t easily change their weight. It’s unforgivable to blame individuals for their body size - shame does not promote health. · Instead, it encourages stereotypes of people in bigger bodies, making those individuals a target for harassment, prejudice, + discrimination. · This has been shown to lead to: low-self esteem/confidence, negative body image, feelings of worthlessness + loneliness, suicidal thoughts + acts, (keep reading in comments)

A post shared by Laura Thomas, PhD, RNutr (@laurathomasphd) on Jul 1, 2019 at 11:42am PDT

And:

Patronising tripe - I hear this all the time. Jobs, stop closing sure start centres, housing, public health investment, support for those to help tackle obesity, affordable transport etc. And a sugar tax too. https://t.co/3XRxoG45Mt

— BreastCancer Chat Ww #BCCWW (@bccww) July 4, 2019

*Added Sunday* To note that I have never been ‘skinny’, but I have been very fit/active - have run 2 x 10k (fastest 1hr 6 mins), walked the Moonwalk, love circuit training, continue to try and do my prehab/rehab, cook a lot of my meals from scratch, don’t drink fizzy drinks (thanks gynae surgeon for assuming that I do) - I had a couple of major illnesses in 2004/2007 (and then cancer in 2017/2019) which have had huge impacts on my energy levels/mental health… you never know when something might hit…

Also, if diets “worked”, and we’ve had commercial diets since, what, the 1950s, why are people heavier now than before diets….

“A cultural fixation on female thinness is not an obsession about female beauty, but an obsession about female obedience. Dieting is the most potent political sedative in women’s history; a quietly mad population is a tractable one.”

– Naomi Wolf

*End of Edit*

Some useful links:

• An Open Letter to Cancer Research UK (by Laura Thomas, signed by an impressive list of names working in the field of ‘obesity’ and non-diet weight specialists) and related petition.
• Cancer Research’s obesity campaign isn’t just misguided – it’s dangerous
• The O-Word Is the Second Preventable Cause of Cancer After Smoking. Is It True? Is It Helpful?
• How Fat Shaming Leads To Eating Disorders
• How ‘weight bias’ is harming us all

Contribute to research:

I’m finally carrying out my research on the experience of weight stigmatisation and coping strategies in response to weight stigma. If you’ve ever been a member of a weight loss programme, please help me raise awareness by carrying out this survey: https://t.co/J38XxZZ1ff ?

— RN. (@MyKneeKing) July 3, 2019

And Remember:

Let’s be clear about something - whatever you did or didn’t do to look after your health before cancer - no one deserves cancer. #bccww

— BreastCancer Chat Ww #BCCWW (@bccww) July 4, 2019

*Added Monday* Thought for the Day from Good Morning Scotland