Apples and Oranges: Separating Lifestyle Behavior and Obesity Conversations

Behavioral theories in the context of health communication creates a framework for understanding perceptions of and driving forces for health-related decision-making. ¹ The importance of effective communication strategies to promote and celebrate healthy behavior choices spans from the population to individual level. Importantly, for those developing and implementing communication strategies related to health issues, an in-depth and objective understanding of scientific evidence is required to ensure alignment between messaging and research findings. While unhealthy lifestyle behaviors and obesity are both complexly linked and prominent health challenges in the current landscape, there are important deficiencies in communication strategies surrounding these issues. Specifically, our communicative approach related to unhealthy lifestyle behaviors and excess body mass, to a degree, are uncoupled from scientific evidence and incorrectly treat these phenomena as a singular entity. The Marion Webster dictionary defines the phrase “apples and oranges” as comparing “things that are very different”. ² From population to individual level, we believe this phrase and its meaning apply to the differences between health communication strategies related to lifestyle behaviors, such as physical activity and nutrition, and obesity.

Obesity stigma, defined as “prejudiced, stereotyped, and discriminatory views and actions towards people with obesity” ³ is a pervasive issue throughout society. Obesity is often considered a “self-inflicted” ⁴ condition that directly results from unhealthy lifestyle behaviors and a lack of individual willpower. A recent opinion piece highlights the societal issue of stigma related to body habitus, particularly for women. Evette Dionne recently wrote about Audi Crooks, an elite collegiate basketball athlete who plays for Iowa State. ⁵ She is rightfully recognized as one of the best athletes in the country, and yet, body-shaming comments have surfaced on social media (not to be repeated here as such comments do not warrant amplification). Similar body-shaming comments have been endured by other female athletes throughout their career, such as Serena Williams, one of the best professional tennis players in the history of the sport. This societal issue highlights the apples and oranges scenario surrounding healthy lifestyle behaviors, in this case physical movement and performance at the highest level (the apple), and body phenotype (the orange). It is also interesting and troubling to note that, throughout the decades of professional athletics at the highest level, it appears that men do not face the same unfair criticism or scrutiny. Evidence indicates that individuals who experience body shaming are less likely to engage in physical activity. ⁶ In this context, body shaming of high profile elite athletes may negatively impact the larger population who may find inspiration in those athletes. As a society, we should vie for such comments to cease in their entirety; athletes who perform at the highest levels should be celebrated for their achievements and the pleasure and inspiration they bring to those who have the privilege of observing their performances.

Individuals who seek careers in healthcare often cite their desire to help others as a primary motivation for their chosen profession. As such, one would expect healthcare professionals to inherently possess empathy and compassion for patients suffering from obesity – unfortunately it would appear the opposite is often the case. Evidence indicates health professionals exhibit “strong explicit and implicit biases against people with obesity” ³ . Carrasco et al. ⁷ recently assessed 235 primary care physicians attitudes regarding obesity and reported the following: (1) 91% correctly recognized obesity as a disease, however; (2) 44% believed the most effective intervention for obesity are healthy lifestyle behaviors; (3) 47% believed is due to a patient’s lack of self-control; (4) 14% described a patients lack of motivation and 22% mentioned laziness as factors for obesity; and (5) 87% stated that weight loss is the patients’ responsibility. On the health professional level, this data provides further support for our apples and oranges case – physical activity and healthy nutrition as behaviors are very different from obesity as a disease and, when obesity is considered as a “self-inflicted” ⁴ condition due to unhealthy lifestyle behaviors, we are incorrectly comparing “things that are very different” ² , which drives suboptimal care and poor outcomes in patients with obesity.

Given the current apples and oranges approach to lifestyle behaviors and obesity, from the population to individual level, it is important to assess current scientific evidence for guidance on how to move forward. While the propensity for weight gain substantially rises in individuals emulating the sedentary lifestyle - poor nutrition phenotype^8,9, obesity is not a lifestyle behavior; rather, obesity is now recognized as a “multifaceted chronic disease that is intricately linked to metabolic, biochemical, and psychosocial dysfunction”. ¹⁰ There is now a recognition that the driving forces of high obesity prevalence are extremely complex and include a broad array of upstream social and environmental factors that have profound impacts on the community/individual level.^3,11,12 Even so, lifestyle behaviors and obesity are often discussed in an integrated, simplified context (e.g., physical activity + poor nutrition = obesity). Craig et al ⁴ argues the following: “Promotion of healthy behaviors is essential to help the population become healthier, but these are not obesity treatment strategies. Twenty percent of patients with obesity may respond to approaches based on healthy behavior, but the 80% who do not respond should not be stigmatized but rather their treatment should be escalated. The unintended consequences of promoting healthy behaviors to patients with obesity can be mitigated by understanding that obesity is likely to be a subset of complex diseases, that require chronic disease management.” Moreover, attaching the success of adherence to healthy lifestyle behaviors to weight loss diminishes the value of achieving the former irrespective of also achieving the latter. Rassy et al. ¹³ recently demonstrated individuals with obesity who adhered to healthy lifestyle behaviors (i.e., not smoking, being physically active, minimizing alcohol use, and consuming a healthy diet) were at lower risk for hypertension, cardiovascular disease, renal disease, gout, and both sleep and mood disorders compared to counterparts also living with obesity but who did not adopt any healthy lifestyle behaviors. In this same study, the risk for certain adverse outcomes remained higher in individuals with obesity who adopted healthy lifestyle behaviors compared to individuals who did not have obesity. ¹³ Previous research has shown these four lifestyle-related behaviors to generate short-term benefits on disease incidence ¹⁴ , emotional health outcomes ¹⁵ , functional status, and long-term impact on life expectancy ¹⁶ , thereby making the point that regardless of weight status, making these behaviors part of one’s daily living generates important health benefits. Collectively, these findings highlight the long-standing importance of healthy lifestyle behaviors to optimize health and longevity outcomes, weight loss to optimize health trajectories, and the importance of active engagement in healthy lifestyle behaviors among those with obesity who maintain that body habitus over the lifespan.

The authors of this commentary propose a new communication approach related to physical activity and nutrition, from reaching populations to engaging with individuals as part of health professional-patient interactions. Independent of an individual’s body type, on the population level, health behavior messaging should focus on: (1) moving more and sitting less; (2) consuming a nutritious diet; (3) avoid smoking; and (4) minimizing alcohol consumption. Such messages are vital components of any plan to improve health irrespective of strategies for weight loss. A recent systematic review on the perceptions of physical activity and sedentary behavior in overweight and obese individuals by Bora et al., ¹⁷ highlights the complexity of motivators and barriers to healthier lifestyle behaviors in this population. Perhaps a simplified, initial approach of adopting healthy lifestyle behaviors irrespective of weight loss, a message that aligns with scientific evidence supporting health improvement, ¹³ would alter the perceptions of obesity and increase the likelihood of adopting healthier behaviors on a population level. When healthcare professionals engage patients suffering from obesity, conversations should be based on and informed by evidence demonstrating that adoption of healthy lifestyle behaviors leads to significant health improvements even if an individual with obesity does not lose any weight. ¹³ The narrative, however, should not be distorted by stigma, bias, or preconceived assumptions about the patient’s obesity. Given these important points, health professionals should talk to their patients about the apples first. We propose a script to follow – “Move your body, your way. Nourish your body, your way. Irrespective of what the scale tells you, or what body mass index value indicates, doing things that are healthier for your body should be celebrated, by me as your healthcare provider, by you as my patient choosing to adopt these behaviors, and by the people around you that provide support.” This message does not detract from the importance of weight loss for optimizing health. However, while physical activity and diet can be viewed as shared human experiences, discussing another person’s body size and type, irrespective of potential health benefits, is a sensitive matter that must be approached in a thoughtful and respectful manner. In this context, starting with conversations about “the orange”, body type and losing weight, without gaining an appreciation for how a person feels about their body, seems entirely the wrong approach. Perhaps, as proposed by others, health professionals should ask permission to discuss weight loss prior to initiating a discussion. ¹⁸ If granted permission to engage in a discussion about a patient’s body and weight loss, it should be approached from the perspective of obesity as a complex disease that requires a comprehensive, individualized plan of care. Body-shaming is not acceptable. No individual has the right to comment on or judge another person’s physical characteristics – the only person to be ashamed in this instance is the person making comments.