ECO2023 NEWSLETTER: DAY THREE – Focus on Ireland – Margaret Steele

ECO2023 NEWSLETTER: DAY THREE – Focus on Ireland – Margaret Steele

Q: Hello Margaret and welcome to ECO2023! For those delegates who don’t know you – please tell us a bit about yourself and where you are based

A: Hi! It’s lovely to be here. I’m a postdoctoral researcher in the School of Public Health at UCC in my hometown of Cork. I’m working on the EU-funded FEAST (Food systems that support transitions to healthy and sustainable diets) project with Dr Janas Harrington. I also hold an honorary research lectureship in the School of Medicine at University of Galway.

Q: How did you first become interested in obesity research?

A: I’ve been trying to make sense of obesity and fatness all my life. I was worried about my weight from very early childhood, and I felt deep shame and self-loathing because I wasn’t as skinny as the other children. Over the years, I realised that the problem was much bigger than me, that diet culture and fatphobia were deeply embedded in our entire culture, and I became curious: Why is it that something as normal as fat tissue carries this enormous cultural weight? And how can we treat the very real health issues around weight and diet without shaming and blaming individuals based on their size or their health status?

Eventually, I wrote my PhD thesis on philosophy of health, focusing on obesity as my central example. Of course, this involved reading obesity research in epidemiology, endocrinology, and many other fields, and I became fascinated by the science. I also became very interested in how our bodies and lives are shaped by government policy and industry practices.

Q: Your study on Obesity As A Disease: Philosophical Considerations (poster PO2.132) throws up some fascinating questions. What gave you the idea to do this study? (link to poster here)

A: It started with my MSc thesis. I was part of the first cohort of the MSc in Obesity at the University of Galway. My co-author on this poster, Professor Francis Finucane (pictured with me here), was my thesis supervisor. I saw a lot of unacknowledged ambiguity around the term “obesity.” Does it refer to a BMI category or to some kind of physiological dysfunction? Which one is the disease? It may seem obvious to many experts at this conference, but I don’t think it’s obvious to the general public, and I think it’s a barrier to better public understanding of obesity – in both senses. I wanted to use my philosophy training to bring a bit more clarity to this terminology, while also engaging with recent developments in the medical understanding of obesity.

Q: What are some of the texts you referred to in your narrative review?

A: We revisited milestone papers like O’Rahilly and Farooqi’s “Human Obesity: A Heritable Neurobehavioral Disorder That Is Highly Sensitive to Environmental Conditions.” The recent NEJM review, “Reassessing Human Adipose Tissue”, by Cypess, was very helpful. The American Association of Clinical Endocrinologists and American College of Endocrinology joint proposal for the new diagnostic term “Adiposity-based chronic disease” was also important.

In the philosophy of medicine, we looked at recent work by Quill Kukla, Shane Glackin, and Alex Broadbent. Kukla, in particular, helped us reframe this debate, as they have recently argued that “disease” can never be defined in one single way, but is rather a term we apply for some strategic purpose.

Q: You highlight that the public often view obesity as a ‘simple’ concept of excess weight – do you think mindsets could be changed if obesity was actually renamed as chronic appetite dysregulation?  (whatever its underlying cause?) 

A: Interestingly, since we submitted this abstract, Francis and I have moved away from the term ‘appetite’, because it’s ambiguous, but I’d definitely still like to see more discussion on what to call the disease. We (medicine, public health, government agencies, education systems) have spent the past three decades teaching the general public that “obese” is the name of a BMI category. And BMI is inextricably linked with weight. Just look at the names we use for the BMI categories: normal/healthy weight, overweight, underweight.

So we’ve essentially taught people that “obese” means “weighing too much.” No wonder people roll their eyes when we say obesity is a disease. “You’re telling me if I gain a little muscle I could suddenly have a disease?!” It’s completely counter-intuitive; it sounds like nonsense. Of course, nobody is actually arguing that high BMI is a disease, but how is the public supposed to know that, if we keep using the term “obesity” for the disease? I must admit, I feel a lot more strongly about this than Francis does! But the way I see it, the word “obesity” is already taken in our culture, and we need another word to refer to the disease.

Q What can governments, international agencies, and the medical community do more effectively to recognise obesity as a disease?

A: I think (Francis might disagree!) that we have to acknowledge that disease recognition won’t help much with stigma. Everyone agrees AIDS is a disease, but it remains profoundly stigmatised. Disease itself is a stigmatised category. What people with obesity want and deserve is not necessarily a single neat disease diagnosis, but appropriate treatment, delivered respectfully, in a timely, affordable, and supportive way. Fatphobia runs very deep in our culture, and it’s inextricably linked with classism, sexism, racism and other structures of oppression. Better communication about the nature of the disease might help improve treatment, and that’s very important, but we need to recognise it won’t change those bigger structures.

Q: Has the idea of renaming obesity had any traction? What are the next steps for your research?

A: Well as I mentioned, the American Association of Clinical Endocrinologists and American College of Endocrinology did propose in 2017 that we should use adiposity-based chronic disease (ABCD), and that did get some traction. From our point of view, this name still over-emphasises adiposity, which we think is downstream of the original dysfunction, but it’s definitely a move in the right direction and worth considering.

As for next steps, we expect to publish the article on which this poster is based in the coming weeks, and we hope to continue the collaboration applying philosophical analysis and concept to various aspects of obesity. Francis and I share a keen interest in commercial determinants of health (also a major focus of our work on FEAST in Cork), so the next thing we write together is likely to be in that area.

Q: Tell us what sessions have caught your eye in this year’s programme?

A: I’m looking forward to the abstract session on Commercial Determinants of Health and also the one on Food Marketing and Young People. In terms of my fellow poster presenters (and fellow Irish researchers), I’m keen to learn more about Fiona Quigley’s work developing a virtual reality training tool to help clinicians improve obesity-related communication.

Thanks and have a great congress Margaret!