What is wellbeing?

A typical GP appointment is 7-10 minutes long. Therefore it was no surprise to me that when I started talking to my GP about my blood pressure a couple of months ago and diverted to talk about my lack of energy, I was referred to the “wellbeing worker” linked with the practise. There was a five week wait for an appointment. I sat in the waiting room at the designated time wondering if this was a new name for a practise counsellor, or an offshoot of IAPT linked to physical health, or whether it was a specific scheme designed to get people eating better and doing more exercise. When she invited me in the wellbeing worker introduced herself and said her remit was to work with people about “diet, exercise, smoking, drug use or to improve your wellbeing”. She asked me to rate my wellbeing on a likert scale for six variables.

So I diligently explained that since being rear-ended by a lorry 2 years ago, I have not been able to make a full range of movement with my left shoulder. This meant I had been unable to continue weight lifting. I also had to have 3 teeth removed and then had a very severe ear infection, causing some other health complications I detailed in an earlier blog. I told her that I have had intermittent earache, headaches, and a feeling of being underwater, which are exacerbated by changes in pressure or getting my ears wet so I had stopped swimming. I have also had ripples in my peripheral vision and a general lack of energy and motivation. I explained that the combination has meant that I had stopped my three times a week gym-and-swim habit and reduced to a fairly sedentary lifestyle with occasional longer walks.

I mentioned that been overweight for my whole adult life, and I had drawn some psychological links to the root of this. I explained that I am fairly comfortable with the idea of being overweight but that stress may have contributed to my more recent problems. I was of the opinion that there is clearly a significant physical component to my health issues, as it has transpired I am anaemic and vitamin D deficient as well as having high blood pressure. But I acknowledged that there is also a lifestyle component, as I had reduced activity and gained weight over the preceding months, and I acknowledged a substantial stress component too.

I noticed that the wellbeing worker had not taken any notes beyond “weight” and “exercise”, so I paused and tried to clarify her role. I asked what professional background she came from, expecting to hear she was a nurse, health worker or psychology graduate. “I’m an admin” she said, and explained that she had taken the job during a reorganisation, having been told that it was predominantly administrative. She said she had initially worried about what she would do if told about problems she didn’t know the answer to, but her manager had been reassuring that it wasn’t her job to solve everything and she could report any concerns to the appropriate person.

It turned out that her job was to identify which pathway to put people onto, from a choice of weight management, exercise, smoking cessation, drugs or alcohol and then fill in the paperwork to make it happen. She booked me in for the weight management group, and gave me a referral to the local council run leisure centre for 12 weeks free membership.

Don’t get me wrong, those things are good low-level interventions. The weight management group is friendly and non-shaming, even though it is pitched at a simplistic level, and I completely endorse exercise on prescription schemes for improving physical and psychological wellbeing. But where was the space to actually talk about what was going on my life? The website for the wellbeing service says:

‘Wellbeing’ means feeling happy, healthy and content in life. Our wellbeing can be affected by our physical and mental health, the people around us, the place that we live, the money that we have and how we spend our time. Our Wellbeing Workers can help you to identify and prioritise changes you might want to make to improve your overall health and wellbeing. They offer lots of support to help inform, motivate and empower you [including through] … Support with confidence issues and to improve self esteem

They offer services to reduce social isolation and assistance to address issues such as debt, housing and education (though this branch appears to prioritise people who have an intellectual disability or socio-economic deprivation) but the only mention of mental health or psychology is in relation to the specialist branch of the weight management pathway for people with BMI over 45 and those considering bariatric surgery. There are also leaflets linked from the weight loss section of the website which talk about “finding happiness” (helpful habits) and “mastering your thoughts” (basic CBT intro) and “relaxation and stress relief” (mindfulness, visualisation/anchoring, breathing exercises). But I was never even told these existed, and even when on the website I had to use the search feature to find them, and as far as I could tell there was no connection to the local IAPT service.

Six weeks later the wellbeing worker rang me up again, to see how I was doing. But again, she didn’t really want to know how I was doing psychologically in any meaningful sense. She wanted to know if I had followed the pathways she had offered. She asked me to give the six ratings again. It felt pretty hollow giving more positive scores, as I didn’t feel like the services provided by the wellbeing service were responsible for the changes – I had lost 10lb in weight before I joined the weight management group (and 2lb since), and feel better because I have more iron, more vitamin D, lower blood pressure, more energy and less pain.

So I was left feeling that it was a service that I was glad existed, but it seemed to tackle symptoms in isolation to their causes, and didn’t seem to connect physical and mental health. I’m guessing that is because public health is still local authority commissioned, whilst mental health is within the NHS. Wouldn’t it be nice if there was a single point of entry to this kind of wellbeing service and IAPT? Surely that would reduce stigma and mean that both symptoms and cause could be addressed, and patients would be able to tackle the interwoven issues of mental and physical health together.

 

Spectator sports

We are in the age of the internet. Adele’s Hello has been viewed 1.8 billion times, yet there are five other music videos on YouTube with more hits, culminating in Gangnam Style’s 2.7 billion view parody of the western status symbols rich south Koreans aspire to. Viral memes emerge and hit millions of page views in a day or two. Websites full of recycled content and filler with clickbait titles make up news stories to profit from the advertising revenue. False news engineered for the most gullible audiences makes tens of thousands of dollars a month. False news created by vested interests including foreign governments sways election results. Trivial stories that involve popular vloggers make headline news. Swedish video game blogger Pewdiepie reached 50 million followers last week and reportedly earns $12 million per year. His empty threats to delete his channel made headlines around the world. The top ten YouTube channels each make in excess of $5 million per year in revenue. Yet many people above the age of 40 have never heard of any of them. Part of what they have in common is what image-hosting site Imgur calls step 1: “Be good looking” although, as has always been the case even prior to the internet, that rules doesn’t seem to apply if the content is funny.

This new class of creators and media is packaged into bite-size content that doesn’t require any critical thinking, often with a catchy title and thumbnail that oversell the contents. Clicking from item to item across quick videos, memes, images and articles seems to make a time-sink trap that captures internet surfers in their millions. Amongst the new population of content creators are people with various different personalities, histories and views about the world, ranging from the ordinary to the extreme. And just as in the responses to any feminist video online, there are then vloggers whose content is made up of critiques of more famous vloggers and their content.

As Katie Hopkins has worked out, being sufficiently unpleasant and controversial generates clicks. It then creates responses that drives more traffic to the original content, and perpetuates discussion. There is then meta-debate about the creator themselves, attempts to shame them, and debate about what to do about them. Even publicising her embarrassing apology and substantial payment of damages for making false racist allegations of terrorist links against a muslim family gives her more notoriety and more clicks.

So it has been with the media rubbernecking the car crash of Eugenia Cooney’s weightloss, from a slim but attractive young woman into an emaciated role model of anorexia (weighing an estimated 4-5 stone) whilst denying she has a problem. A petition to ask YouTube to block her videos until she has sought help reached 18,000 signatures before being removed as inappropriate, and this has created a media circus with numerous vlogs and articles about her weight and whether this represents anorexia or not. Some have commented on the obesity of her mother and brother, and her childlike demeanour and role.

Because she has chosen to put herself in the public eye, and to make money from her audience, she is considered fair game for discussion. Yet if she does indeed have anorexia (and from the little I know of the case that does not seem an unreasonable assumption) she is very vulnerable and likely to have very distorted thinking. In the UK, there might well be a case to section her under the mental health act for treatment if there was not an alternative explanation for her weight loss, because of the lack of insight and high morbidity characteristic of this condition. So there appears to be a dangerous incentive of clicks (and the cash from advertising that follows) for being controversial, and in this case, seemingly putting her own life at risk.

Let us not underestimate the seriousness of eating disorders. One in five people with an eating disorder will die prematurely as a consequence of the condition, making it the mental health condition with the highest level of mortality. There is an increased risk of suicide, and an average duration of eight years for anorexia or five for bulimia, with less than half of all of those diagnosed making a complete recovery to the point they no longer meet the diagnostic criteria for an eating disorder. This is significantly more dangerous for your health than all but the most severe levels of obesity, and yet being too thin is often viewed as a positive characteristic and aspirational. The internet term “thinspiration” has nearly 4 million hits, with the top sites being pro-anorexia websites, with young women sharing tips and setting dangerously unhealthy weight loss goals.

Teenage online model Essana O’Neill bravely exposed the truth behind her instagram profile, which had half a million followers, before quitting social media to focus on real life. She later posted about her insecurity, depression and body dysmorphia. But she was far from alone. Photoshopping of images in magazines has become ubiquitous. Various surveys have shown that half to two thirds of selfies shared by adults or young people on social media have now been edited.

The fact that there are now dangerously thin vloggers denying that they have a problem and giving fashion and lifestyle tips to their followers must be considered concerning. It gives a new set of easily accessible role models that parents and clinicians may be unaware of, with very large audiences of young girls. Eugenia Cooney for example has 900,000 subscribers, who are predominantly teenage girls. There are several anecdotal examples of how this has been a trigger for eating disorders in girls trying to emulate them, and given 6.4% of the population has traits of an eating disorder, with most starting in this age range, that is highly concerning.

On the positive side, there have been growing moves to prevent overly thin models being used in catwalk shows and magazines and to indicate when images used in magazines have been photoshopped (something I would strongly support), so some progress appeared to have been made to present healthier role models to young women. There are many positive messages about health and fitness out there too (personally, I particularly like the goal of being stronger rather than thinner). However, there is a huge challenge when it comes to legislation on the internet, because of the many countries that the vlogger, hosting company and viewer can be situated in. Whilst these logistical pitfalls fail to prevent propagation of eating disordered messages (or other forms of toxic content) on the internet, there is little that we can do to prevent more and more young people normalising or idealising unhealthy role models.

A shallow look at fat

In her usual abrasive style, Katie Hopkins’ latest click-bait project is ‘to fat and back’ – she is putting on 3.5 stone in weight and will then lose it again, to show us how easy weight loss is and how there is no excuse for being fat. Some journalists appear to think there is something in it whilst others are a little more sceptical.

To me it seems obesity isn’t a simple matter of will power. You can’t will yourself thin any more than you can will yourself out of depression or addiction. Your ability to change the pattern will depend on how long it has been around, your biology and what caused it to start in the first place, as well as your commitment to change, support network and what else is going on in your life. In Clinical Psychology we look at the biological, psychological and social contributors to particular behaviours or symptoms and make a formulation of how these interplay, so it is frustrating when people with no expertise pronounce easy solutions which ignore these factors.

If a thin person with very negative ideas about obesity puts on weight for three months, they will find it unpleasant, find losing weight rewarding, and have all the previous factors that made them thin before to revert to. If she is being filmed and paid then she has financial and performance pressures to succeed also, her reputation and career to maintain, as well as a wardrobe to return to. She has the metabolism, muscle tone, neurochemistry and lifestyle of a slimmer person. Will three months change that? She has people around her who expect her to be active and slim, and will support her returning to that familiar mould. And when losing weight she has the money for personal trainers, gym memberships and healthy food (if not diet systems and products).

It’s a million miles away from being a chronically obese person and trying to lose the same amount of weight. To pretend this is a serious experiment that will tell us something about how to lose weight is playing at a serious issue. It reminds me of Pulp’s Common People.

A real obese person may have put on weight after a trauma or loss, during a pregnancy, or to insulate themselves from the world, or because food is the only pleasure in their life. They might comfort eat because feeding is tied in to their experiences of nurture. They might be ignorant about healthy eating, or have other lifestyle constraints that make healthy eating harder, like poverty or chronic sleep deprivation, or a family/peer group that consume huge amounts of calories (whether the 20 pint weekend, the endless cake in the office, massive portions or regular takeaways being delivered). They might have health conditions or disabilities that make exercise or even activity difficult. They may have developed psychological and neurochemical reward pathways for their eating pattern. They may feel shamed by the societal pressures to conform to what is considered attractive in the airbrushed models on glossy magazines and find thinking about losing weight a painful and ever-present topic (see this paper by Ratcliffe and Ellison last year). On the other hand, they may be ambivalent about weight loss. Their partners, parents, friends or kids may be used to their shape and habits. They may have had many experiences of previous attempts at weightloss that have been unsuccessful or were quickly regained. Change in many circumstances is really hard to make, and harder to sustain.

Every story is different. I know people who feel they need to be heavier than a past abuser or dominating partner, so they can’t be pushed around again. I know people who want a layer of protection against a dangerous world. I know people who want fat deeper than a knife blade is long, in case they are attacked again. I know people who want to deter any sexual attention. I know people too anxious to leave their house to shop or exercise, or too poor to afford fruit and veg or to pay for fuel to cook with. I know serotonin junkies where food is their drug of choice. I know exhausted people who fend off tiredness with sugar. I know of people who want to be taken seriously in the workplace and not have their success attributed to using their appearance. I know a lot of unhappy people who don’t think they deserve better, or could ever be attractive or physically fit. I know people who are hopeless about ever losing weight (often within a wider sense of hopelessness about their lives). I know people who have spent their whole lives being fat and living a lifestyle constrained by that fat – tired, big, heavy and excluded from physical activities. Mocked at every turn. Excluded from aspects of society. Disempowered. Weight loss is categorically different from that starting point, and it is not just naive but wilfully ignorant to pretend otherwise.

Of course, I also know people who like being fat or who see their weight as a very low priority in life. There are women who enjoy defying what they see as body fascism or sexist expectations about women’s appearance, or who simply see their curves as sexy. I can see the appeal in filtering away the shallow people who care about how people look more than who they are and what they do. And I’m aware that BMI is a blunt tool for measuring obesity, as it ignores body composition and scores people with high levels of muscle as equivalently “unhealthy” to those with little muscle, despite the positive differences in health that resistance exercise is known to make.

Katie won’t be happy being fat, and maybe it will give her some perspective about how judged and self conscious people feel when they are overweight. Maybe she’ll show some hitherto hidden empathy or concern for others apart from herself, but I doubt it. The promotional spots so far suggest the usual dose of hubris and ignorance, carefully engineered to provide publicity. I see this program as part of our obsession with celebrity and appearance, and the tendency to discuss serious issues (especially those affecting women primarily) with no depth. Hopkins has become the mouthpiece of internalized sexism; the pervasive belief that women need to be decorative rather than functional to be off value, and therefore shouldn’t think about issues beyond their own appearance and judging the appearance of others.

Finally, I am reminded of a line that is helpful to think to yourself when experiencing playground bullies: I’d rather have my weight than your attitude. For all the challenges involved in losing weight, it’s still easier than changing personality or gaining empathy after years as a callous, judgemental, self-serving, attention seeking provocateur.