‘We judge people based on size. I have that unique perspective because I was both sizes’

Agnes O’Shaughnessy was deeply uncomfortable with the way people celebrated her becoming smaller after she underwent gastric bypass surgery 18 months ago.

The realisation that “people valued me more” after losing a lot of weight was very upsetting, she says. Although her appearance has changed, she is the same person. But now she sees the prevalence of weight stigma, which previously she says she had managed to ignore out of self-defence.

“It is unfair. We judge people based on size and we make assumptions of their life. I have that unique perspective now because I was both sizes,” Agnes says.

Agnes is, according to body mass index (BMI) calculations, back to a “normal” weight range, having lost more than 60kg (9st 6lb). But she continues to live with obesity, which is a chronic illness.

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“I have had treatment for my obesity but there is no such thing as a cure,” says the 44-year-old mother of four, who lives in Shannon, Co Clare. “I think that is one thing that people don’t understand.” After having surgery, a person can regain the weight if they have not addressed the “why?”. And the answer to that question will be very individual, amid contributing factors such as genetic predisposition and environment.

For Agnes it started in her early 20s, when she wanted to lose weight after having twins at the age of 19. “I don’t think I knew the word ‘diet’ before that.” Looking back she understands how she became “trapped in a diet mindset”, as she battled through cycles of losing weight, regaining it and adding on another half-dozen kilos each time too.

You can’t look at somebody – whether a child, a teenager or an adult – and say they have obesity

—  Niamh Arthurs

In 2020, after experiencing high blood pressure, she feared her size was impacting her health and self-referred to the weight management service in St Vincent’s Private Hospital in Dublin. Her GP had been “skirting around” her weight being the issue but she believes he did not want to put pressure on her because her son, the youngest of her four children, had been diagnosed with a cancerous tumour in 2019 at the age of 10.

During “the chaos of the previous year”, she had not only gained weight but had also become more conscious of her health. “I just knew I needed help,” Agnes says.

More than one million people in Ireland live with obesity, which is driven by complex biological, environmental and psychosocial factors. The common and prejudicial misconception that people living with obesity simply need to “eat less and move more” was addressed in the first Irish clinical guidelines for management of the condition among adults, published last October.

“While in the short term, restricting energy intake and increasing physical activity leads to a negative energy balance and weight loss, this triggers a cascade of adaptive metabolic and neurohormonal mechanisms that increase hunger, reduce satiety and energy expenditure, attenuate weight loss and promote weight regain,” the guidelines say.

Dietitian Cathy Breen, chair of the Association for the Study of Obesity on the Island of Ireland (ASOI), led in compiling the guidelines, which were adapted from ones in Canada, a world leader in the management of obesity. A key element is the moving away from a body-size diagnosis to a health-linked diagnosis, Breen explains. While BMI has its uses as a screening tool at a broad population level, it takes an individual assessment to diagnose obesity. Likewise, there is a shift in management from weight-change alone to health outcomes and wellbeing for the patient.

“You can’t look at somebody – whether a child, a teenager or an adult – and say they have obesity,” explains Niamh Arthurs, a dietitian who works with the child and adolescent obesity management team at Temple Street Children’s Hospital. “This often shocks people, especially healthcare professionals who say ‘of course I can’.”

They don’t want to take part in PE because they are being bullied; it’s a vicious cycle

—  Niamh Arthurs

Arthurs says that with obesity, “we are not talking about body shape or size. We are talking about the effects of excess fat tissue in the body, which can be driven by so many different reasons”. Only a clinical assessment will determine whether a patient is living with obesity, or is somebody with a bigger body who is healthy and happy.

“If you take a very fit, strong and healthy rugby player, who perhaps has a high body weight because they have a lot of mean muscle mass, they are completely healthy,” says Arthurs. “If you were to classify them according to BMI, that might say they have obesity but they don’t. That is why, clinically, we have all these other tools to diagnose obesity.”

Clinicians and patient groups are keen to use World Obesity Day on Saturday, March 4th, to help change the conversation around obesity. Much of the blaming and shaming is driven by the lack of understanding, says Arthurs, who draws parallels with how stigma once surrounded people with HIV.

She sees how embarrassment can make families reluctant to seek professional help and there is a long waiting list when they do. By the time children and teenagers attend the multidisciplinary team in Temple Street, they may have high blood pressure, damaged eyesight and suffering joint pain that affects their ability to play and do sport.

“Then there is the bullying. They don’t want to take part in PE because they are being bullied; it’s a vicious cycle,” Arthurs says. Sometimes the whole family is struggling. To people who are quick to judge parents of youngsters with obesity, she asks would they apportion blame in the same way if a child had asthma or cancer?

“The clear answer would be no,” Arthurs says. “That is because there is much greater understanding and acceptance in society and in healthcare that asthma, cancer, or any other chronic disease, is caused by a multitude of different factors and sometimes we don’t even know what the underlying causes are.” It is the same case with obesity.

Brendan Fraser’s Oscar-nominated performance of a teacher living with morbid obesity in The Whale presents just one set of circumstances in which a character has developed the illness. Now showing in Irish cinemas, viewers’ reactions will very much depend on whether or not they have personal experience of weight issues, says Susie Birney, executive director of the Irish Coalition of People living with Obesity (ICPO). Elements of it resonated with her but there have been diverging opinions within her organisation about the themes of disgust, self-sabotage, low esteem and enabling the film raises.

“People didn’t like the binge-eating episode; they thought it was going to increase stigma towards people with obesity,” Birney says. Binge eating disorder can be a coexisting condition for people living with obesity and 25 per cent of patients attending one Dublin hospital weight management service are diagnosed with some kind of eating disorder.

Laurence Hoey (67) of Castlebellingham, Co Louth, says “he always had a bit of weight on; over the years it seemed to creep up on me”. At the age of 19 he injured his back after falling six metres on to concrete. He was hospitalised for three weeks and still suffers from it.

“I wasn’t able to exercise as much as maybe I should. When I got older, I started putting on the weight and it just got worse and worse,” Laurence says. “I found I didn’t want to walk any distance because the weight was pulling me down.”

It is not an easy way out. The perception is that I am this picture of health now and I am actually not

—  Agnes O’Shaughnessy

His condition started to become problematic in his late 30s, “eating the wrong food”. It affected Laurence’s self-confidence a bit but never stopped him socialising. Yet he is aware that “people think that because you’ve weight on, that you are brain-dead”. At his lowest point psychologically, Laurence recalls: “I was annoyed that I wasn’t minding myself and I didn’t know how to get out of it, until I went to the doctor.” He was referred to the public weight management service in St Columcille’s Hospital Loughlinstown, Co Dublin, which he has attended for the past 10 years.

As part of his treatment, during which he has lost 70kg (11st), he found learning mindfulness to be a great asset. It helped him to over-ride the impulse to fill himself with “chocolate and that kind of rubbish” after a bad day. He also attends Slimming World locally and finds peer support in the ICPO invaluable. Although Laurence can’t swim, he now goes to a local pool for exercise – “when I was bigger, I wouldn’t go because I was too embarrassed”.

For Agnes, the first six months after the gastric bypass gave her the chance to re-evaluate her relationship with food. At the time she couldn’t each much, wasn’t hungry and was losing weight rapidly. A year and a half on she is “eating normally” but still dealing with minor after-effects of the surgery.

“It is not an easy way out”, she stresses. “The perception is that I am this picture of health now and I am actually not.” However, Agnes believes the treatment was a huge step towards safeguarding her future health. “Intuitive eating” suits her now “but I think it is something I will have to work on for the rest of my life.”