Correspondence

We thank the UK Higher Education Academy, the

Cabot Institute of the University of Bristol, UK, and
the University of East Anglia, UK, for providing
funding for the consultation process.
We declare no competing interests.

*Trevor Thompson, Sarah Walpole,

Isobel Braithwaite, Alice Inman,
Ste Barna, Frances Mortimer
trevor.thompson@bris.ac.uk
School of Social and Community Medicine,
University of Bristol, Bristol BS8 2PS, UK (TT), Hull
York Medical School, York, North Yorkshire, UK
(SW); University College London Medical School,
London, UK (IB); University of Exeter, Exeter, Devon,
UK (AI); Norwich Medical School, University of
East Anglia, Norwich, Norfolk, UK (SB); and Centre
for Sustainable Healthcare, Oxford, UK (FM)
1

Haines A, Ebi KL, Smith KR, Woodward A.

Health risks of climate change: act now or pay
later. Lancet 2014; 384: 107375.
Schroeder K, Thompson T, Frith K, Pencheon D.
Sustainable Healthcare. Chichester, UK;
Wiley-Blackwell, 2012.
Connor A, Mortimer F, Tomson C. Clinical
transformationthe key to green nephrology.
Nephron Clin Pract 2010; 116: 20106.
Main P. A sustainability scholarship
programme in the Severn Deanerys school of
primary care: a case study. Educ Prim Care 2013;
24: 21921.

Dietary patterns need

emphasising
In a thoughtful Series, Ursula Bauer and
colleagues (July 5, p 45)1 somewhat
ambitiously suggest four widespread
health-related strategies, specically
for the effective manage ment of
chronic conditions to deliver healthier
students to schools, healthier workers
to employers and businesses, and a
healthier population to the health-care
system. Exactly how these goals will be
accomplished is not clear. At present,
there is widespread interest in the role
www.thelancet.com Vol 384 November 29, 2014

of diet in primary prevention.2 Thus,

of ve protective patterns of health
behaviour in men in America, diet was
the rst of ve factors mentioned2 and
had too been stressed for in women in
America.3 Furthermore, diet in relation
to disease was first mentioned in
The Lancet in 1947, by Magnus Pyke
and colleagues.4 In 2008, a prospective
cohort study 5 about the role of
lifestyle factors showed, after 24 years
of follow-up, that diet is of major
importance to the health of American
women. Thus, arguments could be
made to suggest that Bauer and
colleagues1 were non-specic in their
four aims that did not emphasise diet
in the prevention of chronic disease.
I declare no competing interests.

Lionel Opie
lionel.opie@uct.ac.za
Department of Medicine, Groote Schuur Hospital;
and Hatter Institute for Cardiovascular Research
Africa, University of Cape Town, Cape Town 7935,
South Africa
1

Bauer UE, Briss PA, Goodman RA, Bowman BA.

Prevention of chronic disease in the 21st
century: elimination of the leading preventable
causes of premature death and disability in the
USA. Lancet 2014; 384: 4552.
Akesson A, Larsson SC, Discacciati A, Wolk A.
Low-risk diet and lifestyle habits in the primary
prevention of myocardial infarction in men: a
population-based prospective cohort study.
J Am Coll Cardiol 2014; 64: 1299306.
Akesson A, Weismayer C, Newby PK, Wolk A.
Combined eect of low-risk dietary and
lifestyle behaviors in primary prevention of
myocardial infarction in women.
Arch Intern Med 2007; 167: 212227.
Pyke M, Holmes S, Harrison R, Chamberlain K.
Nutritional value of diets eaten by old people
in London. Lancet 1947; 250: 46164.
van Dam RM, Li T, Spiegelman D, Franco OH,
Hu FB. Combined impact of lifestyle factors on
mortality: prospective cohort study in US
women. BMJ 2008; 337: a1440.

Obesity stigmatisation
from obesity researchers
Obesity stigmatisation has become
a major topic of research, with
empirical evidence showing negative
consequences for people who are
stigmatised.1 With research showing
that obesity stigmatisation is
widespread and that antifat attitudes
are strong,2 there have been not only

calls for intervention but also criticism

of sources that seem to promote
stigmatisation and stereotypical
messages about overweight and
obese people, such as media portrayals. Stereotypes of overweight
and obese people include poor
intelligence, sexual unattractiveness,
laziness, and gluttony.3
We attended the Association for
the Study for Obesity conference on
Sept 1617, 2014 in Birmingham, UK,
and were surprised at the stigmatising
comments of some of the presenters.
For example, a well known and
established researcher who has
published research about obesity
stigma and the potential effects on
obese people commented that if obese
people lost weight they would have a
lot of sex, which is probably good as
they wont have had it for a while,
in line with the stereotype that obese
people are unattractive and likely to be
sexually inactive. Another renowned
researcher, when speaking about
media sources that have reported that
exercise is bad in general for health,
commented that exercise is rubbish.
That is precisely the message obese
people want to hear, reinforcing
the stereotype that obese people are
lazy. A nal example of a derogatory
comment made by one of the speakers,
who had received the best practice
award, was that the work they had
achieved in decreasing obese patients
bodyweight had provided more
space for commuters on the London
tube. Although research has shown
that stereotypes and antifat attitudes
are evident in various populations,
no research to date has reported that
obesity researchers and even those
studying obesity stigmatisation are
not immune to such perceptions.
Thus, it seems that obesity researchers
also have stereotypical attitudes
towards obese people.
In line with guidelines for
publishing in obesity and journals
of other disciplines4 that adhere to
the standards of the Committee
on Publication Ethics, authors

Science Picture Co/Science Photo Library

the Global Environment (Harvard

University, Cambridge MA, USA) oer
a range of teaching materials.
Learning objectives for sustainable
health care aim to align medical
education with the changes in
emphasis seen in many other academic
disciplines, such as engineering and the
earth sciences. The next challenge will
be to translate these three objectives
into robust and relevant parts of the
medical curriculum.

1925

Correspondence

*Stuart W Flint, Sophie Reale

s.int@shu.ac.uk
Academy of Sport and Physical Activity, Sheeld
Hallam University, Sheeld S10 2BP, UK (SWF, SR)
1

Puhl RM, Brownell KD. Confronting and coping

with weight stigma: an investigation of
overweight and obese adults. Obesity 2006;
14: 180215.
Flint SW, Hudson J, Lavallee D.
Counterconditioning as an intervention to
modify anti-fat attitudes. Health Psychol Res
2013; 1: 12225.
Crandall CS. Prejudice against fat people:
Ideology and self-interest. J Pers Soc Psychol
1994; 66: 88294.
American Psychological Association.
Publication manual of the American
Psychological Association, 6th edn.
Washington, DC: American Psychological
Association, 2010.

Iran: the health cost of a

political order
This summer, the Iranian parliament
began to pass laws for a U turn from
a successful birth control policy 1
(figure) to a birth encouragement
policy that bans permanent sterilisation for the general population
and punishes those who prepare or
encourage contraception, even in the
media. This decision has important
sociomedical implications and needs
careful planningno pilot study
exists on the eects of the new policy
on the diverse population of Iran of
77 million people.
Differences in population growth
between states or ethnic groups can
aect the balance of power between
political actors nationally and
internationally.2,3 Although the political
effects of a birth encouragement
policy is the main concern of Iranian
politicians, the policy will have many
sociomedical effects. First, the new
policy will increase unintended
pregnancies, which are a threat to the
physical and mental health of women
1926

Iran
World

35
30
25
20
15
10
05
0

19
6
19 0
6
19 2
64
19
6
19 6
6
19 8
7
19 0
7
19 2
7
19 4
7
19 6
7
19 8
80
19
8
19 2
84
19
8
19 6
8
19 8
9
19 0
9
19 2
9
19 4
9
19 6
9
20 8
0
20 0
0
20 2
0
20 4
0
20 6
0
20 8
1
20 0
12

We declare no competing interests.

45
40
Population growth rate (%)

should avoid bias and stereotypical

language, which should apply to
all dissemination activity including
academic conferences. Hence, obesity
researchers should adhere to these
standards.

Year

Figure: Population growth rate in Iran

Data are from World Bank.6

and children. Results of a meta-analysis4

show that one third of pregnancies
in Iran are unwanted. This fact shows
the necessity of education and
contraceptive use. Second, if present
family planning services are stopped
or changed, including education and
free condom distribution, HIV and
other sexually transmitted diseases
could more easily spread, especially
between young people.5 Third, the cost
of contraceptiveswhich is already
high because of international sanctions
that target the Iranian economywill
increase. This increased cost could
lead to a rise in birth rates, particularly
in rural and poor populations, which
form a large part of Irans population.
The countrys economic situation
might therefore worsen, adding to
existing issues of high inflation and
unemployment rates, at 39% and 15%
in 2013, respectively.6 Additionally, the
Iranian energy minister warned about
water shortage for more than half
of Irans population.7 This mismatch
between the number of people and
the available water resources should
be addressed in every population
policy. Finally, as legal abortion is only
done if the mothers or fetus lives are
at risk, the new policy could lead to a
rise in illegal abortion, causing medical
and legal diculties for patients and
service providers.
Another factor to consider is that
the new policy contradicts previous
birth control education. All existing

educational materials will therefore

be incorrect according to the new
policy. This conflict will cause
people to doubt medical advice,
and health-care providers will be
conicted because of the dierence
between what science and experience
suggest and what the legislation
enforces. Policy makers should note
that only a healthy population can be
productive and that their surprising
decision could endanger the health of
the society, with the health benets
of their decision being unclear.
We declare no competing interests.

*Mehdi Aloosh, Arash Aloosh

md_aloosh@hotmail.com
Private practice, Tehran, Iran (MA); and BI Norwegian
Business School, Oslo 0484, Norway (AA)
1

Simbar M. Achievements of the Iranian family

planning programmes 19562006.
East Mediterr Health J 2012; 18: 27986.
Kaufmann E, Goldstone JA, Madsen EL,
Haas M. Political demography: how population
changes are reshaping international security
and national politics. Washington, DC;
Jan 10, 2012.
McNicoll P, Demeny G. The political economy
of global population change, 19502050.
New York: Population Council, 2006.
Moosazadeh M, Nekoei-Moghadam M,
Emrani Z, Amiresmaili M. Prevalence of
unwanted pregnancy in Iran: a systematic
review and meta-analysis.
Int J Health Plann Manage 2014; 29: e27790.
Farahani FK, Shah I, Cleland J, Mohammadi MR.
Adolescent males and young females in
Tehran: diering perspectives, behaviors and
needs for reproductive health and implications
for gender sensitive interventions.
J Reprod Infertil 2012; 13: 10110.
The World Bank. Iran, Islamic Republic. http://
data.worldbank.org/country/iran-islamicrepublic (accessed July 1, 2014).

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