Opinion – What DO we do about obesity?

I attended the Childhood Obesity Summit at which the great and the good of the nutrition, medical and behavioural science worlds collided to share their views on what is a global problem.  Obesity is inextricably linked to GDP yet is also associated with societal deprivation.  The UK is ‘the fat man of Europe’ spending more on treating obesity and type 2 diabetes than collectively on policing, the fire service and judiciary, to quote Dame Sally Davies, the Chief Medical Officer.  With the latest Childhood Obesity Plan from the Government seen as a missed opportunity, particularly in early years settings, what should we be doing to combat obesity?

First things first, if I had a pound for every time I heard someone say “We need a whole-systems approach” or “There’s no silver bullet”, let’s just say, I could easily retire.  I have heard so much rhetoric over the years yet obesity prevalence isn’t falling and recent statistics on childhood obesity show that it’s creeping up once more. Details from the 2015/16 National Child Measurement Programme (NCMP) show that at reception age, 9.3% of children are obese (up from 9.1% last year) and at Year 6, when leaving Primary school, this figure is 19.8% (up from 19.1% last year).

The Government’s recently published Childhood Obesity Plan lacked substance with only the sugar levy, voluntary sugar reduction targets in specific food categories and an increased focus on physical activity remaining.  Planned curbs to supermarket promotions on less healthy foods, advertising restrictions and a focus on early years’ settings were abandoned.  For more on why this plan was a missed opportunity, see my previous blog.

What’s the scale of the problem?

Public Health England’s (PHE) data highlight the scale of the issue with childhood and adult obesity being prevalent and widespread.  1 in 5 children are overweight or obese at reception age and this rises to 1 in 3 at Year 6.

For adults, there is an even more depressing set of statistics with nearly 7 in 10 men and 6 in 10 women being overweight or obese.

While obesity is prevalent across all sectors of society, there are also issues of inequality.  The most deprived in our population suffer disproportionately, as shown in the NCMP-derived data below, with similar inequalities present in the adult population.

The costs of obesity are dizzying.  Dame Sally Davies stated that there are 48 thousand deaths a year resulting from obesity-related disease.  Treating obesity and associated issues costs the NHS £5.1 billion.  Add to this the costs to the individual – an obese person has a 55% increased risk of suffering from depression, along with being more likely to suffer from asthma and joint problems as well as the well documented cardiovascular issues and increased risk of certain cancers.

How did we get here?

The causes of obesity are numerous and interlinked.  Too many politicians, commentators and even clinicians write off the obese and overweight as feckless individuals who simply lack the education and willpower to eat healthily.  This message is as dangerous as it is ill-informed.  Dr Giles Yeo eloquently put it that weight gain is caused by eating more calories than we burn but what drives us to eat more calories than we expend is a combination of our genes and our environment.  The Foresight report produced the seminal obesity system map showing the huge number of influences on how much and what we eat that range from biological to psychological and geographical.  It’s well worth a look.

That we live in an obesogenic environment is indisputable.  High calorie, highly palatable foods are abundant and cheap.  Less healthy foods are promoted in supermarkets to a far greater degree than healthy ones and PHE’s research shows that the multibuy discounts not only drive impulse purchase but to increase the amounts consumed of these, usually unhealthy, discretionary foods.  Children are exposed to what’s known to be pervasive advertising, even though high fat, salt and sugar products may not be marketed during children’s TV programmes, via family programmes like the X-Factor and other early evening shows and also via online branded games (known as advergames) which are currently unregulated.  Supermarket product placement knowingly harnesses pester power by putting often unhealthy, child-focussed products at child eye level.  And while supermarkets have removed sweets from their checkouts, they can still be found lining the queue barriers in toy and clothes shops.

So far, so obesogenic.  It’s possible to deal with the above issues ‘relatively’ easily with restrictions on advertising, collaboration with industry to reduce and re-evaluate price promotions and also to reformulate products, although that’s not without its issues.

What is far more difficult is dealing with deep and widening health inequalities across our society.  For many, eating healthy food is a luxury they simply can’t afford.  It’s necessary to buy as many calories as cheaply as possible and for many who also lack the confidence, skills or facilities to cook from scratch, that means takeaway food.  And here is where it gets really tough – fast food outlets are disproportionately located around areas of deprivation with a lack of supermarkets to compound the problem, creating food deserts.  Fast food cafes are also located close to schools and open their doors at 8am and 3.30pm to welcome the school children.  I’ve seen countless children walking to school in the morning with a tray of chips.  Rosie Boycott, chair of the London Food Board observed that you can buy a bag of chips in a London borough for 70p that contains almost 2000 calories.  So we have an issue of over-consumption of calories and under-consumption of nutrients: obesity AND malnutrition.

How else is our environment obesogenic?  Let us count the ways:

• Fast food outlets and vending machines containing sugary drinks and confectionary are revenue drivers for cash strapped hospitals so removing them is not as simple as it seems
• We eat out of home on an almost daily basis with foodservice outlet portion sizes increasing far more than we realise
• Plates and glasses have got bigger over the years, with studies showing we eat far more from larger vessels
• GPs, parents and individuals fail to recognise overweight or obesity in their patients, children or themselves leading to obesity being normalised
• We are working longer hours, spending more time sitting, relying on workplace canteens and vending machines to fuel ever longer days
• We have much less active lifestyles than ever before with sedentary screen-time increasing in children and adults alike

What do we do about it?

To be clear, any single intervention is doomed to failure.  The McKinsey report: Overcoming Obesity makes it clear that there ARE cost effective levers for change but we need to pull around 50 of these levers at once, not just one or two.  A whole systems approach CAN work but it needs everyone to work together and it needs a level playing field.  What does that mean in practice?

1. Industry and Government work together to agree reformulation targets that ALL businesses commit to. Removing sugar, fat and salt is going to affect taste, take time and cost money while effective ways to preserve taste and texture are researched.  The company that does nothing benefits by having a tastier product on the market, while the more responsible companies suffer as their reformulated products are rejected by consumers.
2. Industry, foodservice establishments, public services like hospitals and leisure centres and Government work together on portion size reduction, promotion of healthier options, point of sale nutritional information, inclusion of more vegetables within meals and appropriate vending and catering services that still drive revenue.
3. Retailers reduce multibuy promotions and focus on price promotion of healthier foods, removing ‘pester power’ foods from children’s eye level.
4. Government and industry agree advertising restrictions that include online advertising, advergames and family TV programmes
5. Schools have their menus assessed as part of the Ofsted reviews to effectively implement the School Food Plan. As Linda Cregan of the Children’s Food Trust observed, packed lunches could be a much bigger part of the problem than we think with many packed lunches containing ‘treat’ foods like crisps or chocolate every day.  An effective packed lunch policy is needed.
6. Nurseries and other early years settings’ are now going to be providing up to 30 hours a week of free childcare but funding is not increasing sufficiently to cover the cost of providing more healthy food. Guidelines for food in early years settings are voluntary and not widely publicised.
7. The UK’s breastfeeding rates are among some of the worst in Europe. Increasing breastfeeding rates and educating parents on how best to introduce complementary foods is essential to creating a good relationship with food and better health outcomes.
8. Help people to learn to cook again (and by people I do not mean just women) with cooking groups in Sure Start centres, community centres, supermarkets or restaurants out of hours. Classes should offer tips on making quick, easy, cost effective meals for families using cheap, easy to obtain ingredients, without the need for lots of utensils or skills.
9. Easily accessible weight management services that are recommended appropriately by GPs. Much has been made of the recent report that highlighted that a 30 second GP conversation about a patient’s weight can be enough to bring about a modest but potentially significant cumulative weight loss over time, even more so if the patient takes up the offer of NHS weight management services.
10. As Professor Paul Gately stated, access to appropriate mental health services is essential in reversing obesity. The depression, lack of self-esteem and bullying that many obese people experience makes taking action on their own all the more difficult and appropriate support all the more vital.
11. Town planning officials need to join up with the Government to combat food deserts so that the poorest of our society do not have to resort to takeaways and corner shops for their meals. Fast food outlets should not deliver more revenue to a borough if they are sited near a school and they should not be opening purely to sell huge bags of chips to kids on their way to or from school.
12. Physical activity should be promoted in schools, out of school clubs and workplaces in a way that is accessible and realistic. Better town planning is needed to ensure appropriate pathways and cycle routes to enable activity as part of the commute.

The bottom line is that EVERYONE – the public, NGOs and enthusiastic individuals, the Government, healthcare professionals and industry and catering establishments – needs to work together not against one another.  Buck passing and finger pointing is stalling action and fear that this is too big and complex an issue is not an excuse.  We have a common goal but must agree the right way forward by working together on a long term co-ordinated solution.

Slides from Public Health England