Helen Quinn looks at whether lessons from the Covid crisis will help the latest obesity strategy succeed where others have failed.
The Government’s latest obesity strategy received a £100m boost in March this year, as Boris Johnson upped his commitment to tackling rising rates in the UK.1 But the promises of changes to food labelling and advertising and of new health campaigns mean much of the new strategy sounds all-too familiar. At a time when the obesity crisis has collided with Covid-19 to chilling effect, could we be missing a unique chance to imagine a radically different obesity policy?
In the UK, obesity levels have been high for some time, but the health risks have been thrown into sharp focus by the pandemic. After his own serious brush with Covid, the Prime Minister pronounced: ‘I had a very common underlying condition… I was too fat.’
While experts have pointed out this is a rather simplistic way of looking at it, he is not alone in being overweight and not totally wide of the mark. According to NHS Digital, 63% of adults in the UK are above a healthy weight2 , while one in three schoolchildren leaves primary school overweight.3 In July last year, Public Health England (PHE) announced that ‘living with excess weight puts people at greater risk of serious illness or death from Covid-19’, affecting the respiratory system as well as inflammatory and immune functions.4
‘We knew very early on in the pandemic about the link between the severity of Covid-19 and obesity, the likelihood of ending up needing ventilation and, ultimately, the mortality risk associated with obesity,’ says Dr Matthew Capehorn, a GP and clinical manager of Rotherham Institute for Obesity.
And being overweight does not just aggravate the threat of Covid-19; it also increases the risks of heart problems, cancer, liver and respiratory disease, and type 2 diabetes. Obesity-related illness costs the NHS £6bn a year.5
Obesity policies miss the mark
Obesity was first recognised as a population health challenge in England in 1991.6 The policy paper Tackling obesity: empowering adults and children to live healthier lives7 , published in July 2020, is the 14th such government strategy in England, yet obesity prevalence and associated inequalities have not been consistently reduced.
Given the complex causes of obesity, Dr Capehorn believes the policy may have missed a golden opportunity by concentrating on prevention rather than management. So will the latest funding injection go some way to addressing that?
According to Dolly Theis, a researcher at the Centre for Diet and Activity Research at the University of Cambridge, the success of such policies ‘is not just about the policy ideas as such, it’s also about the way they’re proposed’.
In a recent article examining government obesity policies, Ms Theis found they were largely set out in a way that was ‘unlikely to lead to implementation; the majority were not interventionist and made high demands on individual agency’.7 Elements such as a time frame and an evaluation plan that would support implementation have also been largely absent. She adds: ‘The approach has tended to focus on policies that try to get people to change their own behaviour, without necessarily shaping the environment to make it easier.’ She also says successive governments have not sought evidence from earlier unsuccessful strategies.
Tackling obesity does go further than earlier efforts, with the Government outlining measures to change the environment around us and make unhealthy foods less prominent – particularly those high in sugar, fat and salt. Meanwhile, two-thirds of the new £100m funding will go towards weight management services, and councils and service providers receiving grants will be supported and monitored by Public Health England.
Today in the UK, we live in what has been termed an ‘obesogenic’ environment, where we are surrounded by unhealthy food that is convenient and relatively cheap. Every day we are primed to make unhealthy choices, often without even realising it.
Professor Susan Jebb, a nutrition scientist and professor of diet and population health at the University of Oxford, sees the latest policy as a step in the right direction.
‘For most people, our biological stop-eating signals are just not strong enough. Our genes are essentially hungry genes that are designed to encourage us to eat, and [historically] that was a survival advantage. But now, we’re in a world where that’s not very helpful.’
She added, ‘Everywhere you turn, there’s a food store. Even when you’re in your sitting room watching the television, there’s another advert for food. The obesity plan [does say], let’s get the food adverts off the television, let’s get them off online and let’s control the way food is promoted in supermarkets.’
From April 2022, the Government will introduce restrictions on the promotion of less healthy food and drink in large retail stores, focusing particularly on products that are contributors to sugar and calorie intake in children. Calorie content will be printed on restaurant menus, and changes will be made to labels on food and alcohol to make calorie levels more visible.8
Despite these planned changes, the policy will still rely on a high level of individual agency. There are also concerns that calorie labelling can be counterproductive. Eating disorders charity Beat has accused the Government of ignoring the lack of supportive evidence for labelling.9
And the fact that healthier food is often more expensive10 means making better choices can be difficult. Royal College of Physicians special adviser on obesity Professor Rachel Batterham, writing on the college’s blog, said: ‘Access to healthy food should be a right and not a privilege. It is clear that socio-economic factors such as under-employment or poverty play a key role in driving obesity and poor health.’11
Prevention or treatment?
The reasons we become overweight are complex and are not only determined by environmental factors. Genes account for some of the predisposition to be overweight, and any government policy needs to take into account that for some, weight management will be a lifelong part of their health plan.
For Dr Capehorn, the proposed expansion of weight management services within the NHS is the key to reducing obesity. ‘There’s far too much emphasis on trying to prevent obesity where the evidence just isn’t there that we can prevent it,’ he says. ‘There’s not enough emphasis on treating the individual. And we’ve got evidence on how to do that.’
In 2009, he set up The Rotherham Institute for Obesity (RIO) – a groundbreaking initiative in the South Yorkshire town considered to be one of the nation’s obesity hotspots. With a £3.5m investment from NHS Rotherham, RIO had a blank slate to create a one-stop-shop to help people manage their weight. Over a three-year pilot, RIO helped its patients lose a cumulative total of 34 tons.12
With support from a multidisciplinary team, including specialist obesity nurses, exercise therapists, talking therapists and GPs, as well as an onsite gym and kitchen, the clinic helps people sustain healthy lifestyle habits rather than offering a quick fix. Funding cuts forced RIO to close to NHS patients in 2017 although it still operates on a private basis.
‘I would be setting up the equivalent of what we had in Rotherham in every large town or small city, all around the country,’ Dr Capehorn says. ‘If the Government targets a significant proportion of the money into structured weight-management services, preferably in a primary care setting, then yes, we can make a difference.’
However, weight-management services need significant long-term investment if they are to pay dividends. Savings made from reductions in obesity-related illness and death can be hard to measure, especially in the short term.
The Government’s proposals also include online support, a health campaign, training for primary care teams and an acceleration of the NHS diabetes prevention programme. But Dr Capehorn sees a fundamental problem with the plans. ‘At the moment, commissioners, whether it’s local authorities or clinical commissioning groups, don’t have to fund weightmanagement services. They have to have an obesity strategy, but that might be more cycle paths, less takeaways. Weight management is not a mandated service – that must change.’
Training for primary care nurses
Toni Jenkins, an obesity nurse specialist, believes training in primary care will make a difference. ‘Being overweight is so commonplace now that people have to open their eyes. There should be training funded by the Government for all nurses in general practice, particularly in how to treat and manage people living with obesity,’ she says.
Professor Jebb also highlights the essential role of nurses in weight management. ‘They are the point of contact with the patient. They are the trusted, credible, authoritative source. I would really like to see nurses or primary care teams having sensitive conversations with patients about their weight and motivating them to take action.’
A call to action
The Government is designating its latest obesity strategy a ‘call to action’. A Department of Health and Social Care spokesperson says: ‘It’s vital we take action now to improve our health as a nation. The Government is investing £100m in helping obese people move towards a healthier weight.’
Perhaps one lesson of the Covid-19 crisis is that firm commitments that are actionable and accountable are as important as radical new policies. While the virus remains a threat, obesity and associated morbidity are complex societal issues that require long-term solutions13, and the Government must not neglect the underlying social factors.
As the country looks to a future beyond the pandemic, ministers must recognise the impact of inequality and monitor the outcomes of their latest obesity strategy to ensure it is achieving the desired outcomes.
Children and obesity
The World Health Organization states that overweight and obese children are more likely to stay obese into adulthood and have a higher risk of developing cardiovascular and diabetes at a younger age. (14)
In the UK, nearly a third of children aged between two and 15 years are overweight or obese, with younger generations becoming obese earlier. Children from low-income families are more at risk of obesity. By the age of 11, children from the poorest income groups are three times more likely to be obese compared with more well-off counterparts.
The Department of Health and Social Care launched Childhood obesity; a plan for action in 2016, updating it in 2017.(15) Its main aims are tackling the amount of sugar in products, supporting businesses to make healthier products, providing support for low-income families to access healthier food, encouraging childhood physical activity, working with schools and nurseries to provide healthier food and enabling health professions to support families.
1 DHSC. New specialised support to help those living with obesity to lose weight. London: DHSC, 2021. bit.ly/3xcDIPN
2 NHS Digital. Statistics on Obesity, Physical Activity and Diet, England, 2020. Leeds: NHS Digital, 2020. bit.ly/3gdDQrn
3 Gov.uk Overweight children. March, 2019. bit.ly/2S0HZa1
4 Public Health England. Excess weight can increase risk of serious illness and death from Covid-19. London: PHE, 2020. bit.ly/3gcUQh4 5 Hancock C. Patterns and trends in excess weight among adults in England. London: PHE, 2021. bit.ly/3z4m16s
6 Theis D and White M. Is obesity policy in England fit for purpose? Analysis of government strategies and policies, 1992–2020. Milbank Quarterly 2021;99(1):126-170. bit.ly/3cfW7mu
7 DHSC.Tackling obesity: empowering adults and children to live healthy lives. London: DHSC, 2020. bit.ly/34PY8Se
8 DHSC. Promotions of unhealthy foods restricted from April 2022. London: DHSC, 2020. bit.ly/3plHWS7
9 Beat. Changes needed to government anti-obesity strategies in order to reduce their risk of harm to people with eating disorders. Norwich: Beat, 2020. bit.ly/3g7WaSI
10 Jones N et al. The growing price gap between more and less healthy foods. PLoS One 2014;9(10):e109343. bit.ly/3fSsLg4
11 Batterham R. Health inequalities and obesity. London: Royal College of Physicians, 2020. bit.ly/3igFNpq
12 Lockwood S. The town where obesity levels are high but NHS funding has been cut. Sky News, January 2019. bit.ly/2Sa4ycf
13 Lee A et al. Social and environmental factors influencing obesity. In Feingold K et al. (eds). Endotext, 2019. bit.ly/3g4Chf8
14 WHO. Noncommunicable diseases: childhood overweight and obesity. Geneva: WHO, 2020. bit.ly/3fVV4ut 15 Gov.uk. Childhood obesity: a plan for action, January 2017. bit.ly/34KJ20o
15 Gov.uk. Childhood obesity: a plan for action, January 2017. bit.ly/34KJ20o