Can The Government's Obesity Strategy Tackle The UK's Weight Crisis?
Obesity was a factor in 876,000 hospital admissions in 2018-19 | Alamy Stock
The government’s latest obesity strategy includes a watershed on advertising unhealthy foods and changes to labelling. But is that enough to reverse the crisis, or should the emphasis be on tackling food poverty and improving access to clinical support? Georgina Bailey reports
“I had a very common underlying condition. My friends, I was too fat,” Boris Johnson said as he stood at the podium of Conservative party conference 2020 and told delegates why his experience of Covid-19 the previous April had been so severe.
Like 63% of adults in England, the Prime Minister had been overweight – a major risk factor for complications in not only Covid, but numerous other health conditions including cancer, asthma, diabetes and heart disease.
The Health Survey for England 2019 found that 28% of adults had a BMI of more than 30, and were therefore classed as obese. A BMI of 35-39 is estimated to increase your risk of dying from Covid-19 by 40%; a BMI of more than 40 pushes it to 90%.
Among children, one in three year 6 pupils (aged 10 to 11) was categorised as overweight; one in five as obese.
“Something that Covid has really brought into sharp focus is how much we do have an obesity problem in this country,” says Louisa Mason of the Royal Society for Public Health.
“Between 2017-18 and 2018-19, there was a 23% increase in hospital admissions where obesity was cited as being a factor. In actual numbers, that was 876,000 admissions where obesity was a factor. So it’s not like it’s a small issue that we’re overegging; it’s a big issue.”
The Prime Minister’s own experience with Covid-19 has been widely cited as a factor in his Damascene conversion on tackling obesity. Despite a prior aversion to ‘nanny state’ interventions, he became instrumental in the introduction of an obesity strategy last July, which included wide-ranging advertising bans on unhealthy food on television and online before 9pm, ending ‘buy-one-get-one-free’ offers, mandating where unhealthy items are located in shops, changing labelling on food and alcohol, and publishing calories on menus.
Johnson’s proposal is the 14th government obesity strategy since 1992. But despite the 689 policies introduced in the last 29 years, obesity rates have not dropped – in fact, they have increased.
A study last month from the University of Cambridge found that across all 14 strategies: “Policies were largely proposed in a way that would be unlikely to lead to implementation; the majority were not interventionist and made high demands on individual agency, meaning that they relied on individuals to make behaviour changes rather than shaping external influences, and are thus less likely to be effective or to reduce health inequalities.”
However, other experts see the latest iteration as at least a step in the right direction; although not going anywhere near far enough for many, it at least recognises problems such as the over-promotion of high in fat, sugar and salt (HFSS) foods and the cost differentials between more healthy and less healthy foods.
“It’s complex, but we know that there are several hundred genes involved in obesity"
“The reality, of course, is that we haven’t really seen all the detail yet,” says Professor John Wilding, president of the World Obesity Federation and clinical research lead into obesity, diabetes and endocrinology at the University of Liverpool.
Part of the problem the UK faces is that we live in what experts call an ‘obesogenic environment’. Our national food landscape promotes the over-consumption of unhealthy food, which – along with complex genetic factors – leads to high levels of obesity in the UK. We are pushed into making unhealthy choices every day, often without realising.
“That’s one of the myths, that this is all down to personal choice,” Professor Wilding says. “It’s complex, but we know that there are several hundred genes involved in obesity … [and] outside the personal choice is the environment that we live in.”
As Mason surmises: “There isn’t really as much choice in it as we think … Maybe you can choose between different things on the menu. But if that menu only offers really energy-dense calorific foods, then that’s actually not much of a choice.”
While policies which still rely on high levels of individual agency – such as calorie labelling and public health messaging – may only make a smaller difference to obesity levels, experts are more enthusiastic about the 9pm watershed on advertising of HFSS food on television and online.
The Advertising Agency says that the proposed online HFSS ban would reduce the average child’s intake by just 2.84 calories per day – however, Mason believes that it all must be seen in context as part of a wider lessening of the obesogenic environment, with the potential of going further to increase restrictions on billboard and public transport advertising too.
Another major indicator for obesity is deprivation: children from deprived areas are twice as likely to be obese as children in the richest areas. Acknowledging this, the government included provisions in the obesity strategy to rebalance promotions towards healthier food. However the strategy overall was roundly criticised by experts for not going far enough on poverty.
In its 2020 Broken Plate report, the Food Foundation found that on average, healthy foods were three times more expensive per calorie than less healthy foods – and that the price differential was getting wider, not smaller, over time. In order to meet the government’s UK Eatwell Guide, “the poorest 20% of UK households would need to spend 39% of their disposable income on food”, compared to 8% of their disposable income for the richest 20% of households. The most deprived local authorities are also more likely to have a higher percentage of fast food outlets, in what are known as a ‘food deserts’.
“If you’ve really only got £20 a week to feed your family, you are into super-cheap calories, things like packets of frozen sausage rolls, which just pack in the calories, very low nutrients"
After nearly a year of debate on free school meal provision – and even longer on the use of foodbanks – Anna Taylor from the Food Foundation believes that any conversation about childhood obesity cannot shy away from a discussion about income. “If you’ve really only got £20 a week to feed your family, you are into super-cheap calories, things like packets of frozen sausage rolls, which just pack in the calories, very low nutrients. You’re using those foods because you know your kids are going to eat them. Nothing is going to go in the bin.”
Taylor points to many options for making healthy food more affordable, such as building in a basic floor in benefits calculations to ensure healthy diets are accounted for, boosting real living wage provision, and investment into agricultural R&D – the latter of which is being considered as part of the National Food Strategy, managed by the Department for Environment, Food and Rural Affairs.
The need for a cross-governmental approach to tackle obesity is apparent – from active transport in the Department for Transport, to food technology classes and school meals in the Department for Education, to the potential for tax incentives from the Treasury.
For those who are already living with obesity, the other side of the strategy is delivering an expansion of weight management services across the country. As well as online and app-based weight management support, through the NHS Better Health campaign, the government has committed to increased training for primary care networks to support weight management – and a further roll out of the Diabetes Prevention programme.
However, for the estimated two-thirds of a million to a million people living with severe and complex obesity, further, more specialised intervention is needed.
“The difficulty we have is that it’s a complete postcode lottery,” Wilding explains. “Where I work and live in the area around Merseyside, Liverpool, we actually have quite good services ... but you can go to other parts of the country, and there is literally nothing, there is no opportunity for people to get any sort of clinical support at all. And almost impossible for them to get bariatric surgery, which we know is a very clinically and cost-effective treatment.”
Speaking about his own weight struggles in July, Johnson said he wanted his latest strategy to “just be helpful,” but “not in an excessively bossy or nannying way, I hope”. The reality is that winning the battle on this serious pubic health issue will require drastic and acute action from across government.
A Department of Health and Social Care spokesperson said:
“Our world leading obesity strategy aims to halve the number of children living with obesity by 2030 and is committed to make it easier for families to make healthier choices.
“As set out in the Health and Care Bill White Paper last week we are banning adverts for foods high in fat, salt and sugar (HFSS) being shown on TV before 9pm and have consulted on a total advertising restriction online of these products. We will also introduce restrictions on promotions of unhealthy food and drink in retailers from April 2022.
“We are expanding weight management services and we will also incentivise primary care to have conversations about weight so that more people get the support they need.”