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Obesity thread...
A policy announcement on obesity is long overdue. We face a huge and growing epidemic, and since the Foresight report was published in 2007 there has been no excuse for failing to appreciate the nature of the problem we face, or the magnitude of the challenge.
A policy announcement on obesity is long overdue. We face a huge and growing epidemic, and since the Foresight report was published in 2007 there has been no excuse for failing to appreciate the nature of the problem we face, or the magnitude of the challenge.
As Foresight made clear in 2007: “People in the UK today don’t have less willpower and are not more gluttonous than previous generations. Nor is their biology significantly different to that of their forefathers.” https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf
“Society, however, has radically altered over the past five decades, with major changes in work patterns, transport, food production and food sales.” https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf
But the discourse remains dominated by specious rhetoric about ‘choice’ and ‘lifestyle’, and we're fed campaigns exhorting us to change our behaviour as if obesity was a knowledge deficit disorder. It is not.
Obesity is a problem driven by obesogenic environments in which one can, of course, be physically active and eat healthily, but there are ever-increasing barriers to doing so, and the most disadvantaged people face the greatest obstacles.
And yet responses to obesity remain hugely skewed towards interventions that require high levels of personal agency, even though we know full well that they tend to be of low effectiveness and likely to widen inequalities https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001990
There are many reasons for this, not least of which is an evidence base that shares the same skew, driven by structural factors in research systems that prioritise studies looking at short term outcomes of individual level interventions…
…along with public and political discourse that relentlessly promulgates a stigmatising and utterly erroneous construction of obesity as a ‘failure’ of willpower, a volitional problem
Foresight showed clearly that “the causes of obesity are embedded in an extremely complex biological system, set within an equally complex societal framework. It will take several decades to reverse the factors that are driving current obesity trends.” https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf
…but while we endlessly pay lip service to the notion of ‘complexity’ and ‘whole systems’, policy responses remain trapped in outmoded linear models of cause and effect...
…and simplistically ‘evidence-based’ actions, guided by a skewed distribution of published research that promotes the least effective kinds of responses, driving ever-widening inequalities https://blogs.bmj.com/bmj/2020/07/13/urgent-action-is-needed-to-reduce-widening-inequalities-in-childhood-obesity/
This is not for lack of trying. Both @PHE_uk and @DHSCgovuk have done great work on obesity, and have made excellent proposals in the various iterations of the childhood obesity strategies, some of which - such as the sugar drinks industry levy - have seen the light of day...
…but many of which remain in consultation limbo. These strategies are of course nowhere near enough to tackle the problem - as the previous CMO made clear in her parting report - but they are still more than many countries have, and they’re a good start https://www.gov.uk/government/publications/time-to-solve-childhood-obesity-cmo-special-report
The policy focus to date has been almost entirely on childhood obesity, but it seems that this may finally change given the role of weight status in COVID-19, as has been clearly laid out by @PHE_uk in yesterday’s report, and the imperative this adds https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/903770/PHE_insight_Excess_weight_and_COVID-19.pdf
Discourse around obesity gets split into multiple dichotomies - diet/activity, treatment/prevention, adults/children - which misses the core point made by Foresight that this is a complex *systems* problem: is not either/or for any of these; it requires action across all of them
Even the campaigns I deride have *some* purpose: it’s not their existence I object to, its their prominence and their phasing. It’s all very well to encourage people to walk, or provide cycle training, but in the absence of conducive environments how much can they really achieve?
A central point of a systems response is that it takes account of the whole picture, the interactions between elements, different time scales, multiple levers at multiple levels, feedback, adaptations, emergence…
That’s not easy, but it’s not impossible either, and we’ve had well over a decade since Foresight to work on it. Yes, this stuff takes time, but it doesn’t need to go this slowly, and the longer we wait the more pressing it becomes.
There is at least more understanding now of the causes, in terms of food systems, transport systems, health systems, economic systems, political systems, and the links between them and many others, but very little in the way of real action on the causes of the causes...
…such as entrenched inequalities, or businesses dumping their health and environmental externalities on individuals and society, relentlessly pushing a focus on personal responsibility while abrogating their own. This isn’t only about junk food…
..think how different our eating habits might be if we’d dealt with the scourge of plastic waste properly from the start, instead of being persuaded by the people selling litter that it was unavoidable, and our job to pick it up https://www.sourcewatch.org/index.php/Keep_America_Beautiful
…or what places would look like if we rejected the lie that we only need to switch fuel from petrol or diesel to electricity for our cars to be ‘green’ and got properly to grips with creating healthy, safe, equitable habitations with decent air and truly sustainable mobility
Yes, sure, it is hard to tackle car-dependence or change eating habits, but it is not impossible, and if we are not only to tackle obesity and non-communicable diseases more widely, but also environmental degradation, and even the risks and harms of pandemics, it has to happen
(which is precisely why we have set up our @TheLancet @ChathamHouse Commission on improving population health post COVID-19) https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31184-3/fulltext
As @PHE_uk say in their recent report “Drivers of excess calorie intakes and low levels of physical activity, within the environments people live, will need to change at a national and local level to support population-level weight change.“ https://www.gov.uk/government/publications/excess-weight-and-covid-19-insights-from-new-evidence
Campaigns, even consultations, can contribute, but the time for a few more nudges, some exercise on prescription, and restrictions on TV ads are long, long past. Policy now needs to tackle the drivers, and the drivers of those drivers, robustly and meaningfully.
Those who profit from the status quo will complain, and we’ve already started seeing the usual ‘nanny state’ drivel from the corporate shills - see this great thread on ad restrictions from @LaurenElsie23 - and be prepared for more https://twitter.com/LaurenElsie23/status/1286563800007749633
...so it’s well worth reading this piece by the ever-excellent @felly500 on “Nanny state or savvy state – A nanny state toolkit’ https://gregfellpublichealth.wordpress.com/2018/07/22/nanny-state-or-savvy-state-a-nanny-state-toolkit/
Obesity is an unintended consequence of the ways in which our societies have been set up, the commercial activities that have been prioritised, the vested interests that exert power, the ways in which these things have become embedded, and much, much more...
Changing all that will take time, and the longer we postpone meaningful action the harder it becomes. We urgently need robust action across the life course, across society, and across the entire system, with a relentless focus on inequalities.
The brilliant @muirgray taught me over 20 years ago to “be where the action isn’t.“ When these proposals finally surface don’t just look at what they say, scrutinise them for what they omit. Think long and hard why that might be, who benefits, and what to do about it…
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