A ruinous epidemic
The obesity crisis has been a long time in the making, gathering force despite more than a decade of individual initiatives to reduce the numbers of seriously overweight people. Comprehensive policymaking that touches on the complex roots of obesity has huge potential to reverse the progress of a deadly epidemic linked to growth in economic prosperity
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Obesity is one of the greatest threats to global health. Treating it strains economies and living with it means lethal danger from type 2 diabetes, hypertension and cardiovascular disease.
It is classed as an epidemic by the Organisation for Economic Co-operation and Development (OECD) and the statistics are arresting: more than 1.9 billion adults are overweight with 650 million of them classified as obese, equivalent to almost twice the US population.
The burden and the cost of obesity grows by the day, with the OECD predicting that life expectancy is being sent into reverse for the first time in living memory because of the corrosive effects of obesity. A report in the British Medical Journal found that life expectancy was reduced across Europe because of the condition and called on public health initiatives to address “the multifactorial and complex obesity aetiology.”
After generations of medical and public health advances, the prospect of a reversal in life expectancy is chilling.
A myriad of initiatives, from awareness campaigns to government regulations, has failed to block the spread of obesity. Across societies and cultures the default position has been to blame and stigmatise the obese individual. The crisis has become so critical that experts are increasingly calling for a more coordinated approach that reflects the complexity of obesity, the variety of support needed to deal with it and the conditions that help to nurture it.
No single policy solution
Reasons for the strong hold of obesity are many, involving a complicated interplay between environment, genetics and socioeconomics. Counter measures have to work across elements such as food production, advertising and media, education, mental health and politics as well as personal behaviour. These multiple targets have been resistant to largely fragmented approaches dealing with single issues rather than the adoption of multi-faceted strategies.
“No one policy will fix this so we need simultaneous action across a lot of domains,” says Caroline Cerny of the Obesity Health Alliance (OHA) a coalition of more than 40 leading charities, medical royal colleges and campaign groups supporting the UK government.
“Concentrating on one area will just displace the problem elsewhere so, for example, we need sugar and calorie reduction across all types of foods and drinks and controls on marketing so children see far less junk food marketing. We also need to look at digital marketing and sports sponsorship. And this is just to start with.”
More research on the role genetics and environment play in obesity would also help broaden the evidence base for treatment; policymakers also need a better understanding of the impact of stigma on the mental health of those with obesity.
The warning signs have been around for a long time; in 2007 the UK government’s Foresight report predicted that the NHS would face an annual €11.2 billion bill with wider economic impact reaching €55.8 billion if the rapid increase in obesity continued its trajectory.
That report, which identified multiple drivers outside the health sphere that needed a “comprehensive, co-ordinated” approach, helped frame the UK’s obesity strategy. Despite some success, however, in 2017 one of its key contributors, Susan Jebb, Professor of Diet and Population Health at the Oxford university and a member of the Public Health England Obesity Programme, called for a revisiting of its central themes of recognising the need for partnerships between governments, science, business and civil society.
The most immediate causal factors of obesity are an abundance of cheap, calorie-dense food, major changes in work patterns promoting sedentary lifestyles and widespread access to media awash with powerful advertising and marketing. Public health campaigns bolstered by sugar taxes and shielding children from some advertising have scored success across many regions of the world, but national policies vary in both their scope and implementation.
They also tend to emphasise individual responsibility, which, given huge societal and cultural influences on calorie consumption, can drive stigma rather than compliance.
“It is a complex issue but the real problem is the way it is positioned as an individual responsibility: You are overweight because you eat too much so you need to eat less, which is an approach that absolves the wider issues such as the food manufacturers who say they are just giving people what they want,” adds Cerny. “Advertising, marketing and promotions are very powerful and we are putting the onus on the individual to make the right choices in a flood of relentless messages telling us to do the opposite of adopting healthy eating patterns. The individual does not stand a chance.”
Stigma is a global health challenge that has a significant impact on how public health conceives its responses to obesity, according to research published in the Globalisation and Health journal in 2018.
Monika Arora, a director at the Public Health Foundation of India and a member of WHO’s Commission on Ending Childhood Obesity, believes the best intentions of world bodies will fail unless obesity’s complex drivers are fully recognised and dealt with. “Obesity is not effectively prevented or managed across health systems and societies. Of nine NCD targets set by WHO and agreed by all member states in 2013, only one—to halt the increase of diabetes and obesity at 2010 levels by 2025—is likely to be missed in every country in the world,” she points out in a paper on stigma and obesity, published in Lancet Public Health in October 2019.
Going backwards The OECD has predicted life expectancy is being sent into reverse for the first time in life time because of the effects of obesity
Crucial policy interventions
Arora, a leading public health scientist who has run successful campaigns to reduce NCDs in youth populations, is calling for stronger initiatives and improved coordination across all organisations along with enhanced research into the impact of obesity. Scientific evidence provides governments with strong arguments for implementation of more effective policies.
“Obesity has not been adequately addressed from a policy perspective,” she says. “A valid approach from governments would be to invest in prevention to free up resources and reduce NCDs. Priority interventions can be front of pack labelling, bans on marketing unhealthy food and beverages to children, taxing unhealthy food products and improving access to healthy food and physical activity in schools, colleges and workplaces.”
Arora adds: “However, determinants influencing obesity go beyond individuals. Healthy behaviours require an enabling environment to sustain change, and policy interventions play a crucial role in that.
“We could see changes from policy makers and the general community and that could be a catalyst for better health in the future. But obesity remains a chronic and complex disease and we need broad-based policies across all elements to have the best chance of reducing its terrible impact.”
Family dynamics and other psychological and behavioural factors associated with an individual’s immediate surroundings all contribute to what experts call an “obesogenic” environment. They argue for comprehensive policies that offer a variety of support both inside and outside of the healthcare sector.
It is a complex issue but the real problem is the way it is positioned as an individual responsibility
Solutions within reach
The challenge of obesity is monumental and global, but there is hope. The OECD estimates that a 20% lowering of calorie content in energy dense foods could result in the reduction of 1.1 million NCDs such as diabetes and hypertension, and boost economic output by 0.5% across 42 selected countries.
The World Obesity Federation has launched a Healthy Voices initiative to empower young people to avoid obesity and create a generation that can shape environments and become agents of change. A meeting at the World Economic Forum in January 2020 also advocated a future where all sectors of society contributed towards healthier food environments while noting that initiatives were springing up around the globe, citing diverse programmes in Amsterdam, London, Chile, Malaysia and Mexico dealing with aspects as diverse as nutrition, transport, food taxes and labelling.
The 2020 pandemic could be a watershed moment for obesity as the public realises that a co-morbidity increases their chances of falling ill and compromises their ability to fight infections. Many governments are moving hard and fast to use the new awareness as a lever for behavioural change and to introduce tougher measures across food production, advertising and health provision.
The obesity epidemic will continue to be a blight on the world until the full range of societal, political, commercial, physical and psychological drivers that influence our fundamental health are tackled with coordinated zeal. The coronavirus pandemic has provided a pivotal moment for fighting obesity: bold, strong action combined with growing public understanding can help shape a healthier and more sustainable future.
TEXT Danny Buckland — ILLUSTRATION Clara Selina Bach