Obesity: is it everybody's problem?

20 November 2020

Can government strategy help tip the scales on the UK’s excess weight, or is there too much onus on the individual? And what do CPs think? Journalist Jo Waters reports.

A new government obesity strategy to tackle England’s burgeoning weight problem was announced at the end of July, with the hope of not only improving the nation’s health – but also reducing its susceptibility to Covid-19.

Similar anti-obesity strategies have previously been launched in Scotland (Scottish Government, 2018a), Wales (Welsh Government, 2020a) and Northern Ireland (Northern Ireland Executive, 2012 - updated 2019) each with different emphasis, but the same overarching aims – to trim inches off people’s waistlines and stem the tide of ill-health that accompanies carrying extra weight. This includes type 2 diabetes, coronary heart disease and 12 types of cancer. But can the strategies truly succeed? And is the most recent attempt focusing on the right areas?

How ‘fat’ is the UK?

With around two-thirds of the population in England overweight or obese, and a third of the country’s 10- to 11-year-olds in the same category (with similar statistics across the UK – see A UK-wide issue, left, and childhood obesity further down), the government has realised that urgent action is needed to fight not only Covid-19, but an obesity crisis too.

The extra weight the population is carrying is literally crushing the NHS, costing an estimated £6.1bn a year (Public Health England (PHE), 2017), including 876,000 obesity-related hospital admissions in England in 2018-19 (NHS Digital, 2020a), an alarming 23% increase on 2017-18. And more than half of all pregnant women are overweight at their first midwife booking appointment (Royal College of Obstetricians and Gynaecologists, 2019).

Meanwhile, during the first months of the Covid-19 pandemic, it quickly became apparent that overweight and obese people had higher complication and fatality rates from Covid-19 than people who were a healthy weight. One study found that having a BMI of 35 to 40 could increase the risk of death from Covid-19 by 40%, with a BMI over 40 increasing the risk by 90% (PHE, 2020a).

The prime minister, Boris Johnson, spoke himself of how his own weight may have made him more vulnerable to the effects of the virus, admitting he was ‘too fat’ when he was admitted to intensive care, and how he was on a mission to shed some pounds, at the launch of the government’s new obesity strategy (Department of Health and Social Care (DHSC), 2020; Nugent, 2020).

What the new strategy says

The headline recommendations of the new strategy document were clampdowns on TV and online advertising of unhealthy food between 6pm and 9pm, the end of ‘buy one, get one free’ on high-fat and high-sugar foods, and a weight-loss phone app (see Resources, page 37, for more on the app). Also announced was a consultation on proposals to help parents of young children to make healthier choices through more honest marketing and labelling of infant foods.

The strategy also commits to expanding weight management services through the NHS and PHE’s Better Health Campaign, and acceleration of the NHS Diabetes Prevention Programme. From next year, doctors in England will be offered incentives to ensure people living with obesity are given support for weight loss, and primary care staff will have the opportunity to become ‘healthy weight coaches’ through training. GPs will also be encouraged to prescribe exercise and more social activities to help people keep fit, and offer all primary care networks the opportunity for staff to become healthy weight coaches. See The latest government obesity drive in a nutshell (below) for a summary of the strategy.

The latest Government obesity drive in a nutshell

  • Ban on TV and online adverts for food high in fat, sugar and salt before 9pm
  • Legislation to end deals such as ‘buy one, get one free’ on unhealthy food high in salt, sugar and fat
  • Calories to be displayed on menus to help people make healthier choices when eating out – while alcoholic drinks could soon have to list hidden ‘liquid calories’
  • New campaign to help people lose weight, get active and eat better. To include a 12-week weight- loss programme available as phone app
  • A four-nation review of ‘traffic-light’ food labelling system
  • More resources to support weight loss in primary care – including GPs to prescribe exercise and opportunities for staff to train as weight-loss coaches
  • Consultation on proposals to help parents of young children to make healthier choices through more honest marketing and labelling of infant foods.

DHSC, 2020 

How well has it been received?

Simon Capewell, professor of clinical epidemiology in the Department of Public Health and Policy at the University of Liverpool and a member of the Obesity Health Alliance (OHA), says the new strategy has both positives and negatives.

‘There’s no silver bullet for the obesity crisis,’ he says. ‘Clearly if it was as easy as eating less and moving more, we wouldn’t be in the situation we’re now in, with 63% of the population overweight or obese and one-third of primary school children in the same category.’

Strategy upsides 

‘The positives are that the government now knows that we have an obesity problem in the UK and has acknowledged that it has a duty of care to do something about it to protect both children and adults – this is new,’ says Professor Capewell. ‘The government is officially recognising that people are victims of an obesogenic environment, and can’t just be blamed for “choosing” to be overweight.’

The UK advertising industry spends £1bn a year ‘pushing junk food and sugary drinks and foods’, says Professor Capewell. And although the argument was won more than a decade ago, when broadcasting regulator Ofcom was given responsibility to police advertising of junk food during children’s daytime programmes, the food industry ‘was cunning and quickly found a loophole’, he says, by targeting advertising slots on popular early evening family TV shows.  

‘The government is now putting these proposals to impose restrictions on junk food advertising between 6 and 9pm out for consultation,’ he says. ‘We will be watching that very closely, as this government does have an unfortunate track record of promising things and then going back on them. My OHA colleagues and I therefore want to keep up regular dialogue with them, to make sure that this stays high on the agenda.’

The British Heart Foundation (BHF) and Diabetes UK were among major UK health charities that welcomed the new strategy as a step in the right direction, although they also emphasised the need for prompt and full implementation.

Dr Charmaine Griffiths, chief executive of the BHF, said it was a ‘landmark step towards addressing obesity in the UK’, and that the charity hoped to see the measures implemented fully and at pace. Chris Askew, chief executive at Diabetes UK, said the charity welcomed the ambition outlined to support healthier choices, and ‘most importantly’ the government’s recognition of the action needed. ‘We look forward to hearing more detail on the proposals and urge swift action,’ he said.

Professor Capewell notes that the government’s Soft Drinks Industry Levy, the so-called ‘sugar tax’, has worked well, with most manufacturers reformulating their products with lower sugar content 
– a 44% reduction overall (PHE, 2020b).

However, he says there’s no reason why this tax couldn’t be extended to other high-sugar or high-fat foods. ‘For instance, flavoured milks, which are popular with children, are [currently] exempt from the levy.’

Strategy downsides – blame plus deprivation

‘There is still an element of victim blaming in this obesity strategy – with this mention of educating parents about food labelling for instance,’ says Professor Capewell.’ Most parents do their best, but although they may be able to control the environment within their home, the moment they step outside, their children are battered by advertising. To point the finger at overweight people and shame them, telling them they don’t have self-control, is not helpful. We are all bombarded with marketing and advertising designed to make us want to eat more.’

Adam Briggs, senior policy fellow at the Health Foundation, says that by tackling the issue of food marketing, the obesity strategy took a step in the right direction, but it has notable gaps. ‘There’s nothing on green space, the role of local government, or how to tackle root causes of obesity and inequalities,’ he says.

Adam explains that obesity and inequalities in obesity are predominantly driven by the circumstances in which people live, such as poverty, poor housing or families with poor-quality work or unemployment.  

‘This is reflected in the numbers,’ says Adam. ‘Children from the most deprived areas are twice as likely to have obesity than children from the least deprived areas, with similar patterns for adults. These children and adults are then more likely to develop diabetes, heart disease and joint disease.’  

Ruth du Plessis, a consultant in public health, member of Unite’s Public Health Specialist Committee, and health visitor by background, is concerned families on low incomes are still being blamed if they or their children are overweight or obese.

‘Some live in such poverty they won’t even have a cooker – just a microwave and kettle. Asking them to make healthy choices seems unfair’

‘Poor families actually spend a higher percentage of their income on food than better-off families and often make wise choices for their children if able to,’ says Ruth. ‘But often both parents work and there won’t be much time for cooking. Some live in such poverty they won’t even have a cooker – just a microwave and kettle. Asking them to make healthy choices seems unfair.’

Ruth believes ‘it puts community practitioners in an awkward position too. Advice about healthy eating is useful of course, but talking about healthy eating when they know the circumstances some people are in might feel inappropriate.’

Healthy food costs more, Ruth says: ‘Fresh fruit and vegetables aren’t cheap, and are also perishable. Even the type of food available from food banks is predominately tinned or dried goods for the same reason.’

‘I think the whole thinking on this is warped – it should be the food industry that is made to take some responsibility – not people living in poverty.’

What about childhood obesity?

Dr Julie Lanigan, co-chair of the British Dietetic Association’s Paediatric Specialist Group, stresses the government has to make sure the shift to supporting adults does not distract from helping expectant mothers and children. ‘A ban on adverts and deals that make less healthy foods appealing and more readily available is a positive step, but it’s not just about caring for ourselves,’ says Julie. ‘Government needs to go further to protect children, families and vulnerable people. A life-course approach is essential if we are to tackle the underlying causes of overweight and obesity – and this should start with our youngest.’

Julie explains how this might be tackled: ‘Almost a quarter of children are already overweight when starting primary school. At this age, simple interventions can help slow weight gain and avert the path to obesity. But as children grow older it becomes harder to reverse obesity as lifestyles become ingrained. It’s not enough just to change the environment we live in. A two-pronged strategy that also offers children and families help and support to live a healthy life is essential.’

Louisa Mason, obesity policy lead at the Royal Society for Public Health, says many of the recommendations in the obesity strategy, such as the 9pm watershed for junk food advertising, were already in the Childhood Obesity Plans committed to in 2016 and 2018. ‘If the government is serious about addressing the obesity challenge, we need to move now towards implementation rather than simply producing plans that are put on hold.’

Tackling excess weight in practice

What realities are community practitioners (CPs) facing in the battle against obesity? Olivia Brown,* an HV in a deprived borough of London, says that obesity is yet another area of health where the gap between rich and poor is constantly widening: ‘Childhood poverty is increasing all the time and continues to increase. The reality is that foods high in calories are cheaper and more filling for families on a tight budget – for example, sausage and mash is cheaper than salmon with avocado.

‘As HVs, we discuss healthy eating at every contact, starting antenatally, but with fewer contacts, we have fewer opportunities for discussing these subjects.’

Carol Blackley,* also an HV in London, says local colleagues used to run weaning sessions for all new parents of babies but these have been discontinued and are now only available through the National Childbirth Trust.

‘We also used to have a healthy weight team who worked with under-fives called HENRY (Health, Exercise and Nutrition for the Really Young), which most HVs were trained to run and could refer families to, but sadly this has been cut in our area.’

Carol also said children’s centres, which were usually equipped with kitchens, had previously been used for classes teaching families on low incomes how to make healthy meals from scratch, but these were now closing down too.

Meanwhile, midwives are concerned about rising obesity levels in pregnant women and the high complication rate that results from this – including elevated rates of miscarriage, pulmonary embolisms, prematurity, caesarean sections and difficulties breastfeeding.

Clare Livingstone, a professional policy adviser with the Royal College of Midwives (RCM), explains: ‘It’s really concerning that the government’s obesity strategy doesn’t mention the growing problem of obesity in pregnant women and that we still don’t have evidence-based guidance on weight gain in pregnancy. The RCM is looking at preparing its own guidance to campaign on. We don’t currently have any UK guidance on what weight gain is safe in pregnancy.’

She adds: ‘Pregnancy is a golden opportunity for making healthy lifestyle changes, but there is currently a problem with onward referral – it is really difficult to get appointments for women to see dietitians, for instance.’

The RCM would also like to see a commitment from government to reinstate the Infant Feeding Survey (stopped in 2012), to support breastfeeding, a position also championed by Unite-CPHVA. Clare says: ‘Breastfeeding babies teaches them satiety – learning to stop feeding when they are full, and has so many other health benefits. ‘But it’s really the food industry that needs to change rather than putting all the onus on individuals.’

‘It’s really concerning that the government’s strategy doesn’t mention the growing problem of obesity in pregnant women’

Whose responsibility is it anyway?

Ruth du Plessis is blunt: ‘If ever there was a time to do something radical and tackle the food industry it’s now. Voluntary regulation doesn’t work – we’ve seen that.’

Professor Capewell says: ‘Obesity isn’t a problem that can be easily solved “just” by doctors, nurses, CPs or by individual “choice”. It’s more complex than that – the entire system across our society generates and markets cheap calories, hence obesity.’

Adam at the Health Foundation agrees. ‘There is no single solution to childhood obesity, and any piecemeal approach is unlikely to succeed. As such, the new obesity strategy is just one part of a broader approach needed to ensure everyone in the UK has an equal opportunity to live a healthy life.’

CPs have similar views on how obesity should be tackled, including policy that takes a multi-layered approach, addresses inequalities, looks at how healthy food is marketed, supports families and children right from the start, and vitally invests in public health practitioners (see What do you think?, below, for a selection of CP opinion).

‘I’d say some of the moves in the [government strategy] document are a good start,’ concludes Professor Capewell. ‘However, the proof of the pudding will be in the eating, and we will be watching carefully to see that the government keeps these promises.’  

What do you think? 

CPs give their views on what’s needed to tackle obesity in the UK...

Lauren Herd
HV, Scotland @Laurenherd89

Where to begin? Starting early Including bf support! Addressing formula milk industry influence. Tackling Poverty/food poverty, [increase] access to affordable exercise/play [increase] emotional support and MH services! Putting a stop to the aggressive marketing of processed foods

Natasha Dawe 
SN and clinical lead for childhood obesity, SE England @natashadawe13

Completely agree, early intervention is key. We need more universal support for families so that we can educate parents. There also needs to be a society approach so change in advertising and offers in supermarkets. Government need to invest in public health practitioners

Mental health nurse and HV @MrsGordon05

Addressing cost of fresh food v processed. Budgeting, foodplanning and cooking skills for parents. Many parents on my caseload have no guidance from own parents re prep/cooking meals & snacks. Whole generation brought up on fast food & processed meals

Louise Mann
Assistant director of health board and HV, Wales @LouiseM61053968

A multi-layered approach. There is no simple solution. Revisiting the determinants of health is a good framework. Poverty and inequality is at the heart. Availability & opportunity. Time poverty. Cultural norms & parental behaviours. Knowledge/skills/awareness. Food industry/media

Pediatric nurse and HV @kt_app

Marketing on labels and food jars, families are still taken in by marketing rather than factual evidence based advice given by us. I’m constantly amazed at how much time I’ve spent discussing this in depth using MI techniques and still it falls on deaf ears months later

Michelle Thomas 
HV and senior lecturer, Wales @Michellet15

Invest in breastfeeding, bring back cooking lessons and [increase] awareness of healthy eating. Reduce access to takeaways and unhealthy ready meals. Increase opps for affordable activity. [increase] local support. Make policy achievable



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