On becoming Prime Minister, Boris Johnson was lukewarm at best about some of the major tools suggested to tackle childhood obesity, including taxes. He commissioned another review of childhood obesity from the outgoing Chief Medical Officer (CMO). That was published in October last year with wide-ranging recommendations, many of which were structural, from increasing VAT rates on food to changing planning laws. The two-year anniversary of chapter 2 has just passed, with the latest data showing increasing obesity, excess weight and severe obesity for both boys and girls at reception and for girls at year 6, and inequalities widening.
Boris Johnson has said his own experience of Covid-19 has changed his libertarian perspective on obesity and another bite at obesity seems imminent. What key things would we be looking for in a new obesity strategy?
First, we need a full commitment to deliver what has already been promised. Second, the strategy should focus on not just children but adults too. In England about 7 in 10 men are obese or overweight and 6 in 10 women, 3 in 10 of all adults are obese and, as for children, this is strongly related to deprivation. And this matters: obesity is a risk factor for many adult diseases and chronic conditions, from type 2 diabetes to stroke and osteoarthritis. It’s impact is far wider than being a risk factor for Covid-19.
In order to tackle obesity, a new strategy needs to leave ideology aside and respond to the weight of evidence that all the tools in the toolbox are needed – from prevention, through to treatment and management, and from product formulation to advertising and the design of our towns and cities. Countless reviews and experience from around the world show that there is no silver bullet, instead serious action across all these fronts is needed.
The tendency for government strategies to over-rely on interventions that arm the public with information and individualised support, however well designed (and many are, such as change4life) needs to be avoided. Public information campaigns are rarely effective on their own. As the former CMO’s report argued, the science is increasingly clear that it is changes in the living environment – such as the design of our streets, exposure to advertising and density of fast food outlets – that are shaping everybody’s behaviour and making it much harder for us all to be a healthy weight. What happens in local places therefore matters. In particular, this means providing the funding and tools for local government, in tandem with their communities, to lead on whole systems approaches to obesity. Chapter 2 in particular did not meet all the commitments on schools that its predecessor had promised and didn’t do anything to increase the powers of local government to restrict billboards near schools. Any new obesity strategy therefore needs to give stronger powers to local authorities and in return expect stronger action locally.
Government also has to better use the fiscal levers at its disposal to change the environment we face when we shop. The previous government took a strong lead on this with the soft drinks industry levy; as a result the average sugar content of drinks subject to it fell 28.8 per cent between 2015 and 2018. However, a reliance on voluntary sugar reduction across wider product ranges has yielded more disappointing results, and the government needs now to be more forceful and extend its mandatory approach beyond soft drinks. We know that these measures can work, although they do need care in design to avoid unintended consequences (for example switching to even unhealthier products if they are close substitutes and lie outside the additional tax). Our recent briefing summarises the evidence across food and drink for such change.
Finally, despite much that can and should be done through changing our living and shopping environment and through information campaigns, a successful approach requires reversing funding cuts to public health including obesity spending, so that obesity programmes can be rolled out, and more funding for NHS and local government services such as local weight management services.
What may give the Prime Minister the incentive to follow such a path is the knowledge that the public is more likely than ever to be onside. Our briefing showed that the public, when presented with specific interventions, is far more likely to be pro-government intervention than commonly implied by tired tropes about ‘the nanny-state’; furthermore they get quickly used to and support previously contested policies once implemented, for example on restrictions on smoking in public spaces. Finally, the coronavirus pandemic has strengthened the public’s views that the government has a role in their health. Polling from the Health Foundation shows the percentage of the public that feels that national and local government has a great or fair amount of responsibility for ensuring they stay healthy surging from 61 to 86 per cent and 55 to 76 per cent respectively over the past two years; and 8 in 10 of us saying the same thing of the food and drink industry.
So, are there reasons to be cheerful? This depends on whether the government is willing to follow the evidence and whether the Prime Minister’s own experience helps him go where his predecessors have feared to tread. The knowledge that the public seems ready for bolder action might be the tipping point that lead to significant action.
Now more than ever, the government has to get a firm grip on obesity especially in children. The government has to consult the public with clear SMART objectives in order to get the buy in for such programmes to work. The impact of Covid-19 is forcing the public to think about their health more seriously. More and more people are taking up exercising e.g cycling, so the government needs to step in to make the roads safer in order to keep the momentum going.
The poll from the Health Foundation is reassuring and exciting, especially from a doctor's perspective. There are too many occasions where preventable diseases prevail and result in overcrowded hospitals where patient care is ultimately compromised. Tackling obesity should be at the forefront of the government's health care vision and perhaps we need to start considering cutting funds for end stage coronary artery disease to liberate money for public health?