Confronting Obesity: addressing a systemic challenge

The President of the Royal College of Physicians and Surgeons of Glasgow has chosen obesity as the theme for his President’s Conference, taking place in November this year. Coming after meetings on two issues of top priority to the future of medicine and society - Climate Sustainability and Inequalities – obesity may appear to be an unusual choice. However, there are compelling reasons that medical leaders, the clinical community internationally, and those committed to improving population health need to focus on obesity, and challenge ourselves to achieve a society, and population, that is much more attuned to healthy weight than we are at present.

Obesity Action Scotland is a unit nested in the College in Glasgow, working for the Academy of Royal Colleges and Faculties in Scotland, and it welcomes this event.

Direction of travel

Obesity is a difficult subject, but we have tackled difficult subjects before. Reflecting on times when the vast majority of doctors smoked, when the notion of excessive alcohol consumption was regarded as a normal feature of professional and social life after hours (in Scotland at least), we realise that times have moved on. When surveys of the general population show and, indeed sectors of the health professions, record the majority who have overweight or obesity, and where evidence is steadily accumulating of the health harm and economic damage overweight can cause, we need to act.

The scale of harm is on a par with smoking and alcohol excess – UK estimates place the cost to the NHS in the range £11-19bn for obesity and overweight; costs are running at a similar scale due to the damage caused by tobacco and alcohol. We have tackled and are continuing to tackle the other two, and yet we still need to advocate for obesity and healthy weight getting the attention it needs.

There are insightful reviews of the problem with obesity, most recently from the Health Foundation. Numerous studies have identified the link between overweight, obesity and serious and life-threatening disease. The extent of harm associated with obesity in UK and international contexts is well documented - affecting physical health, mental wellbeing, and social wellbeing which is impacted by stigmatisation. There are new pharmacological interventions to treat obesity where it exists – but it is only effective for as long as people take it. We don’t need to mass-medicate for a healthy weight if we get the conditions right to prevent it.

There is a need, nonetheless, to educate, convince, call to action and influence the future which underpin the purpose of the conference, and the core purposes of Obesity Action Scotland and the Scottish Obesity Alliance, alongside NCD Alliance Scotland. But what is that action we refer to? Here are some thoughts.

Obesity is an issue in every ward in every acute hospital, in almost every primary care setting and clinic. It means greater risk from other co-existing disease, greater risk from medical and surgical intervention, longer stays to treat complications, slow rehabilitation, musculoskeletal risks and pain to patients. Access to Care is also limited as staff must make adjustments to equipment and facilities to meet the needs of patients. care staff alike, adjustments to equipment and facilities in healthcare settings.  As we approach 2040, projections in England for most rapid rises in morbidity are anxiety and depression, chronic pain related to musculoskeletal problems and type 2 diabetes. All are closely linked to obesity as a cause or a consequence.

Musculoskeletal problems and mental health disorders are already major burdens of disease in Scotland as elsewhere. The burden of obesity is also projected to increase in Scotland, with higher prevalences in both adults and children expected by 2030. We cannot ignore a condition and risk factor that is limiting health in so many respects, shortening both our quality of life and its duration.

Obesity is socially patterned, and those with the condition are more likely to have other risk factors. Obesity is fundamentally influenced by factors such as poverty, wealth and the power to access healthy food – inequalities throughout the life course. So, we must incorporate a systemic and common factors approach. We cannot blame the individual when so much in terms of food and calorie consumption, and opportunities for physical activity, are determined by where people live, travel, shop, work and go to school. A person with a weight problem will often struggle to lose weight because the environment they live in offers more barriers to healthy eating than opportunities.

Obesity and harm to the planet are also linked – over-consumption of foods, and the production of foods high in fat, sugar and salt (HFSS) itself consumes energy and affects natural environments. It is clear that obesity has close links to the two previous conference topics – Inequalities and Climate Change.

Overall, the evidence outlines the harm that overweight and obesity causes and informs what we can do to effectively prevent the condition and resolve the epidemic. We must move urgently to implement what we know and continue to learn.

So, what can we do?

First, face the challenge; take obesity and healthy weight every bit as seriously as the most worrying epidemics in the non-communicable disease world.

Second, find common cause with other agendas – health prevention for non-communicable disease including the big killers – cancer and cardiovascular disease; the biggest burdens – including musculoskeletal problems and depression; and key frameworks for action - climate sustainability, cross-government policy action to invest in health and its determinants, clinical safety and realistic medicine, tackling inequalities. Align evidence of what works to create a healthy weight environment to implement effective measures alongside each of these issues.

Third, think of ways that core institutions such as the NHS, healthcare suppliers, local and national government, schools, colleges and universities, alongside other large organisations, can support and sustain a culture of healthy weight without stigmatising those who live with overweight. Support government action that would work to create a healthy-weight society, encourage leaders to go progressively further; and then generate the evidence about whether the action is working and what more needs to be done.

Think of ways to build environments that promote healthy weight in clinical practice wherever prevention is an opportunity. Learn from others, including other public services and voluntary sector programmes, other countries, other industries, and settings.

Advocate for producers and retailers of food – all along the supply chain – to transform their business models, so that they are considerate of consumers in terms of their longer-term health and quality of life, kind to the planet – and build a regulatory framework that makes this model inevitable. Specifically, we should work towards a world where HFSS food is rarely if ever available on offer, labelled appropriately as hazardous to longer term health, alongside strong incentives for food suppliers to market healthy food, encouraging people to prefer healthier options.

We know enough to take action. There is good evidence that these approaches work. We know there are opponents, and particularly commercial interests and their backers, that will seek to slow and frustrate progress. But a conference to confront the challenge, identify prevention and treatment opportunities such as the President’s Conference on 14 November is an important springboard. We can start to correct attitudes that the subject is too difficult, the conditions and poor outcomes inevitable, and the sickness of current environments is tolerable in a society that seeks to progress, learn and improve.

Blog written by Andrew Fraser, Shoba John, and Tom Steiner