Confronting Obesity and Inequalities in Scotland

Many graphs now describe the epidemic of obesity, for children and adults, for men and women, boys and girls, for people living in the most and least deprived areas. These chart not only weight but also the determinants of how we live, what happened during the pandemic, the distribution of food outlets likely to serve up high fat, sugar and salty food, and much more. A few graphs below illustrate the trends for obesity and inequalities [1]. Some key references giving greater detail are listed at the end. The publications section on the Obesity Action Scotland website is a rich library providing much more data, other useful resources, explanations, and signposting to source documents. 

The Obesity Epidemic so far 

So where are we? When the Scottish Health Survey (SHeS) began in 1995, obesity prevalence was already high, but it has risen far higher in the last three decades. Obesity and overweight now affects one third of children and more than two thirds (67%) of adults.   

Large inequalities were already evident and have persisted. This is also true of other countries but, in terms of scale, Scotland is in a worse position. 

For children in Scotland, we are plotting a slow worsening in most groups. The most recent Scottish Health Survey report clearly demonstrated that one-third of Scottish children aged 2-15 (33%) are at risk of overweight or have obesity [4].  

In 2018, in their Diet and Healthy Weight Delivery Plan, the Scottish Government outlined a target to halve child obesity by 2030. Using 2016 as the baseline year, this means achieving a child obesity prevalence of 7%. The graph below illustrates the current proportion of children at risk of obesity, compared to the target. It shows a worrying picture, with over twice as many children at risk of obesity (18%). The data shows us that trends are going in the wrong direction.  

There is some good news. The children aged 4-5 in the most affluent families now entering primary school have reached that 7% target. However, those in the 20% most deprived areas in Scotland have already exceeded twice that level (13.9%). Furthermore, there is a clear gradient on the five quintiles, as illustrated in the graph below.  

We know from the analysis of the Growing Up in Scotland (GUS) survey Dr Anna Pearce and colleagues [6] from the University of Glasgow did for Obesity Action Scotland that transforming diet and food availability is the key. Physical activity levels in children are reported to be broadly even across society - in fact they are even recorded as being slightly higher in more deprived areas - whilst food insecurity has a profound (fourfold) influence on whether a child risks being overweight or having obesity. 

In the area of behaviours that influence the way we eat and drink, our own commissioned polling during the pandemic suggested some positive trends – for instance more cooking with raw ingredients when confined at home, and fewer takeaways (for obvious reasons). However, there was a great deal more sitting about (sedentary behaviour), eating out of boredom, and consequent weight gain in some groups. There was plenty of evidence of socio-economic patterning reflecting environmental circumstances such as income bracket, housing, educational level – and, very likely, the range of alternatives to boredom and sitting around. These behaviours are driven by the environment that people experience on a daily basis.  

We have described the growing epidemic of obesity and some of its chief influences in Scottish men, women and children. These graphs also demonstrate persistent inequalities between affluent and deprived groups. For Scotland to reach the target of halving child obesity by 2030 – for the entire population and not just the most affluent fifth – work needs to start now; the children going to school that we will measure in the target year of 2030 are foetuses now. 

The need to confront these findings is urgent. A diet action plan is already in place for Scotland; it now needs to be implemented in full and be progressive, encompassing new and effective evidence-informed measures. Local variations will benefit through listening to local voices, settings (such as schools and their surroundings) and variations in experience and will help to tune implementation plans. 

Confronting the obesity epidemic 

There are a few enduring truths about the obesity epidemic and its consequent burden of non-communicable diseases.  

First, we did not reach this stage quickly and the epidemic will not subside quickly. But delay in tackling it will continue to damage peoples’ health and widen inequalities. Second, happily, we now know much more about what we can and should do compared with three decades ago.   

We know medical scientific responses are part, but a relatively small part, of the answer. Most are expensive and many tend to widen inequalities. Conversely, prevention policies are much more powerful, rapid, equitable and cost saving. To succeed, we need to recognise that we have a problem, then build consensus in leadership and political will about the most effective ways to address it, while encouraging public willingness to make the necessary changes across society.  

Next comes leveraging key stakeholders to do the right thing, maintaining momentum, and resilience in the face of opposition from currently powerful actors in the food and drink industry and beyond, who prefer to persist with the current state that encourages high fat, sugar and sugar food and drinks to take centre stage in our food environment.  The report of the House of Lord’s Committee on Food, Diet and Obesity [7], published last month, outlines the right things to do in this regard – regulatory measures, mandatory targets and safeguarding policy development from commercial influences. We have to recognise that food and drink is not just nourishment and that it varies socially and culturally too. Achieving a healthy diet for diverse people and groups will be essential [8].  

Every policy action will need to be equitable. As the worldwide authority Sir Michael Marmot has demonstrated, letting inequalities persist is not just unethical, it is also very damaging for society, for the economy and for the climate [9].    

We know from tobacco, alcohol and sugary drinks that only regulatory and fiscal policy interventions work equitably. Relying on individual choice (agency) is naïve. It will just leave people outside enabling environments unable to make that real choice further behind. That is why we need to create an environment that enables everyone to easily and affordably access a healthy balanced diet to deliver and sustain healthy weight. Frameworks are in place – from Government, from public health and clinical leaders – for action. More plans are in the pipeline. We need combined effort to develop regulations, implement them and learn from the results, via robust monitoring, research and evaluation.  

We should of course also address key research questions as they emerge such as: will BMI remain the best measure? Can ultra processed food categories be refined and clarified? Can we expand data sources on obesity levels across other equality characteristics such as ethnicity? These will be important considerations as we move forward.  

Back to now. The obesity epidemic may plateau soon, but this is far from certain. What is certain is that its consequences and harms will continue to scar future decades and generations to come. We therefore must confront obesity, not let it get any worse, and take rapid action that benefits children the most in order to meet our ambitions for 2030 as a gateway towards a better future. By every indicator, we still have a long way to go and, equitably speaking, that means leaving no-one behind. 

Blog written by: Dr Andrew Fraser, Steering Group Chair, Prof Simon Capewell, Steering Group member, Jennifer Forsyth, Policy and Evidence Manager, and Dr Shoba John, Head of Obesity Action Scotland.

References

[1] Scot PHO (2015) Obesity and health inequalities in Scotland. Summary report https://www.scotpho.org.uk/media/1154/scotpho170727-obesity-and-health-inequalities-in-scotland-summary-report.pdf

[2] Scottish Obesity Alliance and Obesity Health Alliance (2024) Turning the Tide Towards Healthy Weight in Scotland https://www.scottishobesityalliance.org/media/jlvai5qg/turning-the-tide-scotland-final-digital-version.pdf

[3] Scottish Health Survey dashboard – data filtered by obesity, year and SIMD quintile https://scotland.shinyapps.io/sg-scottish-health-survey/

[4] Obesity Action Scotland (2024) Childhood Obesity Briefing https://www.obesityactionscotland.org/media/qc4bpoal/obesity-action-scotland-childhood-obesity-briefing-october-2024.pdf

[5] Public Health Scotland (2023) Body Mass Index of Primary 1 children in Scotland. School year 2022/23 report

[6] Miall, N & Pearce, A. Growing up in Scotland: obesity from early childhood to adolescence. Obesity Action Scotland. 2024. doi: 10.36399/gla.pubs.319087

[7] House of Lords Food, Diet and Obesity Committee. Report of Session 2024/25 (2024) Recipe for health: a plan to fix our broken food system https://publications.parliament.uk/pa/ld5901/ldselect/ldmfdo/19/19.pdf

[8] Born in Bradford (2022) Evidence Briefing, diet nutrition and obesity, a growing appetite for change HG2944-BIHR-BiB-Evidence-Briefing-Diet-Research-6.pdf (borninbradford.nhs.uk)

[9] Fair Society, Healthy Lives. The Marmot Review 2010