'Obesity has definitely not had the prominence that it did in the past'

“The weight has quickly come off me, I am no longer on insulin or metformin, and I feel so much better. Instead of dreading having to find something to wear, now I’m spoilt for choice,” says Tricia, six months after starting on diabetes drug Ozempic. “It’s got side effects, but what drug doesn’t? For me, it’s given me my life back,” she writes in a Facebook group for users of semaglutide, the generic name for Ozempic.

Typically prescribed for type 2 diabetes, semaglutide manages blood glucose levels. But there has been an increase in off-label prescribing, despite government guidance not to do so, because one side effect is suppressing users’ appetites. As a result, it’s been described as a miracle drug in the battle against overweight and obesity – and led to supply problems for those requiring Ozempic to manage their diabetes.

“We’re seeing people are really struggling,” says John Kinnear, director of Diabetes Scotland. “We know people that have been taken off Ozempic, or having to have alternatives which are less suitable for them. And we’re seeing people who have been told ‘you would be perfect for Ozempic’ and not able to access it.”

But there is good news on the horizon. The UK medicines agency NICE approved Wegovy – another brand of semaglutide, but one which is specifically for weight loss – for use earlier this year, and specialist NHS weight management services in England began prescribing it this month. The Scottish Medicines Consortium is expected to give Wegovy the green light for use in NHS Scotland next month.

Experts, though, are warning that drugs like semaglutide are no silver bullet for dealing with the long-standing issue with the country’s weight. Dr Avinash Hari Narayanan, of London Medical Laboratory, says: “It’s vital to remember that this new jab is no miracle cure. It addresses obesity as a symptom but not necessarily the underlying cause.”

It’s been five years since we were promised action on this issue. We still don’t have the legislation

Kinnear agrees. “It’s completely understandable that people who’ve tried everything in the book [would look to semaglutide]. People know that they should eat less, move more, eat healthy – it’s not a secret. What we’re starting to recognise is that obesity is a medical condition that’s exacerbated by the environment that we live in, which makes it really hard to maintain a healthy weight.”

For the last 15 years, overweight and obesity rates in Scotland have remained fairly static. Two in three adults are overweight and just under a third are obese, according to the 2021 Scottish Health Survey. This is despite near constant public health messaging encouraging people to eat better and lead more active lives. The knock-on effect of that became prominent during the coronavirus pandemic, when those who were overweight were more likely to suffer more serious harm from the virus. But since the return to post-Covid life, little appears to have been done to get to grips with the issue.

Linda Bauld, a leading professor in public health, says: “When we were in the pandemic, or even just recovering initially from the pandemic, the focus was very much on the health protection part of public health – so communicable disease, the virus.

“The health improvement bit of public health, which is the other big bit of it, basically got sidelined during the pandemic. Lots of services – weight management, which is relevant to this topic, smoking cessation, alcohol treatment, etc – had to shift to online or didn’t exist because the staff were diverted to vaccines, for example. So, the treatment piece had been stepped back and is taking time to come back.

“The other element of it is policy. Governments had very little appetite during the pandemic to do anything on that – you saw at Westminster level multiple delays in their junk-food marketing policies, for example.

“And then the final piece, of course, is that the cost-of-living crisis has meant that the debate about population level interventions, which might include price measures or restrictions on marketing junk food, have been seen as unpalatable because it’s perceived as punishing either the companies or people who buy these products.

“I think all of those things in combination mean that obesity has definitely not had the prominence that it did in the past.”

The UK Government has now rolled out some policies post-pandemic. Calorie counts in menus are now commonplace in England, after legislation for that came into force in April 2022, while last October saw restrictions introduced on the location of foods high in saturated fat, sugar, and salt in shops – in other words, no junk food near tills or at the end of aisles. Next month was meant to see a ban on promotions of these foods, but this has been delayed for two years, with the government citing the cost-of-living crisis.

Scotland’s been fairly ambitious in the past… I do think we need to get back to that

Despite this movement south of the border, the Scottish Government has made little progress on introducing similar measures. In May, public health minister Jenni Minto confirmed the introduction of calories on menus was being delayed, while it was back to the drawing board on junk-food promotions and store placement.

“We have reviewed whether primary legislation is necessary and have concluded that there is a more direct and efficient route to deliver our policy aims,” Minto said. “Therefore, rather than introduce the Public Health (Restriction of Promotions) Bill, I plan to consult on the detail of proposed regulations this autumn. That will include proposals to restrict the promotion of less healthy food and drinks in prominent in-store locations, such as at the end of aisles or beside checkouts. We also propose to target certain price promotions, such as multibuys and unlimited refills, that encourage people to buy more than they actually need.”

That announcement was met with disappointment from those who have been campaigning for such measures for years. Lorraine Tulloch, programme lead at Obesity Action Scotland, tells Holyrood: “The frustrating element is that we’ve now been talking about this for five years, it’s been five years since we were promised action on this issue. We still don’t have the legislation. The legislation has managed to be put through in Westminster, they managed to get that through despite the challenges of the pandemic they were facing. We’re just concerned about the length of time it’s taken.

“In that time, we are consistently missing our dietary targets as a nation. We’re still putting too much unhealthy food in our baskets. There’s some recent data from Food Standards Scotland looking at discretionary foods, which are the foods the Scottish Government are proposing to restrict promotions on. The average adult in Scotland consumes about 260 calories from those kinds of foods – things that we don’t need in our diets like chocolate biscuits, sweet pastries, soft drinks with added sugar, all those things that we don’t need, we’re consuming daily on average 260 calories-worth of them.

“We know that restricting promotions could make a difference to what people choose to put in their basket. We know that the longer that’s delayed, the further away we are from achieving these dietary goals and the further we are from a healthy weight population. We need to see this implemented and it needs legislation.”

The main rationale for pausing [legislation] at UK and Scotland level is the cost crisis, that this isn’t the right time to do it. The counter argument to that is actually obesity is costing us

Such measures aim to change the food environment in which we live to make it easier, cheaper and more accessible to make the healthier choice. Bauld describes the action needed to do that as changing the “four Ps”: price, place, promotion, and product”.

“If you modify those, then you will make an impact or make a difference to behaviours and risk factors,” she says. “It is absolutely about trying to incentivise the system – that includes the retailers and the customers – to shift to different products. And there are plenty of countries that have made changes of this kind. They’ve restricted junk food marketing, they’ve restricted where things are in the retail environment, they’ve required different labelling schemes that are much more progressive than ours. You can see examples from many different places where they’ve moved in the right direction.”

Policymakers’ aversion to introducing measures that might hit consumer pockets is a concern. Rising inflation is already having an impact – not only are food prices higher, but it is also disproportionately impacting healthier food. Tulloch says: “The food it’s hitting the hardest is the staples […] Changes in food prices aren’t quite as much for the unhealthy foods. Confectionery cost hasn’t gone up as much compared with the price of bread or fruit or veg. That therefore means it’s much more expensive to buy a healthier shopping basket.”

But it’s a red herring to suggest ending promotions would automatically result in more expense, she argues, because the evidence suggests promotions merely encourage people to buy more than they need. It is therefore not a saving but an additional cost on top of the weekly shop. And importantly, any mooted BOGOF – buy one get one free – ban would not prevent promotions on healthy food.

And Bauld says the cost of not dealing with the problem is far greater than the cost of intervention. “The main rationale for pausing [legislation] at UK and Scotland level is the cost crisis, that this isn’t the right time to do it. The counter argument to that is actually obesity is costing us. It’s costing us a lot of money… The problem with policymaking often is that there are these different trade-offs and you have to take the long view, to make changes in the short term because you’ll save in the longer term. And that’s quite tricky, too. These are tricky decisions to take,” she says.

New research by Nesta and Frontier Economics estimated the annual cost of obesity in Scotland is £5.3bn. Most of that (£4.1bn) is due to people’s reduced quality of life – whether that’s poorer physical or mental health, or poorer mental wellbeing. A further £776m per year is the cost to the NHS and £456m is other social and economic costs, according to the report. It concluded there is “a compelling case to be made for bold policies and preventive action across government, industry and society”.

Bauld says Scotland has been “fairly ambitious in the past” in taking forward population-level policies for the good of the nation’s health, such as minimum unit pricing of alcohol or the smoking ban. “I do think we need to get back to that, at the same time as helping individuals,” she says.

Tulloch agrees, explaining that the previous focus by governments on “educational interventions or messaging” has failed because food environments “stack the odds against people”. And worse, the focus on individual choice has led to an increase in inequality, with people from the most deprived areas more likely to be overweight or obese than their wealthier counterparts.

Tulloch says: “What we know is that with educational messages, the people with the most resource can respond to them and the people with the least resource can’t. What that very clearly tells us is that if we want to see this change across the whole population, it’s about changing the system, changing the food environment. Educational messages on their own wouldn’t make the difference.”

Likewise with diabetes, those from poorer backgrounds are more likely to have or be at risk of developing the condition. And Kinnear is increasingly concerned about the number of people getting it earlier in life. He says: “We are seeing increasing numbers of people living with type 2 diabetes, and particularly in the under 40s, which is worrying because if you develop type 2 diabetes at a younger age, you’re much more likely to have more serious complications if it’s not managed well.

“That’s a lot to do with the environments in which people live and their access to healthy food. We want to see measures put in place faster and I’m not sure if more consultations are what we need at the moment.”