Tipping the scales: what to do about Scotland's rising levels of obesity

Obesity is a problem that is escalating on a global scale. Though the World Health Organization had wanted to halt the rise in obesity levels by 2025, the World Obesity Federation predicts that one billion people — a fifth of all women and one in seven men — will be living with obesity within the next eight years, double the number recorded in 2010.

Scotland, whose obesity levels are among the highest in the OECD countries, is no exception. In the 2019 Scottish Health Survey, the Scottish Government revealed that two-thirds of adults in the country were overweight at that point in time, with just under half of those classified as obese. The report said that obesity prevalence had remained “relatively static since 2008”, but also noted that as the proportions had nudged up slightly the statistics reflected the “highest prevalence [of overweight and obesity] in the time series since 2003”.

Nor have things improved since. The coronavirus pandemic hampered data collection for the 2020 and 2021 surveys, but a truncated report that was collated from telephone interviews indicated that a significant proportion of people (39 per cent) reported gaining weight during the initial lockdown period.

At the same time, a report published by Public Health Scotland last December found that the proportion of P1 children at risk of becoming overweight or obese had risen sharply between the 2019/20 and 2020/21 school years, up from 10 per cent to 15.5 per cent. Children from the most deprived backgrounds were almost three times as likely to be at risk of obesity compared to those from the least deprived (21 per cent against eight per cent).

The figures may make for uncomfortable reading, but the reasons for Scotland having such a problem with obesity are many and various, according to Professor Alexandra Johnstone, an expert in appetite control at the University of Aberdeen’s Rowett Institute. The country may be famed for the quality of its fresh produce, yet traditionally much of the food consumed here has been highly processed and energy dense.

Add in the fact that the human body readily sends signals when too few calories have been consumed but is less good at flagging over-consumption and it is no surprise that, given contemporary lifestyles, so many people find themselves overweight, she says.

“We live in an obesogenic environment,” Johnstone notes. “Generally speaking, we’ve got a plentiful supply of food, it’s easy to access and it’s relatively cheap. Combined with a sedentary lifestyle that makes it very easy to gain weight. But obesity is multifactorial — it’s so complex in terms of the reasons why we gain weight.”

The various data sets have made clear that socio-economic status adds to that complexity and Lorraine Tulloch, programme lead at Obesity Action Scotland, notes that those facing the choice of heating or eating amid the ongoing cost-of-living crisis are likely to be more focused on ensuring there is enough food to go round than on counting the calorific or nutritional value of what they are serving up.

“People need the safety net of making something everyone in the house likes,” she says. “It’s not a time to experiment with fruit or veg or things that are unknown.”

Yet, as poor diets are linked to poor health outcomes, Johnstone stresses that diet inequalities are, by definition, inextricably linked to health equalities. And while we are now in a situation where the most deprived are feeling the worst effects of the obesity crisis, the patchiness of treatment options is creating another layer of inequality. 

“In meetings with Public Health Scotland and our parliamentary colleagues we’ve made it clear that it’s a bit of a postcode lottery in terms of the services that are available for obesity treatment […],” Johnstone says. “But it’s a progressive disease and it’s relapsing. People need lifelong support.”

Even where treatment options are available, the route to receiving it is not necessarily a straightforward one. Indeed, Johnstone says many people do not realise they are overweight until it becomes “a cosmetic or health issue”, yet her research shows that two-thirds of people living with obesity have not been approached by their GP to discuss their weight. 

Dr Chris Williams, co-chair of the Royal College of General Practitioners in Scotland, says it is vital that doctors help patients make the connection between obesity and conditions such as type two diabetes or hypertension, and to realise that being overweight can complicate surgical treatments like knee replacements that may have been become necessary due to the effects of carrying excess weight. However, he notes that unless patients broach the subject of their weight themselves it can be a difficult subject for doctors to bring up.

“You seldom get people coming into the consulting room asking you to put them on the scales [….] and if you say the word obesity that can come across in a really negative way to people,” he says.

“Even if you are trying to explain you’re using a phrase like that as a clinical term that has specific health implications it becomes a conversation that’s difficult to have and difficult to be part of. GPs are often thought of as expert communicators. When you know your patients, have a trusting relationship and you have a good understanding of each other then that can be a less traumatic conversation to have, but it’s often a conversation that you’ll have over a period of time in terms of trying to help people come to terms with their weight and understand the implications of their weight.”

Building or maintaining those kinds of relationships in the post-Covid world is not necessarily easy to do, with many consultations moving online and patients who do receive face-to-face appointments often having to settle for whoever is available rather than the doctor they would normally opt to see. But Williams says being able to have those difficult conversations, particularly with people who are not yet at the overweight or obese stage, is just one preventative measure that would help avoid the need for medical input for associated medical conditions further down the line.

Tulloch stresses that the focus must not just be on the health profession, though, because if the route into obesity is multi-faceted on an individual level, the route out of it must also be multi-faceted at a population level. By way of example, she notes that urging people to eat five portions of fruit or veg a day has been fine in theory, but in practice it has had little effect; broadening the scope of the Scottish Government’s shelved Restricting Food Promotions Bill and recently introduced Good Food Nation Bill in far-reaching and joined-up policymaking that also focuses on people’s activity levels is what’s required to make such messaging stick.

“The difficulty with this issue is that it’s not one thing that’s causing it and so there’s not one thing we can fix to get it right,” Tulloch says. “A lot of things have happened over a lot of years that have changed our habits and a lot needs to be done to fix that. The whole food environment is influencing the choices we make. The best bargains you can get are the most unhealthy; when you walk down the street, on bus stops most of the adverts are for unhealthy foods; when you go to a café the slice of chocolate cake you get is much bigger than you would have got 20 years ago. We’ve got to shift all those things to really make a difference.

“We need to change the acceptability of unhealthy foods. This is about a whole food culture in this country and us trying to celebrate the right kinds of foods. Rather than being about fizzy juice and chocolate biscuits we should value healthy foods. That’s a long-term cultural shift. Everyone knows about the five-a-day message but we are still way off the mark in Scotland. It’s more than telling people about the right thing to do, it’s about changing the environment and then shifting what we value. Over time we should start to see the shift we need.”

When the World Obesity Federation released its prediction about obesity levels at the beginning of this month, its chief executive Johanna Ralston said she was not so much shocked by the numbers as by how predictable it was that we would get here. The warning signs have been there for all to see, yet the response from political and public health leaders has, she says, been wholly inadequate.

Noting that everyone has the “basic right to prevention, treatment and management access which works for them”, Ralston stresses that “the missed opportunity of the last decade should be a warning that success will only come if we all work together and invest in implementing and supporting comprehensive actions to prevent, manage and treat obesity throughout the life course”.

For the growing number of Scots living with obesity and all the related health issues it brings, measures like the Good Food Nation and Restricting Food Promotions bills cannot come quickly enough.