A growing concern

Obesity is one of today’s most visible public health challenges. But are we paying it the attention it deserves?

When the most recent statistics from the annual Scottish Health Survey were published last month they painted a bleak picture of the scale of the challenge facing Scotland. In 2011 just under two-thirds – 64.3 per cent – of adults aged 16 and over were overweight or obese. More than a quarter – 27.7 per cent – were obese. Additionally, just two-thirds – 65.6 per cent – of children had a healthy weight, a decrease from 70.3 per cent in 1998.

The tell-tale signs of obesity are also evident in our bulging waistlines. A recent study by human nutrition researchers from the University of Glasgow found that over the last ten years, the average woman’s waist circumference has expanded from 32.5 inches to 35 inches, while the average man’s has grown from 37 inches to 39 inches.

Professor Mike Lean, who led the research, believes that waist circumference is a simpler and more revealing indicator of obesity than the more traditional Body Mass Index (BMI). He explains that their findings suggest that muscle mass is falling.

“What we found is that although BMI hasn’t changed that much, waist circumferences are increasing really quite rapidly. That means people are getting fatter but not heavier, and the only way you can get fatter but not heavier is by losing something. That something has to be muscle.” With an ageing population, the future implications of these decreases in muscle mass are significant, heralding loss of physical capacity and metabolic decline. However, overweight and obesity already pose real risks to the health of the Scottish population and are currently one of the main causes of premature mortality and ill-health in Scotland.

Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight, which the Scottish Government published jointly with COSLA, outlines the threat posed to our population and economy.

Being overweight and obese can increase the risk of developing a range of serious diseases, it states, including type-2 diabetes, hypertension, heart disease, some cancers and has been shown to be associated with at least as much ill-health as poverty, smoking and problem drinking and with as much premature mortality as smoking. If current trends continue, the Scottish Government predicts that by 2030 more than 40 per cent of adults in Scotland will be obese, an increase of more than 50 per cent on 2008 levels. It estimates that the direct cost to NHSScotland will almost double in the same period, with the total yearly cost potentially reaching as high as £3bn.

However, this situation is preventable. In its first decade, Scotland’s parliamentarians raised their heads above the parapet and chose to take brave steps to tackle public health challenges such as tobacco and alcohol, introducing the ban on smoking in public places ahead of our neighbours in England and Wales and bringing forward daring legislation on minimum pricing for alcohol.

So, is it now time for more decisive action on obesity?

Certainly, there is no shortage of international examples from which to draw inspiration. Scotland is by no means alone in the problems it faces – the global prevalence of obesity has more than doubled since 1980 – and as such there is much that can be learned from international efforts to tackle the global obesity epidemic. In countries such as Denmark, which last year introduced a surcharge on foods that are high in saturated fat, dubbed the “world’s first fat tax”, and France, which has approved a tax on sugar sweetened beverages, the impact of increasing prices is currently being explored.

“There is ample evidence that if you change the price of things, people respond,” Professor Anne Ludbrook, chair of health economics at the University of Aberdeen’s Health Economics Research Unit, explains.

“From that you get the idea of, just as we tax tobacco and alcohol, should we tax things like fat and sugar, which are energy dense and perhaps contribute to this problem of too much energy in, which is one side of the obesity problem.” This is not simple or straightforward, she acknowledges, as unlike with alcohol and tobacco, we all have to eat and do need some fat in our diet.  

“It may be that we need to be a little bit cleverer than just saying, let’s tax fat and sugar, and say, what are the most energydense foods? Should we have a cut-off point as to how energy dense something should be? Should we have a cut-off in terms of the proportion of fat and sugar in something? Should we think about the kinds of foods, so it wouldn’t necessarily be fat and sugar in all foods but we might think about the discretionary foods – the snacks, the things we might eat on top of our meals that we don’t really need to eat.”

The other side of this would be to also take steps to make healthy foods more affordable. During the debate on minimum pricing, the Scottish Government argued that an additional consequence of the legislation is that it could bring grocery bills down if other goods are no longer subsidising loss-leading alcohol discounts.

Ludbrook agrees that this is “certainly a possibility” and says there is a “lack of transparency” about cross-subsidisation generally. In addition to price, she suggests there may also be further inspiration to be taken from recent legislation on alcohol, such as measures relating to the prominent placement of goods at the entrances to shops and bulk discounting.

“We are quite keen to try and do some research around that – looking at volume discounts in the same way as it has been used for alcohol, because it is undoubtedly the case that if you take home more things then they just go quicker,” she says.

However, alongside steps to control excessive energy consumption, further action is also required around energy expenditure. Physical inactivity in itself has a significant bearing on ill-health, contributing to nearly 2,500 deaths each year in Scotland. There are high hopes that the after-glow of the London Olympics and build-up to the 2014 Commonwealth Games in Glasgow will act as a catalyst for change and inspire Scotland’s population to be more physically active. But next to efforts to increase sporting uptake lies a more humble ambition: to get more Scots walking.

“Walking or cycling to school is an easy way to increase daily physical activity, making a contribution towards the recommended 60 minutes a day,” Shona Robison MSP, Minister for Commonwealth Games and Sport, said as she launched Walk to School Month in early October.

Over the past decade, the number of children who walk to school in Scotland has dropped significantly from approximately 56 per cent to less than half.

“Even from an early age, we know that regular physical activity is a protective factor from diseases such as heart disease, diabetes and some cancers and is a major contributor to overall health and wellbeing and quality of life. Establishing a pattern of daily physical activity can have a positive effect on children’s educational attainment and life chances and is most likely to lead to sustained physical activity in adult life. The more regularly active they become, the more they’ll start to enjoy the benefits of physical activity”, Robison Said.

Earlier this year the Scottish Government announced that it would develop a National Walking Strategy, which is expected to be published shortly. Keith Irving, Head of Living Streets Scotland, welcomes the plans for a strategy:

“We are delighted that we’ve got away from the old image of Mr Teabag and the Ministry of Silly Walks. Although it is regrettably ripe for lampooning, it is actually essential and walking is the basic building block of any strategy that is going to create a more physically active population,” he says.

Irving would like to see the plan complement the existing cycling action plan by including a target for the percentage of walked journeys.

He explains: “The cycling action plan had a target of 10 per cent of all journeys to be cycled and we think it would be complementary to have a target of 25 per cent of all journeys being walked. That is not particularly ambitious in that the current level of walking is 23 per cent. But what it means is that you are maintaining the basic physical activity levels of the population.”

Irving believes it is important that people are made aware of the dangers of physical inactivity and sedentary behaviour. A report published last week by researchers from Leicester and Loughborough universities warned that sitting for long periods can double the risk of diabetes, heart disease and death, arguing that harm is done even if people also exercise.
Irving says that simple measures like breaking up the day by having a short walk around the office will have a significant impact on health and should be encouraged. He also argues that employers have a role to play in the obesity and physical inactivity debate, and points out that some have already started instigating innovative practices, like walking meetings as a way of reducing sedentary office practices.

John Mooney, who has been leading a stream of work for the Scottish Collaboration for Public Health Research and Policy (SCPHRP) around policy interventions to tackle the obesogenic environment, argues there is strong evidence of successful interventions to address obesity around defined populations, such as workplaces.

The collaboration’s early to mid-working life working group has been researching and developing a series of policy recommendations that might help reduce the incidence of obesity in adults in Scotland.

“Obesity is, basically, a normal response to an abnormal environment. So we have to try and tackle the abnormal environment,” Mooney explains.

After a review of international evidence, the group has now begun trialling a number of workplace interventions that are based around incentivising people to eat more healthily within their workplace and increasing their awareness of healthy eating messages in the hope that these will also translate to the family household.

“On the whole, it is fairly well recognised now that in spite of the energy in, energy out debate that the real means of being able to tackle obesity will really depend on tackling the over-consumption of cheap high energy foods,” explains Mooney.

In the modern environment, there is so much opportunity to over-consume the wrong types of food, he says, and so at a ‘big picture’ level, he argues there is also a need to engage with the food industry on these issues. “It is important not to demonise food retailers and industry,” he says.

“I think they are starting to take notice of the sort of things that need to be done. For instance, every major supermarket does a healthy range and they run promotions. So baby steps have been taken but there is a fair way to go.”

Labour’s public health spokesperson, Dr Richard Simpson MSP, agrees it is “absolutely vital” to engage with the food industry as part of this debate, but explains he would rather see these healthy ranges become the rule rather than the exception.

“We are eating foods that are very calorie dense and in big portions. So I think the approach has got to be that we have to persuade the industry that they have to start really looking at what they have on offer, and not describing normal food as diet food but describing it as normal and saying the others are actually for people who are taking vigorous exercise and therefore, need extra calories, rather than doing it the other way around.”

Simpson would like to see products clearly labelled and believes the traffic-light system of food labelling is in the public’s best interest. He is also a long-time advocate of including calorie values on menus, such as has been introduced in New York and now, after eight years of concerted effort on Simpson’s part, the Scottish Parliament’s canteen. Such information helps individuals to make informed choices about the food and drinks they consume, he says. However, he acknowledges that a greater task remains to educate the public about the risks of obesity and, in doing so, create an appetite for meaningful political action.

“There comes a tipping point in politics, which is often a tipping point that is well behind the medical tipping point,” he says.

“I think we are at the medical tipping point at the moment – I think people are genuinely alarmed about what is happening.

“But I think the public are not yet alarmed and we have to really do more to make the public aware of the increased risks of cancer, the increased risks of heart disease and so on, and how serious these are in order to get people to say it is time that politicians acted.”

Intervention: Counterweight

To tackle obesity, Scotland has developed the “best primary care service there is in the world”, according to Professor Mike Lean, chair of Human Nutrition, University of Glasgow.

Lean explains what makes the obesity management programme, Counterweight, which helps obese patients achieve a healthier lifestyle and lose weight, world leading:

“They called upon a group of national specialists in diabetes and obesity, of which I am one, who were able to work together to develop this – we weren’t working in competition and we had dieticians supported by psychologists in multidisciplinary teams from the very beginning.”

Scotland was the first country in the world to develop guidelines for managing obesity, he says, and the Counterweight programme grew out of these SIGN guidelines.

“By writing guidelines, we were able to say this is the service that we need and then we developed it. So that is possibly why it has worked out to be rather better than anything that went before.”

The Scottish Government initially funded the development of the innovative programme. However, Lean says this funding has now been devolved to health boards and some are “dragging their heels” about implementation.

Lean believes the health boards “need a bit of a kick to recognise that by not providing Counterweight they are actually wasting taxpayers’ money,” as he says the evidence-based programme has been found to save money.

However, he says that no one service will “wipe obesity off the map” and he acknowledges that it will not be successful in all cases. Consequently, he explains he has been involved in developing an 800 calorie low energy liquid diet that, he says, has been found to help achieve significant weight loss.

“We did a study of 91 obese people in Scotland and what we are finding is the average weight loss, over one year, was 17 kilos.

“These are people who had failed using conventional methods. So what we are now saying is, by all means have your clubs and things besides, but when people become clearly overweight and obese, the first step should be an evidence-based Counterweight service, which we developed with the health department. That will solve the problem, if you like, for about 30-40 per cent. Then we have to say, ok, the next stage up, we’ve got the liquid diet,” adding that for those who don’t succeed with that, surgery might then be appropriate.

Lean, who says they have recently had a paper about the liquid diet accepted for publication, says they have found that 30-40 per cent can lose more than 15 kilos and keep it off for a year: “And that is actually rather better than we’ve done with any other treatment.”

Support to maintain weight loss is another key part of the programme. Various forms of liquid diets have been around for years but Lean says there was a need for a proper maintenance programme to accompany it.

“That is what we’ve done through the Counterweight programme in Scotland and that is why we’ve been very successful at 12 months and hopefully it will go on longer than 12 months. So that is now potentially available and will require a quantum leap in the thinking of the health boards to say we will do that.”