Scotland's obesity strategy - a heavy burden

Supermarket choices - Holyrood

Obesity rates in Scotland are amongst the highest in the world, even higher than in the rest of the UK. 

Two in every three adults in Scotland are overweight, meaning people of normal weight in Scotland are now in the minority.

According to figures released by ISD Scotland last month, more than a fifth of children in Scotland are at risk of being overweight or obese by the time they start school.

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Being obese increases your chances of heart disease, type 2 diabetes and cancer.

While attempts are being made to get an increasingly sedentary population moving, diet is seen as a major factor. Only a fifth of Scots eat enough fruit and vegetables, while consumption of sugary soft drinks is the highest in the UK.

Last summer the UK Government’s much anticipated childhood obesity strategy was met by disappointment from health campaigners, who called it a “missed opportunity”.

Instead of being called a strategy, the document was downgraded to ‘a plan’.

Public Health England had advised tougher restrictions on sugary products, including curbs on marketing and promotion, but aside from the levy on soft drinks, the Department of Health instead opted for voluntary action and self-regulation by industry.

Sarah Wollaston, Tory chair of the House of Commons Health Select Committee, said it had been watered down.

“The key message on childhood obesity should have been about the importance of reducing junk calories,” she said.

“In completely removing whole sections from the draft strategy, it is hugely disappointing that the obesity plan puts the interests of the advertising industry ahead of the interests of children.

“The plan also misses the opportunity to improve children’s diets by reining in the saturation marketing and promotion of junk food.”

Scotland’s food safety body, Food Standards Scotland, put tackling obesity as a central pillar of its three-year corporate plan and five-year strategy last summer.

“Rebalancing the diet must be a shared responsibility – shared between individuals, communities, the food-and-drink industry and both local and central government,” said FSS chief executive Geoff Ogle.

Yet Scotland’s obesity strategy has still to emerge.

The Scottish Parliament’s Health and Sport Committee recently wrote to Public Health Minister, Aileen Campbell, to call for bold action.

The committee said Scotland has a policy framework which could enable the Scottish Government to make decisions “that may initially be unpopular” when introducing new initiatives, while being better at implementing existing policies.

Unhealthy food is “more available and more heavily promoted than in other countries”, the letter said.

Health campaigners also hope for more ambition from the Scottish Government. 

Among those is research giant Cancer Research UK (CRUK), who point out that being overweight or obese is the single biggest risk factor for cancer after smoking in Scotland, and is linked to 13 types of cancer.

While the Scottish Government’s powers to make an impact are limited to what levers are devolved, CRUK argues it has an opportunity to tackle price promotions and supermarket multi-buy offers. 

Figures from FSS reveal nearly 40 per cent of all calories consumed are purchased as a result of price promotions, but a recent survey commissioned by CRUK suggests seven out of 10 Scots support a ban on supermarket multi-buy promotions of junk food.

A separate YouGov poll also showed six in 10 Scots are buying unhealthy food on promotion at least every week.

CRUK’s cancer prevention expert, Professor Linda Bauld, who is based at the University of Stirling, says shopping habits are at the heart of the problem.

“Because the English strategy was so disappointing, with nothing in particular on promotion and the only glimmer of light being the levy, what we hope is the Scottish Government will be much more ambitious,” she tells Holyrood.

Bauld says evidence from other public health initiatives shows population-level change is brought about by action on what she calls “the four ‘p’s” – price, promotion, place of sale and the products themselves. 

With limited power to reformulate the ingredients of products, the Scottish Government has an opportunity to look at the three other ‘p’s’, according to Bauld. 

“It could do things around availability, and it can do things on price and promotion, definitely.”

A restriction on multi-buy promotions would be the first non-voluntary action on obesity in the UK, and therefore could be controversial for some sectors of the industry. Bauld has worked on tobacco policy for a number of years, and says she expects there would be “a negative response from some parties to this” but points to the public support.

But with the Scottish Government still pursuing minimum unit pricing for alcohol – which was due in 2013 – through the courts, there may be little appetite for further conflict with industry.

Bauld says minimum unit pricing has no precedent internationally, but that isn’t the case for multi-buy restrictions.

“I think the threat of litigation from this one is probably minimal, because we have had a ban, as you know, on multi-buy promotions on alcohol. You used to be able to buy three bottles of wine for £10 or whatever and you don’t see that anymore. They didn’t fight that one.”

Opposition to the idea could also come from those who would see it potentially stifling economic growth. However, Geoff Ogle argues the long-term economic risks associated with higher levels of obesity must be taken into account.

“What we need to understand is what the consequences are; the trajectory not just of financial inequalities and health inequalities but also the economics,” he tells Holyrood. 

“If the health inequalities and health issues continue and the cost of healthcare continues to rise then that’s got to be paid for somehow. Either through increased taxes, reduced spending in other areas or by increasing the taxation burden on businesses, so you can’t take out some of the economics that come with the health issues.”

But those with an interest in economics are not the only ones who need to be convinced of the implications of high obesity rates. CRUK’s facilitator programme, which provides face-to-face support to primary care teams, has revealed awareness of the link between obesity and cancer is low even among some health professionals.

Thirteen different types of cancer are linked with obesity, including the most common, breast and bowel, points out Bauld.

“The big concern of course is that our population is growing, and has grown in Scotland in recent years. Even if trends continue just as they are, we’re going to have almost 700,000 preventable cases of obesity-related cancer in the UK over the next 20 years. It’s just the sheer scale,” she says. 

“If we could just reduce those rates just by one per cent each year, which we’ve achieved for tobacco, so we could achieve that here, that could prevent around 54,000 cases of cancer and probably save around £40 million to the NHS. Even just a modest reduction would achieve a lot.”

With obesity rates among children tracking into adulthood, a multi-buy ban would also act as a prevention measure, argues Bauld, as parents look to buy snacks and lunchbox items for school. 

“To put it in context, with tobacco the rates of smoking amongst 13 year olds in Scotland now are less than two per cent, so we’ve made huge progress in preventing smoking, but actually, once people start smoking in our most deprived areas, we’ve made very little progress. It’s actually a lot easier to prevent it in childhood.”

Indeed, tackling multi-buy promotions is only a first step in a more long-term approach, she argues.

“We do need what we would call comprehensive action, so even though we are focusing on a few priorities for policy at the moment, I think we’d like to see a long-term strategy from the Scottish Government that introduces some things right now but leaves the door open for others in the future.”

What other things could be learned, then, from policy successes on tobacco? 

“A lot of people talk about ‘smoke free’ and say that was a fantastic success and it was, but actually, the policy measures that have made the biggest impact on tobacco use are gradually removing all the forms of marketing. 

“Taking away the TV ads, which is what we’re arguing for at a UK level on junk food before the watershed as well, and then dealing with other forms of promotion, like sport sponsorship, giant billboards, on public transport and that type of thing.”

Bauld acknowledges food and tobacco are very different things, and she says focus should be on products with “limited nutritional value” and engaging with industry.

“We need to keep presenting the evidence,” she says. 

“I think we’re still at a stage in policy development in obesity where the industry is round the table. We’re not locking them out of the room in the way we have done with other harmful industries so I welcome that kind of dialogue.”

With measures backed up with hard evidence and ongoing evaluation, the opportunity is there for the Scottish Government to make a real difference, she says.

“Levels of people who are overweight or obese in Scotland are the worst in the UK and our shopping habits are at the heart of the problem. 

“We need bold action now to prevent thousands of cancers in the future.”