The role of obesity in cancer is too big to ignore.
What is agreed is that Scotland needs a bold and brave strategy for tackling obesity. There will be no “one size fits all”. In our blog published on January 1st, we reflected on what has happened in 10 years and where we might progress. This week we are continuing this theme and have asked SCPN friends who have many years experience in the obesity field to give us their top 5 aspirations for the forthcoming obesity strategy?
First off, Joyce Thompson, Chair of the Scottish Board of the British Dietetic Association, gave us her thoughts, followed by Dr Drew Walker Director of Public Health at NHS Tayside and Professor Naveed Sataar, Professor of Metabolic medicine, University of Glasgow.
Now we turn to Professor Mike Lean, Professor of Human Nutrition, University of Glasgow who has been grappling with obesity issues in Scotland for almost four decades.
You cannot solve any complex multifactorial disease problems with 5 actions, or political selections from 5 ‘key’ actions proposed by experts. However, after complete lack of success with our most common and most expensive single disease, despite Scotland having led the world with our SIGN evidence-based obesity guidelines, it is high time to start. Here are 5 steps for starters, largely based on those SIGN guidelines.
1. Government commitment: Only with minister-led policy, and expert guidance, can a strategy, and then appropriate packages of interventions be developed. We have an epidemic (with prevalence beyond the ‘critical threshold for intervention’ defined by WHO) of obesity, causing secondary epidemics of type 2 diabetes and many other consequences. Government must therefore ensure governance over (1) medical services providing best medical treatments for affected individuals, within resource-limits, and (2) government actions supporting effective, sustainable, prevention.
2. Early intervention outside the NHS: Many adults with overweight and uncomplicated obesity can achieve a healthier weight with community-based and self-help activities. Commercial slimming agencies, work-place schemes, voluntary sector activities and Scottish Football Fans in Training are examples of evidence based initiatives from existing enthusiastic, Scottish, efforts. They all deserve further exploration and support for expansion, providing they can demonstrate effectiveness
3. NHS Medical Treatments: We currently spend disproportionate amounts on secondary medical conditions caused by obesity (hypertension, type 2 diabetes, depression, arthritis, etc), and fail to treat the underlying disease. As specified in the 2010 SIGN guideline, weight loss of 5-10% is inadequate and enhanced, more intensive, medical interventions are needed, aiming for sustained weight loss of >15kg (>10%). The SG Health Department for several years supported Scottish enthusiasm and research excellence to develop the Counterweight-Plus programme, to do just that. This structured programme, focused on long-term weight maintenance, is still only provided by half our Health Boards, and to quite limited numbers. A funding redistribution from treating the complications of obesity is needed urgently, to improve staff training, stop reinventing the wheel up and down the country in each dietetic department, and make this service available as standard to people with severe and complicated obesity. Another priority group is obese NHS staff: visible untreated disease in staff sends out all the wrong messages.
4. Population-directed prevention: Special need groups should not be ignored, but with over 80% of the entire population currently overweight by the age of 65, 40% obese, public health preventive interventions must address the whole population, at critical points for unwanted weight gain. The critical age where weight gain is most rapid is teens to early 20s. But young people are hard-to-reach and tend to reject advice. And they soon become new parents with behaviours to pass on. Conventional health promotion has very visibly failed, but modern digital methods and social media offer young people exactly what is needed, and RCT evidence is already available – from Scotland. With no help, young people gained several kilos over a year. Those offered on-line guidance about calories and avoiding weight gain (from a non-commercial source) gained no weight over a year. A third group of young people offered a programme on environmental and political aspects of food production and marketing also gained no weight.
So large numbers of young people are willing to engage using digital technology, and that they will make beneficial behavioural changes if they are guided in ways which they find attractive. This type of intervention is cheap and could be offered to all young people in Scotland.
5. Fiscal measures: The elephant in the room is the food industry, contentedly now serving up 20% more food-calories to our overweight population every day. That is the only way we can maintain, our current levels of obesity, through bigger portion-sizes and packs, and extra fat and sugar. The proposed tax on sugary drinks will do no harm and will send out a clear message to the food industry that government is beginning to recognise where the free market has unacceptable ‘externalities’ in terms of consumer ill-health. Cutting sugar from 10% to 8%, involves under 1% of calories consumed, so will have little or no effect on obesity, especially if companies add artificial sweeteners. The evidence suggests that constant exposure to sweetness, in virtually every drink, stimulates appetite for snacks, especially sugary snacks, between meals. We need all sweetened drinks (sugary and artificial) to be taxed and reformulated, step-wise over a few years, reaching substantially lower sweetness levels. We should also ban caffeine addition. Caffeine is slipped in as a food additive under European law as a ‘flavouring’, but it has no detectable flavour in a sweetened drink or food. In fact it has been added by manufacturers, for about 100 years, in my view, because it is mildly addictive: it makes consumers eat and buy more. A dirty trick!