04.09.2020

Worse than useless

Too little, too late. James Linney takes apart the Tories’ so-called ‘obesity strategy’

On July 27 the government unveiled its new strategy to tackle the UK’s obesity crisis.¹ According to the official press release, the policy aims to enable the country to “lose weight” to beat coronavirus and “protect the NHS”. A statement so idiotic that we could spend the rest of the article on just why it is so misguided (don’t worry: I won’t). Even a genuinely competent attempt at reducing rates of obesity would not be able to reduce them quickly enough to impact the harm from Covid-19. Even if obesity was eradicated tomorrow, this would only reduce a small portion of mortality and morbidity from Covid-19: there are other factors like age, underlying comorbidities and deprivation. You cannot ‘beat’ coronavirus by simply losing weight.

The reason for framing this obesity policy as a continuation of a Tory battle against Covid-19 is, the story goes, because Boris Johnson underwent some kind of awakening during his own coronavirus illness, leading him to abandon his lifelong ideological opposition to ‘nanny state’ interference in our health and setting him on a one-man crusade to defeat obesity. Despite the media happily echoing this narrative, it is obviously utter nonsense.

For evidence of this we need look no further than the content of the new obesity strategy itself. As we will see, it is no more than a pathetic PR stunt to distract us from the fact that the Tories’ handling of the pandemic has been disastrous, resulting in England having the highest excess death rate in Europe² - a situation exacerbated by the Tories’ relentless defunding and privatisation of the national health service. Covid-19 has in fact been used as another opportunity for them to transfer more NHS services to the private sector: from ‘track and trace’ and drive-in testing to provision of personal protective equipment and the building of Nightingale hospitals.

Poverty

The obesity strategy document begins by highlighting the enormity of the problem in the UK, the rates of which have quadrupled in the past 25 years. Around a quarter of adults are now classified as obese (meaning a body mass index exceeding 30) and 63% of adults have a BMI above what is deemed healthy (25). Almost one in five children are overweight when they start primary school - a figure which rises to one in three by secondary school - and it is estimated that by the end of 2020 half of all children will be overweight or obese.³

The most revealing sentence and perhaps the only one worth keeping in the entire document reads:

Obesity prevalence is highest amongst the most deprived groups in society. Children in the most deprived parts of the country are more than twice as likely to be obese as their peers living in the richest areas.

The admission that poverty and inequality are the biggest determinants for a person’s risk of obesity seems bizarre in the light of the rest of the document, which not only fails to pay lip service to tackling poverty, but essentially blames the poor themselves for being obese.

The link between poverty and obesity obviously goes beyond the inability to afford nutritious, quality food. It also includes a lack of access to adequate cooking facilities and to green spaces for exercise, having less leisure time for exercise, having less time for cooking, being more likely to suffer with mental or physical health conditions ... and many more reasons. As we will see though, the government has no time for such considerations: better, it proposes, to make those lazy, stupid people make better choices.

Before we look at each of the proposals, it is worth briefly summarising the existing evidence for medical interventions available for treating obesity. In 2007 a systematic review gathered information from all large clinical studies, comparing weight loss treatments, excluding surgery, after a minimum of a 12-month follow-up.⁴ These treatments included exercise alone, diet alone, diet advice and exercise, intensive support with a very low-calorie diet and weight loss medication (Orlistat).

The results are a depressing read. Whilst some of the treatments show some modest weight loss at six months - most notably the very low-calorie diet (about 18kg weight loss on average) - by 36 months all of the interventions show the vast majority of the weight loss has been regained. Some interventions, such as healthy lifestyle advice alone or exercise alone, show no significant weight loss. Even more shocking is that studies which have longer follow-up periods often show that by five years not only have the vast majority of people regained their original weight loss, but most have actually exceeded it.

One of the reasons for this reversal is biological. Our bodies have evolved a safety net in the form of a metabolic set point, which is determined early in life. This adaption developed over the tens of thousands of years that we lived as hunter-gatherers in an environment of potential food scarcity. As a result the human body strongly favour high-calorie foods, such as sugar and fat, and does all it can to store them when they are available in abundance in preparation for spells of imposed fasting.

In our calorie-abundant modern society this had become a maladaptation - meaning that the body of someone who has been obese since a child or young adult, and then loses weight by dieting, adjusts its internal mechanisms in order to maintain its obese state. It does this by slowing its basal metabolic rate, encouraging more fat storage and increasing hunger hormones. Even more unfairly, the body often overcompensates and fixes its new metabolic set point above the original level, meaning the dieter has a net gain in weight, which in turn leads to disheartenment and loss of motivation.

I must clarify that this does not mean that some people cannot successfully lose weight and retain that weight loss by changing their diet: it just means that it is very difficult to do so, requiring a lot of motivation, time and effort. And, yes, you will also have a small number of outliers whose genes are kinder to them and who find it easier.

However, on a population level the type of fad diets that fuel the very lucrative diet industry (from which plenty of medical professionals profit) are actually not just a waste of time and money, but are actually harmful. It turns out the advice that you just need to eat less and exercise more is not that helpful.

I apologise for getting somewhat bogged down in the details of the evidence for weight loss interventions, but it is necessary if we are to understand the effectiveness of the proposals contained within the Tories’ obesity strategy and, as we shall see, that the authors should have spent a little more time thinking things through themselves.

Useless

The first proposal of the obesity strategy focuses on primary care. We are promised “a new campaign - a call to action to take steps to move towards a healthier weight”. This bold statement, we soon learn, essentially equates to a free NHS 12-week weight loss app.

However, what little evidence there is on the effectiveness of apps in aiding weight loss concludes that they are not helpful.⁵ Which is not surprising, given that, as we have seen, even if people are given 12 weeks of face-to-face, intensive coaching on diet and exercise, weight loss is still only very modest and difficult to maintain. Apps are also largely based on calorie counting, which can prove to be a problematic way to try to lose weight. Again I am not saying that an app cannot motivate some people to change their diet in positive ways, but for some it can encourage a pathological relationship with food. Every meal can become an exercise in feeling guilty and trying to balance numbers, turning meal time into an ordeal and often leaving people easily disheartened or, worse, with disordered eating.

The second part of this new ‘call to action’ claims that the Tories will “expand weight management services, so that more people get the support they need to lose weight”, by offering “Primary Care Networks the opportunity to equip their staff to become healthy weight coaches”. Given the Tories’ systematic and vicious campaign of cuts and privatisation of the NHS over the past decade, these statements can only be read as some kind of sick joke. Weight management has, like most NHS services, been left decimated. To offer a typical example, the clinical commissioning group (CCG) where I work tendered out weight loss services to a private company, which then, predictably, rolled out a shoe string service. This essentially involved offering patients a referral to Slimming World, with whom the company had obviously done a deal. Now the only way a patient qualifies to be seen by a dietician is if their BMI is already above 50 - way too late - and sadly at this point bariatric surgery is often the only option. Simultaneously the CCG was forced to make annual ‘efficiency savings’ that led, disgracefully, to people with a BMI above 35 being refused all non-emergency surgery.

The next strategy proposal informs us that legislation will be introduced requiring large restaurants (more than 250 employees) and fast-food chains to provide calorie information on their menus. As we have already seen. calorie counting is not usually helpful and can be harmful. People do not eat at Macdonald’s because they think it is healthy, so highlighting this is not really going to help. A contradictory message here is that the government recognises that “On average the portions of food or drink that people eat out or eat as takeaway meals contain twice as many calories as their equivalent bought in a shop”, whilst simultaneously pushing its ‘Eat out to help out’ scheme, which gives you 50% off at Burger King, KFC, Macdonald’s ...

The final two proposals of the document somehow manage to be even more useless than those preceding them. At some point in the future the government aims to discourage supermarkets from having unhealthy food near the tills and from having ‘buy one get one free deals (BOGOFs)’ on high sugar, salt and fatty foods. I guess this is the government’s pretence at playing hardball with the supermarkets? If so, this is beyond pathetic and should fool no-one with any sense. Even if the ban on BOGOFs is enforced, which it almost certainly will not be, the only group suffering here are the people whose poverty forces them to rely on cheaper, less healthy food, which, let’s face it, is better than no food. These proposals are even less likely to have any impact on obesity than the government’s misguided ‘sugar tax’ legislation, introduced in 2018 - which mainstream media, almost universally, declared a success before it was even published⁶.The levy placed a tax on the soft drink industry for products with a high sugar content, which has reportedly led to a 30% reduction in drinks with sugar content above 5g per 100mls⁷. Yet all this means is that manufacturers are now selling very slightly less sugary drinks, whilst sales of sugar free soft drinks have nearly doubled – by no means a good thing for the nation’s health. The ingredients on a can of a sugar free soft drink is a scary read, it’s a long list with an array of sweeteners, E numbers, miscellaneous acids, colourings and preservatives.

The crazy thing is that the sugar tax and the new obesity strategy are actively encouraging food manufactures to use these types of toxic ingredients in more foods and allowing them to be marketed as ‘healthy alternatives’. Be suspicious of any product that advertises itself as low in fat or sugar!

The final proposal of the government’s obesity strategy manages to be the most meagre of all - a ban on advertisements for food high in sugar, fat or salt on TV before 9pm. Little more needs to be said about this than that on page 75 of the government’s own research paper⁸ - here being cited to justify introducing this ban - we find this conclusion about its effectiveness: “Therefore, after adjusting for displacement, we estimate children’s calorie consumption will reduce by 1.74 kcal/day.”

So the government wants to fight child obesity by introducing a measure that, by its own admission, will at best reduce a child’s daily intake by the amount of calories in a single Tic-Tac? It would be amusing if it was not such a blatant disregard for a lifetime of morbidity and suffering for millions of children.

Real disease

Of course, this document is not really a serious effort to tackle obesity. It is the minimum the Tories feel they can get away with to give the appearance of caring, whilst not upsetting the food industry. They were hoping for some positive headlines regarding Covid-19 for once, and in this they have succeeded.

Anyone interested in actually tackling the obesity crisis will know there is nothing of merit in this document. The truth is that, although medical or public health interventions can help the few, they will not provide a solution. That will have to be far more radical. For a start, obesity is a global issue and any solution needs to be undertaken on a global scale - the reason being that our diets are inextricably linked with the way capitalism manufactures and markets food. The oligopolistic food industry has led to the homogenisation of global diets in favour of highly processed, high-calorie, but nutritionally poor foods.

At the same time our diets have offered capitalism - forever searching for new markets - an opportunity for new ways to sell us products. The aisles in our supermarkets are case studies in the illogical, harmful way capitalism has commodified our diets at the cost of our health. The biggest 10 food companies essentially now own everything in a supermarket and, of course, each item they make is produced by a workforce on long hours, little pay and often dreadful conditions.

In the 19th century, when industrialisation was young, the working class in Britain was mostly subjected to hard, manual-labour jobs - and food scarcity. In his book, The condition of the working class in England, Engels memorably documents some of the horrific diseases of malnutrition, resulting in premature death, that this environment was inflicting on our class. Despite advances in sanitation, medicine and technology allowing people to live longer, diseases like obesity or mental health issues, addiction, type 2 diabetes and many more continue to be the health burden the working class carries on behalf of capitalism.

This is a malady that will continue until we are able rid ourselves of that underlying disease.