31 Jul 2020
Dr Hilda Mulrooney RD considers the government’s latest obesity strategy in more detail on behalf of the BDA Obesity Specialist Group (OSG). Read the OSGs full response here
The BDA has cautiously welcomed the launch of the new Obesity Strategy, which represents an important milestone in recognition of obesity as a serious health issue. However, there are a number of gaps in the strategy which are of concern.
Addressing root causes and taking a preventative approach
Obesity has been “an immediate concern” for our health and care services for decades, but there has been little sustained long-term action to address the fundamental drivers which cause and maintain obesity. Obesity does not just “sow the seeds of adult disease and health inequalities in early childhood”; health and social inequalities themselves are fundamental to the development and maintenance of obesity. Unless these fundamental inequalities are seriously addressed, any obesity strategy is likely to simply provide sticking plaster remedies.
An intention to ‘focus more on public health and prevention’ is welcome, but the focus must be backed up by new, ring-fenced, long-term public health funding. In addition, a focus on public health will not address the need for adequate service provision, equality of access and funding inequalities which result in unequal treatment provision across England.
We agree that obesity is a major modifiable risk factor, and one of the few for COVID-19. However, we would urge recognition of the complexity of obesity by equally considering the genetic, psychological, environmental and social drivers of the disease which increase risk in many people. Individual efforts to achieve or maintain a healthy weight are very difficult. A compassionate and non-stigmatising approach is needed.
While we recognise that there are health and social costs of obesity and excess weight, the emphasis on losing weight as a ‘patriotic duty’ is unfair and risks further stigmatising those who struggle with their weight, despite sustained effort. Realistically, individual efforts to achieve and maintain a healthy weight will struggle in a system which fails to recognise the impact of emotional distress and food insecurity on eating behaviour, when combined with an environment which promotes over-consumption and a sedentary lifestyle. Indeed, research shows this to be the case.
Is the ‘Better Health’ campaign more of the same?
It is unclear how the PHE’s new “Better Health” campaign will differ from previous (and indeed current) public health campaigns. The NHS BMI calculator and the NHS 12-week programme are not new, and evidence of the efficacy of campaigns is limited apart from raising awareness of the issue. It is unclear that it is lack of awareness that is the problem, rather than the practical difficulties of managing to be adequately active and nourished, in an affordable way, on limited time and resource. It is also unclear whether the demographic groups who have highest prevalence of obesity are also the groups that actually access such resources.
Obesity is a chronic, relapsing disease that requires lifelong support and treatment in order to achieve successful weight loss and health benefits. We are therefore concerned that current treatment strategies to help those with obesity are only being provided in the short term (12-weeks). We encourage the government to consider how it plans to offer long-term continued support following the conclusions of the programme to enable weight-loss maintenance.
Furthermore, if the delivery of the 12-week programme is entirely online and app based, it will not be equally accessible to those in digital poverty. The likely consequence is people most in need and at higher risk of obesity and ill health e.g. BAME communities, and those in lower socio-economic groups, will be further disadvantaged.
Much more detail needed on weight management
We welcome an intention to ‘expand weight management services in the NHS’ but we need detail. Many questions remain unanswered. When and how will this expansion occur? With what funding?
We do not think that an intention by government to ‘encourage provision’ of weight management services is either fair or realistic, given the funding crisis in local authorities. Leadership, comprehensive support and funding, provided on a long-term basis, are need to ensure that local authorities are able to provide such services.
We are interested in the proposal to ensure that it is ‘easier for those struggling with their weight to be referred to specialist support’. What is meant by ‘specialist services’? Although NICE CG189 Obesity recommends access to specialist weight management services (tier 3) and bariatric and metabolic surgery services (tier 4), there is a well-documented lack of suitable specialist weight management services at tiers 3 and 4 across the country.
We are need to understand more about the proposal for ‘healthy weight coaches’ in Primary Care Networks. Weight management is a specialist area requiring current accurate knowledge, communication skills and appropriate non-stigmatising venues and resources. Training provided needs to be extensive and ongoing, and supervision and oversight of healthy weight coaches will be vital. It is not clear who these coaches will be, but they must not be care “on the cheap”. With dietitians being the only profession regulated by law to give dietary advice we would urge greater funding for access to dietitians within both primary and secondary care to deliver specialist advice.
What else is missing?
There are some areas that have not been addressed at all, which is concerning. We are disappointed that breastfeeding and maternal health have not been included, since both have long-term effects on the health and well-being of children, including their weight.
Consideration of mental health and psychological factors is absent from the strategy, which is a serious gap given their central role as a cause of obesity and its treatment. The long-touted ban on the sale of energy drinks to young people under 16 years, which has already been consulted on, is another clear gap.
We are very disappointed that there is no commitment to subsidising healthy foods, which would make them affordable for the most at-risk and vulnerable groups.
BDA Obesity Specialist Group