Updated: Sep 11, 2020
Key Contributors: Shane McAuliffe, Marjorie Lima do Vale, Elaine Macaninch, James Bradfield, Dominic Crocombe, Sento Kargbo, Daniele Del Rio, Emily Fallon, Kathy Martyn, Martin Kohlmeier, Eleanor Beck, Suzana Almoosawi, Sumantra Ray
Acknowledgements: NNEdPro Virtual Core and Global Innovation Panel; Nutrition and COVID19 Taskforce
In late July, following considerable interest and reporting on the relationship between obesity and COVID-19, the UK Government released a policy paper:
‘Tackling obesity: empowering adults and children to live healthier lives’
We commend and celebrate with optimism any commitment to encourage positive lifestyle change and improve population health. However, along with other members of the nutrition and health community, we fear that this response may be overly focused on a limited view of overweight and obesity, considering the enormous complexity of the condition, its determinants, and co-existing conditions.
As a group of nutrition researchers, educators and clinicians, we recognise the complexity which spans diet, nutrition and health interfacing with diverse domains such as the social sciences, economics and politics on one hand as well as genetics and biomedical sciences on the other. We also recognise the complexities associated with obesity and weight loss. Therefore, we advocate for the appreciation and adoption of a wider, complete understanding of the science behind obesity and the strategies which are needed to address it. In this blog post, we will discuss four points of the proposed obesity strategy and provide recommendations for a more comprehensive and impactful response.
As an organization whose mission is to improve knowledge, skills and capacity in Nutrition and Health, we will also continue to educate medical students, doctors, and the nutrition leaders of tomorrow so that the maximum number of patients and members of the public can learn from this collective, organisational knowledge.
First, improve the focus and messaging through valuing lived experiences and co-participation
In this policy paper, much of the narrative appears to suggest that the development and maintenance of overweight and obesity is often due to poor decision-making and that stronger willpower and individual commitment to change might be the key to success. While these factors are not without merit, our knowledge of the complexity of overweight and obesity and its root causes are now much further than the seasoned narrative of “eat less, move more” (Foresight-Obesity System Map, 2020). Nevertheless, it seems as though obesity is still widely considered as a self-inflicted condition, which is often reflected in the public’s perception, wider messaging and consequently, public policies employed by both health and social systems (CMAJ, 2020). Much of the actions proposed by the UK Obesity Strategy, for instance, are focused on individual action, such as engagement in app-based weight management interventions, changes in (un)healthy food labels, advertisement and promotion.
Through this lens, we risk stigmatising and increasing the psychological difficulty of those individuals affected by overweight and obesity, which is counterproductive, given that research tells us weight bias and stigma contribute to morbidity and mortality independent of weight or Body Mass Index (BMI) (CMAJ, 2020). Placing responsibilities on individuals for their own health and well-being might also contribute to mental distress already caused by the COVID-19 pandemic. Tackling excess weight and related metabolic health outcomes should not be disentangled from the context of the pandemic and its subsequent burden on individual’s socioeconomic and health domains.
“We owe it to the NHS to move towards a healthier weight. Obesity puts pressure on our health service. It is estimated that overweight and obesity related conditions across the UK are costing the NHS £6.1 billion each year”
This quote further amplifies the idea that as a public, it is our duty to comply to help relieve the pressure that the COVID-19 pandemic has brought on the NHS. While patients are often encouraged to only avail of services when required, for instance, avoiding unnecessary A&E visits, they should not be stigmatised for making use of public services that are crucial to their health and well-being. Further, this adds to the emphasis on personal responsibility to lose weight, while suggesting that not doing so will increase the burden on our already stretched healthcare system. It would appear that this designation of responsibility is both unfounded and unfair, when considering the structural factors driving food choices and consumption, and along with overweight and obesity and the multitude of other factors that have put the NHS under such strain during this pandemic such as cut-backs and the recognised staff-shortages nationally (BMA, 2020).
Whereas negative messaging can be stigmatising and hurtful, meaning those on the receiving end may ultimately be less likely to engage. On the other hand, use of inclusive, positive and supportive language is understood to be an important facet of effective patient care. Effective messaging, to help inspire change, should be inclusive, collaborative and non-judgemental (NHS England – Language Matters, 2018). Beyond avoiding messages that reinforce victim-blaming, valuing individual’s lived experiences during the pandemic and promoting co-participation in the development of messages used in public national campaigns could be one important strategy to be used.
Second, understand, monitor and address the drivers of food choices and nutritional status
“Obesity prevalence is highest amongst the most deprived groups in society”
The mortality rates from COVID-19 in the most deprived areas of the UK have been more than double that of the least deprived areas (Deaths involving COVID-19 by local area and socioeconomic deprivation - Office for National Statistics, 2020). ICNARC data reflects that a larger proportion of patients admitted to intensive care units (ICU) with COVID-19 were from the most deprived quintile of areas (25.0%) versus the least deprived (14.7%) (ICNARC, 2020). COVID-19 is seen to be more prevalent among ethnic minorities and highly deprived communities, mirroring the national obesity trends and figures. This could be partially attributable to workers from Black, Asian and minority ethnic communities being more likely to live in densely populated urban areas and be disproportionately represented in high-risk, key worker jobs.
“it’s hard to eat healthily, especially if we are busy or tired or stressed”
“Food isn’t the answer to people needing food banks” (Trussell Trust).
Research has shown that households referred to food banks are on average, left with just £50 per week after housing costs, which includes rent, electricity and other utility bills. Financial strain is likely to increase for more socioeconomically deprived households as we emerge from lockdown, with furlough schemes and additional social support subsiding. With additional pressure from housing and other bills, food often becomes less of a priority for struggling families, many of whom have lost jobs and livelihoods. Lack of time, income and resources are often far bigger contributors to poor health choices than lack of knowledge. Unless we equip individuals with the means to implement advice, provision of this information is less likely to be successful.
While reducing volume and promotion of foods high in fat, sugar and sodium might be effective in reducing consumers purchase in some contexts, this might not be the case in scenarios where resources allocated to food purchase or food preparation are already scarce. For instance, a report published in 2018 showed that the cost of the minimum essential food basket can range to one-fourth to almost a half of take-home pay among those dependent solely on state benefits in Northern Ireland (Food Standards Agency, 2018). Moreover, processed, convenience foods may seem more expensive than fresh produce at face value, but when measured as cost per calorie they provide high value for money. In a state of food insecurity, many are likely to make decisions based on these factors as well as how long the food will last and the resources required to prepare and store foods. Consequently, the choice of food by individuals in this position is often calorie dense, high in fat, salt, and sugar but remarkably nutrient poor. While these food choices most likely contribute to the development of overweight and obesity, they may also potentially contribute to underlying micronutrient deficiencies, which we know to be prevalent in the UK, particularly among young adults (Derbyshire, 2018).
The Trussell Trust reports a soaring 81% increase for emergency food parcels from food banks in its network during the last two weeks of March 2020, compared to the same period in 2019 (Trussell Trust, 2020). Food parcel provision is generally based around the foods described above which are lower in cost and non-perishable as opposed to fresher options. Food bank parcels have been shown to exceed energy requirements and provide disproportionately high sugar and carbohydrate and inadequate vitamin A and D compared to the UK guidelines (Fallaize et al, 2020).
A common theme throughout the obesity strategy is that of “Giving everyone a fair deal”. The reality, however, is that structural inequality renders some groups more vulnerable than others, meaning the consequences of the pandemic will be felt unevenly across our society – which is also reflected in our food system. Unless we tackle the root cause of social inequality and inequity, there will be many individuals who are fighting an uphill battle, due to poorer access to quality food or lack thereof, and as a result, poorer health (Health Foundation, 2020). It is crucial to address reports of increasing rates of food poverty during the pandemic response if the government’s strategy to improve the overall health of vulnerable populations is to be effective (Baranuik, 2020).
Coordinated efforts to support food assistance programmes in providing emergency food parcels and baskets along with the involvement of nutrition professionals will be a crucial factor in ensuring that the nutritional quality of food provision is maximised, particularly when resources are scarce. This has already been demonstrated during the pandemic, through the involvement of specialist dietitians in the formation of an Oncology tailored food bank. This repurposing of food destined for the Macmillan Cafe enabled patients to access foods that were appropriate for their health conditions (Macaninch et al., 2020). In fact, tailored community nutrition support programmes have been gaining significant attention in recent times, with a multitude of examples in the United States of their effectiveness to date (Downer et al., 2020).
While improving the quality of food parcels delivered to those most in need will be an important step, it will likely be insufficient. We must consider ways in which to facilitate those living with limited means to make the most of what is available to them. First, in order to maximize success and effect, a combination of food taxes on unhealthy food options in tandem with subsidies for healthy alternatives might be preferable (Niebylski, Redburn, Duhaney & Campbell, 2015). Implementing monitoring and surveillance systems are required to monitor impact for adverse effects. Data must be collected from vulnerable groups of society, who might be under-represented in convenience sampling strategies. Second, food literacy is an important piece of this puzzle. Providing cooking skills to those with limited resources, including ways to minimise waste and how to manage food purchases on a budget will add value (Garcia et al., 2017). Further, we must also provide individuals with the opportunity to implement this knowledge - something as basic as provision of cooking equipment alongside food parcels and nutrition education, in a way that is both practical and accessible. Such food skills programmes can be a highly effective means of improving self-efficacy, psychological capability, and healthy behaviours (Garcia et al., 2017). Further steps to improve abilities related to financial management, tailored to help those on limited income to live within their means, will go a long way in addressing issues of food security (Trussell Trust – Eat Well Spend Less Programme).
Third, promote healthy eating habits from early years
“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”
National Childhood Measurement Programme data shows increased widening of childhood obesity prevalence between higher and lower socioeconomic groups. These patterns reflect the inequalities seen throughout the life course which need to be addressed early in life as part of an effective obesity prevention and management strategy. Rising prices and reduced access to fresh food exacerbates the difficulties some families already face in putting a healthy meal on the table. This poverty loop exacerbates nutrition insecurity where all 3 forms of poor nutrition co-exist throughout the life course. For instance, the diet of pregnant women directly affects their babies growth, and in turn influence genetic development. Poorer foundations have been shown to increase the risk of metabolic disorders (obesity, cardiovascular, type 2 diabetes) later in life, with evidence that these changes can have an influence across generations (Edwards, 2017). This means that there is an opportunity to influence genetic potential in early stages of life, in order to provide the best chance of healthy growth and development.
It may not be enough to simply focus on those who are already living with obesity. We must address the root cause of the problem to ensure fair and equitable access to healthy food for all, from the earliest stages of life. This can be achieved through reinstating initiatives such as the healthy start programme and providing pre-natal vitamins for all pregnant women. Early years nutrition interventions are also possible and potentially effective, which includes educating nurses, midwives, and health workers.
Furthermore, the food environment can be influenced effectively in the early learning sector and schools. More investment in early learning and school food environments is a good starting point, which has been highlighted more than ever during the COVID-19 pandemic (Baraniuk, 2020). Alongside this, the role of nutrition and food literacy cannot be overlooked. Health professionals are a part of the picture in improving nutrition literacy among early learning providers, school teachers and school-going children. In Japan, for example, there are a multitude of dietitians, employed at schools to teach children. A nudge towards nutrition as part of school curriculum would be helpful. Advocating for a better education on food science and nutrition from early learning sectors might represent a big leap towards increased awareness from the beginning of life, even before a person starts making these decisions. Early learning sector and schools provide a perfect platform for health promotion - a ready-made opportunity to instil healthy eating habits as well as the opportunity for engagement with both peers and parents (Oostindjer et al., 2016).
Fourth, address the Complexity of Obesity – Nutrition and Health
“These risks increase progressively as an individual’s body mass index (BMI) increases”
“You can start by weighing and measuring yourself and checking your BMI through the NHS BMI tool. If you are overweight, you can start your weight loss journey with the free NHS 12-week weight loss plan app”
We fear that the focus on weight as the primary marker of health is erroneous and potentially stigmatising. While BMI is a useful surveillance mechanism for tracking population health, we must acknowledge its flaws as a marker of health on an individual level. BMI alone is not an accurate measure of adiposity-related complications, especially when we consider its lack of generalisability across cultures and ethnicities, through underestimating adiposity in South Asian populations and overestimating it in Black Caribbean populations.
“working to expand weight management services available through the NHS, so more people get the support they need to lose weight
“We need to make sure that across the nation we don’t take in more calories than we need
“That is why we want to make sure that our labelling of products in store and in cafes and coffee shops helps us to make healthier choices”
“It is fundamental that we all have access to the information we need to support a healthier weight, and this starts with knowing how calorific our food is”
In a similar vein, we must acknowledge the complexity of foods beyond a single metric or marker of quality. Calories, like BMI, provide a very crude marker of the ‘healthiness’ of food. The focus on calories as the marker of a healthy diet runs the risk of being misinterpreted and oversimplified.
We are delighted to see such a positive commitment through increasing the funding for NHS weight management services, who do such amazing work for their patients. Although, it seems that the role of dietitians and other nutrition professionals has not been acknowledged in the policy paper, which is concerning. The provision of nutrition & dietetic professionals has been chronically inadequate within the health system at primary and secondary care, as well as public health levels. Needless to say, developing successful effective initiatives requires a diverse, multi-disciplinary workforce. We must ensure funding & training is adequate for those healthcare professionals best equipped to deliver these services most effectively. It will be important to ensure that the complexities of nutrition and health science are understood and acknowledged, to reduce the risk of judgements being made on oversimplified or misguided perceptions of the relationship of food and weight with health.
In addition to that, evidence on the effectiveness of app-based interventions to improve diet and physical activity while promoting weight loss must be interpreted with caution. From an implementation perspective, there are several barriers related to access to and literacy in using such technologies that could limit their reach, use and impact. In addition to that, groups included in trials of app-based interventions fail to represent groups with socio-economic restrictions (Ghelani et al., 2020), thus widening inequality.
Human health is complex and multi-dimensional, meaning that focussing on a single metric runs the risk of oversimplifying this complexity and undervaluing the importance of healthy behaviours, even if they are not directly associated with weight. Better language could and should be chosen to encourage positive lifestyle habits, rather than a narrow focus on weight or BMI on an individual level, especially when we consider how difficult long-term weight loss maintenance is to achieve. Individuals should be encouraged to adopt healthy behaviours that are not captured by BMI and therefore important regardless of this measurement, for example; eating 5 portions of fruit and vegetables per day, adequate hydration, the eat well guide, aiming for 30 mins physical activity, resistance training and adequate sleep - to name but a few. For example, those following a Mediterranean diet high in fruit, vegetables, fibre, fish, nuts and olive oil have been shown to reduce their risk of heart disease and type 2 diabetes by a third - without losing weight (Salas-Salvado et al., 2010). This suggests the potential for effectiveness with nutrition-based goals, where success is measured by additional factors beyond just weight, such as blood pressure, lipids, and mental health.
In terms of information and food labelling focused on calories, the public could be better served through education on food-based guidelines and an emphasis on healthy dietary patterns and lifestyle behaviours, in a way that is practical, measurable, and easily understood. The source of calories should be a more important focus than the calories themselves. Perhaps further development of the traffic light system could be used to assess the nutritional quality of foods, beyond just a focus on calories. We might also focus on health-promoting aspects of individual foods. Additional markers of quality might include a tick for foods high in whole grains, or highlighting a good source of certain vitamins or omega-3. The most effective initiatives should be engaging but not overwhelming or complex - simple messaging is key.
All in all, an integrated systems approach ought to be developed with a multipronged intervention strategy equipped with data systems for surveillance and monitoring of targets at population level using routine data, as well as at individual level, from health-related encounters. On one hand we need to target food production, food supply and food environments as well as food marketing to firstly improve the availability of as well as accessibility to more nutrient-rich but less energy-dense foods. These combined with appropriate food education for consumers would enable more consistently healthy food choices. A systemic shift in such food choices towards dietary patterns with proven impact on nutritional status and health outcomes can improve health outcomes particularly. When considering an at-risk obese/overweight population with concurrent micronutrient deficiencies can be an effective form of primary disease prevention or indeed secondary prevention of disease complications and adverse health outcomes particularly in the wake of the COVID19 pandemic.
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