Scotland’s obesity epidemic
Scotland is becoming a nation of fatties, putting a burden on the health service and the public purse
Scotland's obesity epidemic - Image credit: Holyrood
Most Scottish people are overweight, eat too much junk food, don’t exercise enough and many are eating so much they are becoming a burden on the NHS and wider society.
It sounds like a nasty stereotype or a reactionary tabloid headline, but this is the truth behind the sanitised jargon like ‘co-morbidities’ and ‘calorific intake’ that we often see in public health strategies.
Two-thirds of Scottish adults are overweight or obese – the highest in the UK and amongst the highest in the world – while about a third of children are at risk of becoming overweight or obese.
The food and retail industry has thus far refused to engage meaningfully with the problem – and still tempts children with tasty treats during prime-time TV, and entices adults into gluttony with three-for-two, ‘can’t afford to miss’ mega deals on calorific-laden convenience foods that most of them don’t even want, need or can afford.
Some experts think it’s time for the gloves to come off and we need to get tough with retailers and their apologists who use cherished human rights like personal choice, privacy and freedom of expression to sell cheap junk to poor people who often lack the finances and capacity to resist.
Some radical solutions are now being suggested, such as encouraging retailers to share their loyalty card data with the government to help health providers encourage people to make better choices.
This sounds like a surveillance society nightmare, but when you compare the health figures on obesity to some of the other crises we’ve been willing to tackle head on to save lives, like banning smoking in public places and wearing seat belts, it seems a more sensible approach.
Many are willing to give the security services access to emails and guns to policemen to protect a few hundred people from terrorist attacks, but would recoil at the thought of the government finding out how many burgers they buy despite the thousands of people who die from illnesses directly related to obesity.
Experts also want GPs to challenge patients about their weight, as they do already about their smoking habits, drinking and even risks of domestic violence.
Smoking is fast becoming an antisocial activity, and is therefore fair game, but eating so much that you make yourself ill is somehow seen as a personal choice and off-limits for doctors and regulators.
Many senior consultants admit that they find the prospect of raising someone’s weight problem just too embarrassing.
But the voluntary approach and softly-softly advice we’ve used in recent years has not worked, as obesity levels have not come down while the number of severely obese people has doubled.
The annual cost to NHS Scotland of overweight and obesity combined is thought to be as much as £600m.
Average healthcare costs for people with a body mass index (BMI) of 40 (severe obesity) are estimated to be at least twice those for people with a BMI of 20 (within normal weight range).
And the stark evidence of the consequences of this obesity epidemic on the NHS are all too obvious on hospital wards, with larger beds required – some hospitals have resorted to using surgical beds normally used by vets – and incubators on intensive care neonatal wards filled with larger than average babies born to larger than average mothers and already struggling with weight-related illnesses.
Estimates of the total economic costs of obesity to Scotland range from £0.9bn to £4.6bn per year.
Geoff Ogle, chief executive of government agency Food Standards Scotland, thinks now is the time for some tough solutions.
“The more solutions you take off the table, the harder it is to solve the problem,” he told Holyrood.
“You need to look at things like subliminal messages in advertising, and what you can do to change the advertising regime.
“If you look at the psychology around product placement when you go into supermarkets, it’s exactly that sort of approach that could be used to promote healthier products.
“If you can use a particular strategy to promote a high fat, salt or sugar product, it seems to me that there is no reason why that sort of strategy cannot be used to promote healthier foods.
“We are seeing a bit of a rollback and reduction in the use of promotions like this from industry, with more of a drive towards ‘everyday low prices’ – which is the current mantra.
“There are issues around price, availability, portion size and even, funnily enough, around having a smaller plate. A smaller plate that is full will do the trick in terms of reducing calorific intake.
“Subliminal advertising is to do with what is advertised, when it is advertised and who it is targeting.
“It’s not just TV nowadays – we’re also now talking about social media and the promotion of sweets, treats, crisps, chocolates and other things that are particularly attractive to children, basically.”
It’s not hard for advertisers to pull adverts that have become socially unacceptable – if enough people in society tell them it has become so.
For example, advertisers recently boycotted YouTube amid fears that their adverts were being placed alongside extremist videos, demonstrating that they have the ability to discern which particular social issues they want to be associated with.
If they can pull an advert from a hate speech because it’s deemed bad for business – why can’t they uncouple chocolate bars from cartoons?
Ogle said: “Just look at the number of advertisers that pulled their product from social media because of concerns around where the advertising was being placed.
“I’m not making any equation between food and terrorism – but I’m just using it to illustrate the amount of advertising that is done on social media.
“The impact on Google was something like $750m in terms of lost revenue from advertising, so the figures are out there that show advertising is used quite extensively across social media.”
Ogle has called for a more targeted approach to health marketing, to make sure the right health messages are getting to the right people.
It’s too easy for affluent people to think obesity is just an issue for the poor, when their dietary habits are having an impact on their own health and wider society.
“The lowest socioeconomic groups tend to consume more sugar than higher socioeconomic groups, but higher socioeconomic groups consume more saturated fat,” said Ogle.
“There are, without a doubt, clear links between diet and social deprivation.”
He added: “The trap we fall into, collectively, is that messages around diet tend to be rather generalised.
“If it’s not very specific about who it is aimed at then people obviously think: ‘Well, they don’t mean me.’
“For us, the issue is much more around thinking about what kind of messages we want to give, who we need to target, and what is going to resonate with those particular groups.
“It’s a waste of public money talking about the problems associated with foods with high saturated fat if you’re not targeting the people, such as those in higher socioeconomic groups, who consume the most.
“Teenagers consume a huge amount of soft drinks, but if you go through a lifecycle, consumption patterns change.
“What you eat in your 20s may be hugely different to what you eat in your 30s, and what you feed your children aged three will be different to what they eat at 15 when they’re more independent and have more choice over what they consume, so we need a more stratified approach to understand what consumption is happening where, and in what particular groups.”
This is where the thorny issue of using private data to inform public health messages comes in.
Ogle is well aware of the potential outcry such a suggestion may cause, but is willing to raise it to foster a debate about the potential solutions to Scotland’s obesity crisis.
“If you look at things like loyalty cards and reward cards, there is a lot of information there that can be used collectively to help with that sort of messaging and targeting,” he said.
“The trick is understanding what the consumption is, because until you understand what the consumption is in terms of the different groups, it’s very difficult to come up with messages that can actually target people.
“By and large, government doesn’t have that information, but industry does.
“There are undoubtedly commercial sensitivities that industry would have concerns about, but there must be ways in which we can overcome that and start thinking about ways we can use information and be much more targeted in what we are trying to do, because general messages don’t work.”
He added: “One reason I would be slightly hesitant is the concerns around consumer attitudes, because you have got to take consumers with you on the journey.
“If I’ve got a Clubcard that I use at Tesco, or a Nectar card at Sainsbury’s, or whatever, I’m kind of assuming that they are gathering information about what I purchase, but I’m also assuming that they will use that information for my benefit as a customer.
“It’s a slightly different proposition to say if you use your Clubcard there’s a good chance that information will go to the government.
“It is something that has potential, but you can’t rush into it, and you have to take consumers with you because there will be concerns around it.
“Government, industry and individuals all have a responsibility to engage with this.”
While industry can come in for a lot of criticism, ultimately, it is the individual that must decide to make better health and dietary choices.
Few people lack the capacity to understand the impact their diet is having on their health, particularly if they have access to the right information and guidance.
Ogle said: “Consumers can have an influence, because retailers will sell what consumers buy, and if consumers stop buying certain products then retailers will stop selling those products because they won’t make money from it.
“Consumers do have a fair amount of control over what they consume and purchase, but they probably just don’t recognise that that is the situation.
“Since we’ve been FSS, I think we’re now much closer to a general consensus from government, industry and consumers that something must be done on diet, and something must be done differently.
“Certainly, on things like removing sugar, from our research there is a high degree of acceptance amongst consumers for that.
“I think the risk is that you just focus on sugar and forget about things like saturated fat, or you forget about things like eating more fruit, vegetables and fibre which are just as important as cutting sugar and fat.
“It’s important we don’t get fixated on particular commodities when it is actually a range of things.”
Levels of obesity are predicted to rise to around 40 per cent in Scotland by 2030, bringing increases in type-2 diabetes, cancer and other health issues which will impact on health spending.
Ogle said: “If you’ve got a 40 per cent obesity level then, economically, you’re going to be less productive because you’re going to have an unhealthy workforce, sickness absences are likely to increase and levels of productivity will go down.
“If your health costs are going up and your economic productivity is going down, that is not a good place to be.
“In terms of how the profile of obesity looks in Scotland – it doesn’t look very good, to be honest.”
There are other, softer measures that policymakers could use to cut calories, such as addressing the age-old habits that many of us have grown up with.
Why can’t you just have tea – rather than tea ’n’ biscuits – and does fish really have to come with chips?
Ogle said: “You might think you’ve got a healthy diet because you eat three square meals a day, but then you ignore all the snacks you have in between.
“There’s a real dichotomy between the two-thirds of adults who are overweight and obese, and the 75 per cent of adults who think they have got a healthy diet.
“Those two figures are clearly inconsistent.
“Part of the problem is price and availability. Everybody likes a bargain, but there is an issue with easy access to foods with high fat and sugar content which can be attractive in terms of price, taste and the desire to treat yourself.
“The problem is we’re treating ourselves too often, really, so a lot of it is about breaking bad habits.”
Ogle also warns against the “nanny state approach” in public health messages.
“If you say ‘thou shalt not’, you tend to get an adverse reaction,” he said.
“But at the most basic level, if you consume more calories than you get rid of then you are going to put on weight.
“So, you need to think, ‘what do I consume and how do I expend energy’, and there is a big issue around that.
“All the evidence shows that the ‘big stick’ approach with food and drink doesn’t really work, partly because it focuses on downstream risks – the notion that what you do today has an impact 10 or 20 years later – so direct shock tactics don’t always work.
“We ran a healthy eating campaign recently trying to focus on parental behaviour, and what parents can do to influence their child’s diet, so some of it is around the social responsibility factors and what you can do to actually influence behaviours there.
“But again, you have to be quite careful about that as well, because it is very easy for assumptions to be made about parents and that is not the message at all, so it is a sensitive area.”
FSS has welcomed the UK Government’s soft drinks levy as “a good start” but thinks more needs to be done to address sugar in other foodstuffs.
“If you look at sugar content then there are other food products which probably have a higher sugar content than soft drinks,” said Ogle.
Scotland can also turn to international examples to improve public health.
Thirty years ago, Finland was one of the world’s unhealthiest nations. The diet was poor, people were inactive and heart disease was at record levels, but now it’s one of the fittest countries on earth.
It started with the sparsely populated frontier region of North Karelia, the sickest region of a desperately sick country, which was overturned by a massive positive health campaign in the 1970s.
Instead of saying ‘thou shalt not’, policymakers set positive incentives like ‘quit and win’ competitions for smokers.
Ogle said: “I’m not sure any country has a single silver bullet solution, but there are certainly views about the benefits of certain diets like the Mediterranean diet or Asian diets, which can be seen as more healthy.”
Linda Bauld, Professor of Health Policy at Stirling University, has identified some other countries that Scotland could follow.
“Mexico has a really high rate of obesity and introduced a sugar levy, fundamentally changed their school meal environment, and took some action on price promotion, even though they have some economic challenges that we don’t face,” she said.
“Scandinavian countries have some generally good models, and France is another good example where they have introduced some restrictions on junk food marketing, [and] will introduce a sugar levy next year.”
She added: “Unfortunately, our obesity rates in Scotland are amongst the highest in the world – even higher than England and higher than most countries in Western Europe.
“Two out of three adults in Scotland are overweight – that’s 65 per cent so people of a healthy weight are in the minority.
“Our rates of childhood obesity are also significantly higher than the rest of the UK.
“We’ve got about one third of children, aged two to 15, who are overweight or obese, and 17 per cent of them are obese.
“That’s not great, and the problem is it grows through childhood.
“Around one in five children who start school in primary one are overweight or obese, and that goes up as they go through school and increases on into secondary school.
“How did we get here? The main thing is changes in the food environment, and the types of food that we are eating.
“We are getting more of our daily calories from foods that are high in salt, sugar and fat.
“Also, a lot of the products that aren’t very good for us are cheap and widely available.
“People often point out to me that in the past people did a lot more manual work, and so were a lot more physically active.
“While that is true to a certain extent, the major cause of obesity is related to our diet – the amount of calories we consume and where we get those calories from.
“This really has changed a lot in the last few decades.”
She added: “Obesity is directly linked to deprivation, just like smoking where there is a very clear gradient.
“You see the greatest rates of obesity in the most deprived quintile, far higher than in the most affluent.
“Part of the ‘Glasgow effect’ is to do with poverty. Those communities are generally poorer, and so the people in those communities tend to be larger as a result of their diet.
“But in Glasgow you also have co-morbidities through smoking and the consumption of too much alcohol.
“When you combine diet, smoking and drinking, we know that this is probably the reason why cancer is higher in the west of Scotland than elsewhere.
“Of course, poverty also makes people’s lives difficult, so they’re less resilient, they have poorer mental health and that puts them at risk of certain conditions.
“These things tend to come together.
“There are also some theories about genetic and hereditary factors in the Glasgow area, with many people descended from immigrants fleeing the Irish potato famine, for example.”
Bauld has urged the Scottish Government to take on board some of the radical solutions experts have suggested to bring down obesity – as the existing tactics just aren’t working.
“The existing Scottish Government obesity strategy is now a number of years old,” she said.
“Local authorities were tasked with doing things like improving the quality of school meals, extending the free school meals programme for younger children to older children, and making sure that kids have an opportunity to be physically active during the day.
“These are things that local authorities are doing, and I guess they have also, to some extent, been trying to create more sustainable transport options to encourage people to walk and cycle.
“Obviously other services they provide, like social care, encourage people to be more active in later life.
“The health service has been encouraged to invest in weight management services, but these remain patchy throughout Scotland and vary between health boards.
“One thing we haven’t been doing is integrating weight into primary care.
“It’s quite common for a GP to ask about smoking and then refer people to smoking cessation services, but it doesn’t really happen in primary care for overweight and obesity.
“From a Cancer Research UK perspective, this is something that we would like to see a real sea change on.”
She added: “The policy team working on the obesity strategy and the Public Health Minister Aileen Campbell recognise that the previous strategy put a lot of emphasis on a voluntary approach with the food and drinks industry, and to some extent with the voluntary decisions that individuals might make with their diet.
“Basically, that didn’t work because we haven’t seen any reduction or change in overweight or obesity.
“What we are looking for this time is more action on the ‘Four Ps’: price, place, promotion and products.
“Price would include things like the UK Government’s soft drinks levy, and we would like to see the Scottish Government take action on price and promotion in Scotland, so we have called for restrictions on price promotions in the retail environment – particularly multibuy offers.
“We did a YouGov survey recently which showed that around 70 per cent of Scots were supportive of restricting multibuy offers in supermarkets, things like three-for-two on biscuits.
“We’ve also asked the industry if they can find a way to restrict junk food marketing to children, but I think that is difficult because Scotland has limited powers on that front.
“Scotland is aspiring to be a good food nation, and the manufacturers have a part to play in that as well.”
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