- Aseem Malhotra, interventional cardiology specialist registrar, Royal Free Hospital, London
A fundamental misunderstanding in the scientific community and among the lay public has interfered with our collective ability to curb the obesity epidemic. The belief that we make our food choices deliberately and that they reflect our true desires sustains the status quo and obscures the reality that decisions about the food we buy and consume are often automatic and made without full awareness.1 2
Progress in reversing what now poses to be the greatest threat to our health worldwide can be made only once we take seriously the root cause of diet related disease: the food environment. An oversupply of nutritionally poor and energy dense foods loaded with sugar, salt, and trans fats—fuelled by the junk food industry’s aggressive and irresponsible marketing—has even been allowed to hijack the very institutions that are supposed to set an example: our hospitals. On daily ward rounds it is appalling to see patients, some of whom are not fully mobile, gorging on crisps, confectionery, sports drinks, and cola—the very food items that may have contributed to their admission in the first place. That these consumables are sold to patients through the portable hospital trolleys reflects a marketing strategy by junk food companies to make their products available and accessible to anyone, anywhere, at any time. It is obscene that many hospitals continue to have high street fast food franchises on site, as well as corridors littered with vending machines selling junk food. Such practice legitimises the acceptability and consumption of such foods in the daily diet.
A US study found that families who took their children to paediatric hospitals with a fast food restaurant on site were four times as likely to eat junk food once they left the premises.3 Consuming fast food more than twice a week has a strongly positive association with weight gain and doubles the risk of insulin resistance.4 Randomised controlled trials and observational studies have implicated the consumption of sugary beverages in the rising prevalence of obesity and cardio-metabolic abnormalities.5 6 7 8 The American Heart Association has said that the consumption of sugary drinks accounts for 180 000 deaths each year worldwide from diabetes, cardiovascular disease, and cancer.9 Consumption of 100% fruit juice, which can contain as much sugar as a can of cola and lacks the fibre of whole fruits, is also a health hazard.10
A recent study published in the American Journal of Clinical Nutrition showed that teenagers who drank one soft drink a day were at increased risk of developing type 2 diabetes and cardiovascular disease, even those who were of normal weight.11 It is important to appreciate that diet related disease develops not only in obese people: up to 40% of those who develop the metabolic syndrome (defined as having three of hypertension, raised fasting glucose concentrations, raised triglycerides, low HDL cholesterol, and increased waist circumference) have a normal BMI.12 And two thirds of people admitted to hospital with acute myocardial infarction qualify for a diagnosis of metabolic syndrome, with a 50% increased risk of mortality or rehospitalisation at one year.13 A tax on sugary drinks would reduce consumption and save tens of thousands of lives and prevent morbidity from type 2 diabetes, cardiovascular disease, and stroke and should be supported.14
Another misconception that hinders progress is that reducing morbidity and mortality from these diseases through diet will take decades. A wealth of literature shows that dietary change can have rapid and substantial effects on cardiovascular outcomes.15 The recently published Predimed randomised controlled trial was stopped early after showing that a Mediterranean diet (specifically consisting of extra virgin olive oil, nuts, and oily fish), achieved a 30% reduction in cardiovascular events in a large cohort of high risk individuals when compared with a “low fat” diet.16 How many clinicians are aware that adopting a Mediterranean diet after a heart attack is almost three times more powerful a lifesaving tool than taking a statin for life17 and far more acceptable to patients than taking a drug that can cause significant side effects in a fifth?18 A small but statistically significant study showed that a low carbohydrate diet reversed diastolic dysfunction (which affects 30-50% of all people with heart failure) within weeks of implementation in patients with diabetes.19
In my view, a GP spending 30 seconds counselling patients on specific dietary recommendations would be more effective than patients filling in a meaningless questionnaire on their exercise habits, especially as the evidence linking physical activity and obesity is weak. Referring to the UK as a nation of “lazy porkers” is counterproductive and doesn’t reflect independent evidence.
The increasing burden of non-communicable disease represents a lottery win for big pharma, but its management is upside down. Prevention is certainly going to be more cost effective than cure. Obesity alone is costing the NHS £6bn (€7bn; $9.2bn) a year.20 Three quarters of all US healthcare dollars are spent on treating morbidity associated with the metabolic syndrome.21 The cost of diabetes has risen 41% in five years in the US, reaching a staggering $245bn in 2012.22 Tobacco control has succeeded by targeting the “three As”: availability, acceptability, and affordability. Added sugar, through its unavoidability, toxicity, potential for misuse, and negative effects on society, also fulfils criteria that justify its regulation.21
Patients in hospitals continue to be served disgraceful meals of poor nutritional value, slowing their recovery, lengthening their stay, and increasing costs.23 The fact that a half of the 1.4 million NHS employees are overweight or obese24 is a clear demonstration that education is ineffective when an unhealthy food environment in the workplace is working against you. For too long, short term financial considerations of hospital management have taken precedence over the health of the community. The obesity epidemic represents a public health crisis, but it is a public health scandal that by legitimising junk food hospitals have themselves become a risk factor for diet related disease by perpetuating the revolving door of healthcare. It’s time for the BMA to join the Academy of Medical Royal Colleges in lobbying for a ban on sales of junk food and beverages in hospitals. We must start in our own back yard. It’s time to stop selling sickness in the hospital grounds.
Cite this as: BMJ 2013;346:f3932
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.