Obesity and covid-19: the role of the food industryBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2237 (Published 10 June 2020) Cite this as: BMJ 2020;369:m2237
All rapid responses
In their editorial ‘Obesity and covid-19: the role of the food industry’ the authors conclude that ‘it is now clear that the food industry shares the blame not only for the obesity pandemic but also for the severity of covid-19 disease and its devastating consequences’. They state that ‘food industries around the world must immediately stop promoting, and governments must force reformation of, unhealthy foods and drinks’ .
This is a way of framing in which reality is deliberately simplified into a triangle with three corner points: the victim, villain and the rescuer. This resembles the drama triangle of Karpman which is well known in psychotherapy. In this triangular frame the victim is the population who overuses highly processed foods and drinks, the food industry is the villain and the authors, by writing this editorial, step in the comfortable rescuer position. If governments do not react to the author’s call they also become villains who do not take their responsibily to protect the population of their country. This way of framing is commonly used by politicians, but also by activists in the food, tobacco and alcohol discussions.
We believe that the oversimplication of massive overconsumption in the drama triangle needs to be nuanced, because unhealthy behaviour is socially contagious. Therefore, many of our patients and colleagues are in essence not less a villain than the industry. It is known that within social networks individuals (un)conciously seduce others to also buy and eat, drink or smoke the same unhealthy products. Especially within families this social contagiousness can be observed. For example, children of parents who smoke have a 2-3 times higher chance to become a smoker themselves compared to children of non-smoking parents. This relatively higher intergenerational transmission between parents and children is also true for overusing highly processes foods and drinking alcohol. Resulting lifestyle related illnesses should therefore better not be called non communicable diseases as the behaviour is communicable between humans . The industry is fully aware of this social contagiousness and uses this knowledge in their marketing strategies. As such, individual users can be considered free marketing instruments of the industry spreading the use of their products and this unhealthy behaviour.
Of course our governments have to help to counteract the marketing strategies of the industries by implementing the so called WHO-‘best buys’ , but we also have to prevent the interhuman transmission of the overuse of unhealthy products? Can we perhaps learn from the current social contagious SARS-CoV-2 pandemic? Should we also implement social distancing and isolating norms for people already eating junkfood, smoking cigarettes or drinking alcohol? In The Netherlands we successfully started a mass (smokefree generation) movement in which we protect all children to become a smoker by collectively not smoking near children . This strategy is based on the social contagiousness smoking. The result is isolation of smokers to prevent interhuman transmission of their behaviour. A next challenge is to generalise these principles for alcohol use and consumption of processed food. We believe that we are all villains ánd victims as long as we do not improve our own behaviour or (as physicians) help others to achieve this. But if we do change our lifestyle all of us can be rescuers who together can reduce these lifestyle pandemics more quickly than if we only point to the industry and government.
1. Tan M, He FJ, MacGregor GA. Obesity and covid-19: the role of the food industry. MBJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2237
2. Allen LN., Feigl AB. Reframing non-communicable diseases as socially transmitted conditions. Lancet 2017; 5: E644-E646. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30200-0/fulltext
3. WHO (2017). ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Updated (2017) appendix of the global action plan for the prevention and control of noncommunicable diseases 2013-2020. https://www.who.int/ncds/management/WHO_Appendix_BestBuys.pdf
4. National Prevention Agreement - Tobacco, The Netherlands (2018). https://www.government.nl/documents/reports/2019/06/30/the-national-prev...
Competing interests: No competing interests
Obesity - a potential risk factor for COVID-19 associated morbidity and mortality in urban Bangladesh
Obesity has become one of the major public health problems of the modern world (1). Developed countries are the most affected owing to the high prevalence (2). However, the escalating numbers of new cases in developing countries have turned obesity into a preeminent public health issue (3), specifically among the poorly distributed urban populations (4,5). Evidence suggests that the prevalence of overweight and obesity is mounting in Bangladesh (6,7), which probably underlies the high number of COVID-19 associated morbidity and mortality in the country.
The first case of COVID-19 was identified in Bangladesh in early March (8). It did not take much time for the country to be among the top 20 countries with COVID-19 burden (9). To date, 90,619 COVID-19 cases have been identified, which are mostly concentrated in the urban areas of Dhaka and Chittagong division (10). The Government took radical measures, such as lockdown, shutting down educational institutions and offices, putting restrictions on the movement of vehicles (11). Despite the countrywide lockdown, there is no sign of flattening the curve of case identification.
To ensure social distancing, the Government of Bangladesh has asked everyone to stay at home. This is now in practice among the densely populated urban community, which ultimately has reduced the daily movement of the adolescent and adult population (12). Gymnasiums have been shut down and visiting local parks is banned. Being confined at home for an extended period has also affected their mental health. Several reports of increasing depressive illness and suicidal tendencies have been surfaced up, however, receiving little attention from the authorities (13,14). Limited access to health care providers is further flaring up the scenario (15). People tend to eat more while in depression (16,17). This prolonged lockdown and closure of the educational institutions are triggering this depression episodes and excessive eating habits (18). Regardless of the pandemic situation, 68% of the urban college students consume fast food regularly, and 29.9% of them are obese (19). Besides, due to the lack of outside recreation activity and social distancing, people are becoming prone to binge eating and taking unhealthy snacks (20). Processed food industries and restaurants in the country are loosely regulated, and the nutrition value of the foods is often overlooked (21). All these factors are leading to increased overweight and obesity, which is associated with weakened immunity (22).
Currently, there is a lack of studies which can educate us regarding the risk factors of COVID-19 in Bangladesh. However, earlier reports from the World Health Organization suggest that there is a substantial epidemiological shift among the vulnerable age groups in Bangladesh in comparison to other countries. Although older people are still vulnerable, nearly 70% of the cases and 22% of all deaths took place among people aged 20-50 years, which is incidentally the age group with the highest prevalence of overweight and obesity (9). We presume that the high prevalence of overweight and obesity among the urban population has played a critical role in lowering immunity and increased morbidity and mortality in COVID-19 in Bangladesh. There is a dire need for a large scale epidemiological study to investigate this association and well-planned public health programs to improve the knowledge and practice to reduce overweight and obesity among urban populations through healthy eating.
1. Cotti C, Tefft N. Fast food prices, obesity, and the minimum wage. Econ Hum Biol. 2013 Mar;11(2):134–47.
2. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes. 2006 Jan;1(1):11–25.
3. de Onis M, Blössner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 2010 Nov 1;92(5):1257–64.
4. Saklayen MG. The Global Epidemic of the Metabolic Syndrome. Curr Hypertens Rep. 2018 26;20(2):12.
5. Ford ND, Patel SA, Narayan KMV. Obesity in Low- and Middle-Income Countries: Burden, Drivers, and Emerging Challenges. Annu Rev Public Health. 2017 Mar 20;38:145–64.
6. Banik S, Rahman M. Prevalence of Overweight and Obesity in Bangladesh: a Systematic Review of the Literature. Curr Obes Rep. 2018 Dec;7(4):247–53.
7. Bulbul T, Hoque M. Prevalence of childhood obesity and overweight in Bangladesh: findings from a countrywide epidemiological study. BMC Pediatr. 2014 Dec;14(1):86.
8. IEDCR. Covid-19 Vital Statistics [Internet]. Instituion of Epidemiology Disease Control and Research; 2020 [cited 2020 Jun 16]. (COVID-19 in Bangladesh). Available from: https://www.iedcr.gov.bd
9. WHO. COVID-19 Situation Report [Internet]. 2020 Jun [cited 2020 Jun 16]. Report No.: 16. Available from: https://www.who.int/docs/default-source/searo/bangladesh/covid-19-who-ba...
10. IEDCR. Distribution of confimed cases in Bangladesh [Internet]. Institute of Epidemiology Disease Control and Research; 2020 Jun [cited 2020 Jun 16]. Available from: https://iedcr.gov.bd/website/images/files/nCoV/Case_dist_13_June_upload.pdf
11. Mamun S. Govt for strictly enforcing travel ban as general holiday extends to May 30. Dhaka Tribune [Internet]. 2020 May 14 [cited 2020 Jun 16]; Available from: https://www.dhakatribune.com/bangladesh/2020/05/14/govt-for-strictly-enf...
12. O’Riordan M. COVID-19 Lockdown Inactivity May Spell Trouble for CVD Prevention. tctMD/ the heart beat [Internet]. 2020 Apr 24 [cited 2020 Jun 16]; Available from: https://www.tctmd.com/news/covid-19-lockdown-inactivity-may-spell-troubl...
13. Sakib N, Bhuiyan AKMI, Hossain S, Al Mamun F, Hosen I, Abdullah AH, et al. Psychometric Validation of the Bangla Fear of COVID-19 Scale: Confirmatory Factor Analysis and Rasch Analysis. Int J Ment Health Addict [Internet]. 2020 May 11 [cited 2020 Jun 16]; Available from: http://link.springer.com/10.1007/s11469-020-00289-x
14. Mamun MA, Griffiths MD. First COVID-19 suicide case in Bangladesh due to fear of COVID-19 and xenophobia: Possible suicide prevention strategies. Asian J Psychiatry. 2020 Jun;51:102073.
15. UNDP. Covid-19: A reality check for Bangladesh’s healthcare system [Internet]. UNDP Bangladesh Research Facility; 2020 May [cited 2020 Jun 16]. Available from: https://www.bd.undp.org/content/bangladesh/en/home/stories/a-reality-che...
16. Gluck ME, Geliebter A, Satov T. Night Eating Syndrome Is Associated with Depression, Low Self-Esteem, Reduced Daytime Hunger, and Less Weight Loss in Obese Outpatients. Obes Res. 2001 Apr;9(4):264–7.
17. van Strien T, Konttinen H, Homberg JR, Engels RCME, Winkens LHH. Emotional eating as a mediator between depression and weight gain. Appetite. 2016 May 1;100:216–24.
18. Odriozola-González P, Planchuelo-Gómez Á, Irurtia MJ, de Luis-García R. Psychological effects of the COVID-19 outbreak and lockdown among students and workers of a Spanish university. Psychiatry Res. 2020 May 19;290:113108.
19. Banik R, Naher S, Pervez S, Hossain MdM. Fast food consumption and obesity among urban college going adolescents in Bangladesh: A cross-sectional study. Obes Med. 2020 Mar;17:100161.
20. Sidor A, Rzymski P. Dietary Choices and Habits during COVID-19 Lockdown: Experience from Poland. Nutrients. 2020 Jun 3;12(6):1657.
21. Ali ANMA. Food safety and public health issues in bangladesh: A regulatory concern. Eur Food Feed Law Rev. 2013 Jan 1;8:31–40.
22. Samartı́n S, Chandra RK. Obesity, overnutrition and the immune system. Nutr Res. 2001 Jan;21(1–2):243–62.
Competing interests: No competing interests
It is remarkable that two seemingly disparate risk factors have emerged for susceptibility and severity of covid-19: obesity1 and ethnicity.2 Whilst several characteristics including socioeconomic, cultural, or lifestyle factors, genetic predisposition, or pathophysiological differences may influence susceptibility or response to COVID-19 in people from black, Asian, and minority ethnic heritage,3 it should be remarked that black adults are the most likely out of all ethnic groups to be overweight or obese.4 Furthermore, we suggest that one poorly-recognised risk factor in ethnic minority communities could be normal-weight obesity wherein individuals have excessive body fat, particularly visceral fat, despite a normal weight based on body mass index (BMI).5 In people with conventional or normal-weight obesity, insulin resistance, hyperinsulinaemia, type 2 diabetes, hypertension, hypertriglyceridaemia, atherosclerotic cardiovascular disease and higher levels of pro-inflammatory cytokines expressed in adipose tissue may augment the critical effects of covid-19.6
We also wish to draw attention to the often-overlooked matter of obesity as a cause of suboptimal treatment in infectious diseases due to its adverse influence on pharmacokinetic and pharmacodynamic properties of drugs, and their efficacy and safety. Obesity also impairs the protective immune response to virus infection and vaccination, as seen with influenza, through alterations of cellular immunity.7 8 Higher BMI is associated with greater decline in antibody titres 12 months after vaccination and impairment of CD8+ T-cell activation and functional responses to ex vivo influenza virus challenge.7 Furthermore, vaccinated adults with obesity have twice the risk of influenza despite equal serological response compared with healthy-weight adults. The reduced immune response to vaccination can be detrimental not only to the individual but also herd immunity.
Global efforts at development of therapeutics for COVID-19 have focussed on drug-repurposing, immunotherapies including convalescent plasma and monoclonal antibodies, and vaccines. Despite obesity prevalence rates of 40% in the US, 29% in England and 13% globally, none of the several thousand clinical studies of covid-19 in international clinical trial registries to our knowledge proactively recruit participants with obesity. On the contrary, several studies consider overweight and/or obesity as exclusion criteria. We call for proportional representation of people with obesity in clinical trials of drugs and vaccines, including dose-finding studies.
1. Tan M, He FJ, MacGregor GA. Obesity and covid-19: the role of the food industry. BMJ 2020 doi: 10.1136/bmj.m2237
2. Patel P, Hiam L, Sowemimo A, et al. Ethnicity and covid-19. BMJ 2020;369:m2282. doi: 10.1136/bmj.m2282
3. Khunti K, Singh AK, Pareek M, et al. Is ethnicity linked to incidence or outcomes of covid-19? BMJ 2020;369:m1548. doi: 10.1136/bmj.m1548
4. Overweight adults: Public Health England; 2020 [cited 2020 16 Jun]. Available from: https://www.ethnicity-facts-figures.service.gov.uk/health/diet-and-exerc... accessed 16 Jun 2020.
5. Franco LP, Morais CC, Cominetti C. Normal-weight obesity syndrome: diagnosis, prevalence, and clinical implications. Nutrition reviews 2016;74:558-70. doi: 10.1093/nutrit/nuw019
6. Sattar N, McInnes IB, McMurray JJV. Obesity a Risk Factor for Severe COVID-19 Infection: Multiple Potential Mechanisms. Circulation 2020 doi: 10.1161/circulationaha.120.047659
7. Sheridan PA, Paich HA, Handy J, et al. Obesity is associated with impaired immune response to influenza vaccination in humans. International journal of obesity (2005) 2012;36:1072-7. doi: 10.1038/ijo.2011.208
8. Green WD, Beck MA. Obesity Impairs the Adaptive Immune Response to Influenza Virus. Annals of the American Thoracic Society 2017;14:S406-S09. doi: 10.1513/AnnalsATS.201706-447AW
Competing interests: No competing interests
Thank you for raising this pertinent point about the food industry's role in obesity, especially now that the awareness of the danger of obesity has grown with Covid-19. This increased alertness, along with the looming food policy and trade changes due to Brexit, make this a pivotal time to take action. You importantly highlight the fact that calorific, processed food is cheap. How can we make sure policy changes act on this problem without disproportionately affecting lower income groups? "Sin" taxes (on tobacco, alcohol, fat, sugar etc.) have historically been shown to disproportionately affect poorer families, and the sugar tax is no exception. Lower income households are more likely to consume sugary drinks and the evidence shows that higher prices are not enough to deter everyone from buying their favourite sugary beverage. As a result, poorer families are hit the hardest. Faced with an even smaller disposable income, how will they afford the more expensive nutritious foods that we promote? For this reason, it is imperative that taxation on "sinful" products is met with subsidies on healthier foods, such as fruits and vegetables. Otherwise, families will choose cheaper, yet still highly calorific brands, as has been the case in Sweden, Hungary, Germany, Finland and the USA.
As you mention, the UK government spent over £6 billion in one year (2014-2015) on direct consequences of obesity. Over time, part of this could be invested in a “healthy food” subsidy that would be attractive to the individual, industries, and the government and prevent, rather than treat, obesity-related disease. Government subsidy programs have been proven to enable emerging “green” industries to gain scale and relevance. Compare the UK government’s current “cycle to work” scheme (30% discount for bikers; 13% reduction in NI contributions for employers) and the US and German governments’ subsidies of their solar power industries. Such successes provide a model for obesity interventions. There is no better time to take action than now in this period of raised awareness and political transition. Thank you again for bringing this issue to the forefront at such a crucial time.
1. Ross J, Lozano-Rojas F. Are Sugar-Sweetened Beverage Taxes Regressive? Evidence from Household Retail Purchases [Internet]. Washington, DC: Tax Foundation; 2018. Available from: https://files.taxfoundation.org/20180618173927/Tax-Foundation-FF592.pdf
2. Sugar taxes: A Briefing [Internet]. Institute of Economic Affairs. 2016 [cited 16 June 2020]. Available from: https://iea.org.uk/wp-content/uploads/2016/07/IEA%20Sugar%20Taxes%20Brie...
3. Reid C. U.K. Government Boosts Bicycling And Walking With Ambitious £2 Billion Post-Pandemic Plan [Internet]. Forbes. 2020 [cited 16 June 2020]. Available from: https://www.forbes.com/sites/carltonreid/2020/05/09/uk-government-boosts...
4. Meyer G. US solar industry powers ahead as investors back batteries [Internet]. Financial Times. 2020 [cited 16 June 2020]. Available from: https://www.ft.com/content/ca578516-4d0e-11ea-95a0-43d18ec715f5
Competing interests: No competing interests
As the threat from the covid-19 pandemic appears to recede (at least in the immediate term), political attention is inevitably and quite rightly turning towards rebuilding the economy, future proofing against a possible second surge and helping the NHS get back to usual capacity. We must not however let preventative healthcare become neglected.
Interventions to enable the population to source inexpensive and healthy food, to increase food preparation skills, and to increase the accessibility of activities that improve fitness are crucial not only in reducing the population risk from covid-19 but also in reducing the inequalities entrenched by the pandemic.
Further, reducing the morbidity associated with obesity can only be economically beneficial by increasing population levels of health, freedom from illness and improving the population's ability to engage with society and employment. When thoughts turn to stimulating the economy by investing in infrastructure, let us fly the flag for stimulating the economy by investment in preventative healthcare, to help our patients and our country along the long road to recovery after the pandemic.
Competing interests: No competing interests
To complement our editorial, we illustrate with this Figure (link: http://www.actiononsugar.org/media/actiononsugar/Picture-1.png) the current situation created by the global food industry, and the actions required from both the public and private sectors to remedy it in order to improve the diets and risk factor levels in populations, and ultimately reduce our susceptibility to COVID-19 and all of the other consequences of obesity.
CURRENT SITUATION: we live in food environments where we are surrounded by cheap sugar sweetened beverages and ultra-processed foods that are very high in sugar, fat, and salt and provide little satiation. This is the result of aggressive and unchecked marketing, promotion, and advertising from the food industry. This leads to poor diets and to the majority of the population now being overweight or obese, thus putting us at a much higher risk for both chronic diseases (e.g. type 2 diabetes, cardiovascular disease, cancers) and infectious diseases (e.g. COVID-19, H1N1).
ACTIONS REQUIRED: over the short term, healthier diets could improve our immune response and over the longer term, help weight loss. Governments must now seize this opportunity to force the food industry to produce foods with less sugar, fat, and salt and immediately cease all forms of marketing of unhealthy foods. In addition, clear labelling must be mandated and fiscal measures adopted, building upon the success of the Soft Drinks Industry Levy in reducing sugar in soft drinks.
Competing interests: FJH is a member of the Consensus Action on Salt & Health group, a non-profit charitable organisation, and its international branch, World Action on Salt & Health, and does not receive any financial support from the Consensus Action on Salt & Health or World Action on Salt & Health. GAM is the Chairman of Blood Pressure UK, Chairman of the Consensus Action on Salt & Health, and Chairman of World Action on Salt & Health and does not receive any financial support from any of these organisations. Blood Pressure UK, the Consensus Action on Salt & Health, and World Action on Salt & Health are non-profit charitable organisations. MT declares no competing interests.