Obese and hungry: two faces of a nationBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3084 (Published 06 August 2020) Cite this as: BMJ 2020;370:m3084
All rapid responses
Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. According to studies conducted by the World Health Organization (WHO) the global burden of disease has grown to epidemic proportions, and over 4 million individuals died each year as a result of being overweight or obese (WHO, 2020).
Rates of overweight and obesity continue to grow in adults and children. Data gathered for the period 1975 to 2016, revealed that the prevalence of overweight or obese children and adolescents aged 5–19 years increased more than four-fold from 4% to 18% internationally. Obesity was previously considered a problem only in high-income nations, overweight and obesity are now radically on the rise in low- and middle-income nations, particularly in the metropolitan settings. The vast majority of overweight or obese children live in developing countries, where the rate of increase has been more than 30% higher than that of developed countries (WHO, 2020).
With the COVID 19 pandemic this issue will continue to be a challenge as an important intervention utilized globally to combat the COVID-19 pandemic has been the implementation of social distancing. To enable this measure, governments have enforced interventions, such as lockdowns, in the public and private sectors. In countries with obesogenic environs, this outcome might exacerbate rates of obesity and obesity-linked metabolic comorbidities. Socioeconomic status and risk of obesity, a widening societal inequality propelled by the government strategies against COVID-19 might translate into an increase in obesity occurrence and metabolic diseases in groups with a lower socioeconomic status. This is as a result of an abundance of highly processed, energy-rich, palatable, cheap and readily available foods which promotes calorie intake beyond energetic needs, these foods are usually selected by persons with a lower socioeconomic status who have limited income and resources (Clemmensen, Petersen, & Sørensen, 2020).
This problem will be further escalated as person may also have lost their jobs and have to eat what is readily available to prevent starvation even though it may not be nutritional adequate. I agree with the writer regarding the notion that efforts to solve the underlying socioeconomic inequalities which dictate dietary and health choices are paramount to addressing obesity. I will also add that these individuals need to be in agreement with the stated solution for this to be a success. If this is not adhered to the pandemic will further escalate the epidemic of obesity. As home confinement during the COVID-19 pandemic affords a different food cue exposure, which could challenge the person’s mental restraint and increase impulsive eating behaviour.
Additionally, emotional eating is often used to relieve negative feelings, which might increase under these circumstances (Clemmensen, Petersen, & Sørensen, 2020). I am also in agreement that efforts to improve access to healthy foods are more important than policy which limits unhealthy dietary behaviours; as well as individual commitment towards reducing the occurrence of obesity/overweight as this is far more favourable that the consequences of it later in life.
Clemmensen, C., Petersen, M. B., & Sørensen, T. I. (2020). Will the COVID-19 pandemic worsen the obesity epidemic?. Nature Reviews Endocrinology, 1-2.
World Health Organization (2020). Obesity Retrieved from https://www.who.int/health-topics/obesity#tab=tab_1
Competing interests: No competing interests
Moore and Evans have emphasised the need to address socioeconomic inequalities to support the success of the government’s new obesity strategy, introduced as a result of the COVID-19 pandemic.1 The strategy describes policies such as the limiting of unhealthy food advertising and the introduction of calorie labels on foods sold in restaurants, cafes and takeaways.2 The strategy is a welcomed effort to address obesity in the UK, however the policy proposals do not recognise important factors underlying people’s dietary choices.
Efforts to solve the underlying socioeconomic inequalities which dictate dietary and health choices are paramount to addressing obesity. The UK government’s strategy is too reliant on the belief that all people in the UK possess the individual agency to make dietary choices and does not recognise the systemic issues contributing to obesity. Phenomena such as ‘food deserts’ are an important example of systemic failures leading to poor health outcomes.3 In the UK, 1.2 million people live in areas in which poverty, insufficient public transport, and a lack of large supermarkets limits their access to fresh fruit and vegetables.3 No amount of restriction upon unhealthy food advertising will provide those in ‘food deserts’ with the access to healthy food options.
Therefore, efforts to improve access to healthy foods are arguably more important than policy which limits unhealthy dietary behaviours. Overall, the UK government’s obesity strategy is focussed upon preventative measures and neglects systematic factors which can only be addressed through social and economic equity.
1 Moore JB, Evans C EL. Obese and hungry: two faces of a nation. BMJ 2020;370:m3084. doi:10.1136/bmj.m3084
2 Department of Health and Social Care. Tackling obesity: empowering adults and children to live healthier lives. 27 Jul 2020. https://www.gov.uk/government/publications/tackling-obesity-government-s...
3 What are the barriers to eating healthily in the UK? Social Market Foundation. 8 Aug 2020. https://www.smf.co.uk/publications/barriers-eating-healthily-uk/
Competing interests: No competing interests
The NHS plasters its message to the world, on Twitter:
Extra weight puts extra pressure on your body. Which makes it harder to fight against diseases like cancer, heart disease and now, Covid-19. Losing weight can help reduce your risk. #BetterHealth
These instructions are all-consuming, reductive and dangerous, from the point of view of more than 1.25 million people in the UK who have an eating disorders and the millions more who are at risk of developing one. Are we supposed to have better health and a better life, then, if we listen to our eating disorder and lose weight?
Overweight and obesity have been growing in the UK over the last 40 years, now affecting about 60-70% of adults and 20-30% of children. It is well documented that obesity is strongly related to deprivation, particularly in children. There have been repeated policy attempts at tackling the challenge of obesity. These have mostly focused on encouraging the population to restrict calories and increase exercise, but they have not yielded results. The potential harm for people who may suffer from, or are at risk of, developing eating disorders have never been considered, even though international data show that the prevalence of eating disorders and dieting has been increasing in parallel with the obesity epidemic.1-5 In the UK, there has been no national prevalence study since the 2007 Adult Psychiatric morbidity survey, which showed that approximately 6% of the population screened positive for an eating disorder, affecting all age groups and both genders. This is a largely hidden epidemic: a recent population-based study of women showed that 15% in mid-life had a diagnosable eating disorder, but the majority were not known to services.2
The new ‘Tackling obesity: empowering adults and children to live healthier lives’ strategy recommends the reduction of unhealthy product promotions and banning junk food advertising before 9pm, but it does not go far enough. There is still too much emphasis on individual choice and responsibility, instead of addressing systemic issues with policy interventions.
We are concerned about the ongoing emphasis on calorie labelling and calorie counting. Decades of guidelines promoting reduced calorie intake and increased exercise have been ineffective in halting the obesity epidemic,6 despite the amplification of this message through advertising in supermarkets, on television, in magazines and also in schools and hospitals. Low fat and calorie counted products have become ubiquitous, and are recommended and seen as the healthy option by the population, but they have quite clearly not stopped the obesity epidemic. Continuing with the same message is unlikely to produce a different outcome, and it may cause collateral damage by precipitating or worsening existing eating disorders. This is what our patients tell us, and what we see in clinical settings.
For example, the free NHS weight loss app promotes calorie counting for weight loss. This is based on an outdated idea that equates human metabolism and appetite regulation with a bomb calorimeter. Furthermore, the government proposes to extend calorie labelling to menus at restaurants and takeaway menus to ‘help people make healthier, informed choices as part of a balanced diet’. This idea is flawed and damaging, particularly for people who have (or are vulnerable towards having) eating disorders, for whom calorie counting is already an injurious, inescapable obsession. Teaching young people and the general public to watch or count calories can only breed disordered eating. Counting calories also detracts from good nutrition. The quality of calories is more important.7 For example, the calories from alcoholic or sugary drinks affect health and satiety very differently from those associated with minimally processed foods, high in protein or fats.
Neurobiological studies have shown that food cues activate the striatum in humans, the magnitude of these responses being regulated by metabolic signals independently of liking, and that this process regulates food intake according to energy requirement.8 Under normal circumstances, this mechanism prevents over- or under-eating.However, non-nutritive sweeteners, and combinations of sugars and fats, result in supra-additive effects.9 The use of non-caloric sweeteners disrupts the brain’s ability to accurately estimate the energy value of foods.10 These findings elucidate the biological mechanisms underlying the overconsumption of ultra-processed foods and are consistent with observational studies, and randomized controlled trial evidence.11, 12
As the former CMO’s report argued, the science is increasingly clear that it is changes in the living and food environment that are shaping everybody’s behaviour and making it much harder for the population as a whole to be a healthy weight. Research suggests that, in the UK, for most age groups, including children, more than half of the foods consumed are ultra-processed.13 14 Any successful national strategy needs to address the ultra-processed food environment as these products have been consistently shown to increase obesity and metabolic disorders by stimulating overeating.11, 15-17
Ultra-processed foods may be cheap, but the associated health care cost harms the economy, and there have been calls to regulate this market.18 International examples, such as Japan and Korea, show that there are successful alternatives. It is important to remove (or at least reduce) these foods from schools and hospital menus, and to replace them with freshly prepared food choices.
As a Patient Representative (Lorna Collins), I listen to my peers who have eating disorders. We are appalled by the government’s obesity policy, when it tells us that we need (and it is our responsibility) to ‘lose weight to beat coronavirus (COVID-19) and protect the NHS’. This is a confusing, counter-productive, damaging strategy. It re-enforces the singular focus on weight and food, bringing us shame, whilst celebrating restriction and loss. These are the things that maintain our eating disorders (the most fatal of all psychiatric illnesses). Going on a diet or shaming how much you weigh is never going to solve the far-reaching problems that cause obesity. Putting calorie labels everywhere will create a nation which is even more toxic and disordered with food. Food is an expression of (not the reason for) obesity and eating disorder crises. A far more extensive, integrative and accessible approach is needed to broach these parallel situations.
Lorna Collins and Agnes Ayton
Agnes Ayton is a Consultant Psychiatrist at Cotswold House Specialist Eating Disorders Service, and the Chair of the Faculty of Eating Disorders at the Royal College of Psychiatrists.
Lorna Collins is an expert by experience of eating disorders, Peer Support Worker with Oxford Health NHS Eating Disorder Service, and Patient Representative at the Royal College of Psychiatrists Faculty of Eating Disorders.
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Competing interests: No competing interests