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
- J Bernadette Moore, associate professor of obesity,
- Charlotte EL Evans, associate professor in nutritional epidemiology and public health nutrition
- Correspondence to: J Bernadette Moore
Framed in the context of evidence that obesity increases the risk of severe complications and death from covid-19, some long overdue aspects of the obesity strategy are welcome. These include restrictions on the promotion, by volume (such as buy one get one free) and location (near check out) of foods high in fat, sugar, and salt, as well as a ban on advertising such foods before 9 pm on television and online.
Nonetheless, with further consultation planned and a long timeline for implementation (end of 2022), impatience remains justified. The evidence that food marketing through advertising and product placement has an adverse effect on people’s food preferences and consumption patterns is irrefutable. The World Health Organization made strong recommendations against such marketing a decade ago to protect children,3 as has Public Health England—first in 2015 and again as part of the childhood obesity plan, promising consultation “before the end of 2018.”45
Political will has always been influenced by factors other than scientific evidence (tobacco is an obvious example),6 and restrictions that were originally included in an obesity plan developed by David Cameron’s administration were not included in the much weaker version released in 2016 by his successor Theresa May.7 Although the current political momentum under Boris Johnson is welcome, that it depends on the prime minister’s own brush with covid-19 is disturbing.8
Equally worrying, the obesity strategy’s “call to action” still emphasises individual willpower and personal responsibility in its promotion of a weight loss app and food labelling. This ignores the biological, social, and environmental determinants of obesity,9 and fails to acknowledge the physiological adaptations to weight loss that make long term maintenance of weight loss challenging without ongoing support.10 Pledges to expand weight management services are welcome but difficult to reconcile with the steep reductions in local authority funding for public health that have occurred in the past five years.11
Any efforts to control obesity should consider socioeconomic and health inequalities. Interventions that use information to improve diet and reduce obesity (mass media campaigns, nutrition labelling, referral to weight loss programmes) will benefit only people with the time and cognitive, psychological, and material resources required to engage.12 Interventions requiring high personal agency favour those with socioeconomic advantages and are likely to increase health inequalities further.13 Obesity, in particular childhood obesity, is closely linked to socioeconomic status: In England, the prevalence of childhood obesity at age 11 is 26.9% in the most deprived areas compared with 11.4% in the least deprived. This gap has widened dramatically over 10 years, from 9% in 2007 to 15% in 2017 when the last data were available.14
Moreover, cuts to public health funding have disproportionately affected deprived communities,13 as has covid-19.15 Food insecurity in households with children has at least doubled during the pandemic, and the crisis of health and social inequalities related to nutrition was underscored in the National Food Strategy review.2 School meals contribute substantially to children’s overall diet quality,16 and the Food Strategy report makes urgent recommendations for the expansion of free school meals and holiday food programmes to all households in receipt of universal credit. It is disappointing that it took the efforts of a popular footballer, Marcus Rashford, to convince the government to provide meals during school holidays to even the poorest children in households with incomes less than £7400 (€8200; $9700) a year.17
Currently, more than 30% of children in the UK live in poverty, 20% of those aged 10-11 are already affected by obesity, and there are more UK adults with overweight or obesity than normal weight. The relationship between food poverty, poor nutrition, and obesity is clear, and the need to better prevent and manage obesity, reduce health inequalities, and improve food security is unarguable.
We echo the recent Marmot review that pre-dated the covid-19 economic crisis13—a national strategy on health inequalities is urgently required, and equity considerations should be at the heart of all policy relating to food, diet, and obesity. Strong leadership and concerted action are now needed to transform the UK’s food system and reverse the current trajectory in health inequalities.
Provenance and peer review: Commissioned, not peer reviewed.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: None.