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The increasing levels of obesity are a serious concern, given the levels of morbidity and mortality associated with obesity. It is estimated that obese people in Scotland are 18% more likely to be admitted to hospital than those of normal weight. Reductions in levels of obesity will lead to fewer hospital admissions, reductions in disability from osteoarthritis, reductions in asthma, hypertension and diabetes. Reductions in levels of obesity will also lead to levelling off of health inequalities.

The epidemic of obesity is now recognised as a global public health problem (1). The disease burden of obesity is similar to that of smoking. Preliminary analysis from the Institute of Public Health in Sweden (2) suggests that 4.5% of disability adjusted life years (DALYs) are lost in EU countries due to poor quality nutrition, with an additional independent loss of 3.7% and 1.4% due to obesity and physical inactivity. The total percentage of DALYs lost related to poor nutrition and physical inactivity is therefore 9.6%, compared with 9% due to smoking alone. With realisation of the health benefits of the introduction of the ban on smoking in public places, obesity will become a proportionally larger contributor to ill health in the future, unless it can be prevented.

In Scotland, 62% of men and 54% of women are classed as either overweight or obese (3). When obesity alone is considered, the figures for Scotland are: 19% of men, 22% of women, 8% of boys and 7% of girls. The Lothian Health and Life Survey (LH&LS) (4) showed that in Lothian, 52% of men and 41% of women were overweight including obese, with 13% of men and 14% of women being classed as obese. The LH&LS was self-reported so the true figure is likely to have been slightly higher. This explains why the Scottish Lifestyle Survey carried out in 2003 gave higher estimates in Lothian of 62.1% of men and 58.6% of women overweight including obese (5).

NHS Health Scotland recently published an independent review of the first 10 years of the Scottish Diet Action Plan (SDAP) (6). The review found that:

“…despite the considerable progress that has been made in implementing the SDAP recommendations, overall the action taken has not had a significant impact on population trends in food consumption and nutrient intakes in Scotland over the last 10 years…the dietary targets set for 2005 are overwhelmingly not being achieved.”

The review proposed four overarching strategic themes to guide Scotland’s future policy:

  • Closer integration between the policy goals of improving Scotland’s diet-related ill-health and those of social justice, sustainable development and agriculture. They suggest a new Sustainable Food and Health Policy;
  • The centrality of the principle of equality in this proposed new Sustainable Food and Health Policy;
  • The need to re-establish the grounds for engagement with the food industry in Scotland so that public health and sustainability are the over-riding drivers for food production and supply; and
  • The need to develop new multilevel governance structures, institutions and leadership.

Obesogenic environments

The term ‘obesogenic environment’ arose in the 1990s to describe an environment that discourages physical activity and encourages the consumption of energy-dense foods, high in fat, salt and sugar. Energy expenditure through physical activity may be purposeful exercise, or may take place secondary to some other primary purpose, e.g. transport, work or basic activities of daily living. The decline in daily levels of physical activity and a rise in sedentary lifestyles are increasingly seen as major factors contributing to the obesity epidemic in developing countries (1). People expend most energy when travelling under their own power – usually walking or cycling – and least when using cars. Increasingly efficient transport systems, combined with increasing levels of car ownership, provide little incentive to walk as part of daily activities. At the same time there is increasing evidence that the Scottish diet is low in fruit and vegetables but rich in high-energy, processed foods.

Health promotion aims to create situations where healthier choices are the easy choices. This means moving the focus from exhorting individuals (victim blaming), to one where we make changes to our physical and social environments that will encourage people to expend more energy and to enjoy a healthier diet. Changes to the environment which benefit health will shift the behaviour of large numbers of people and prevent them from gaining weight. As these changes require political will, they rely on good evidence for benefits. There is also a need to consider global influences on behaviour of multinational companies through changes to legislation and education. Placing health at the centre of Government policies and incentives requires development in the fields of transport, education, planning, culture, media, sport and public health.

Many of the adjustments we have tried to make to our environment have been described as marginal, for example, providing free swimming for children, building cycle paths and offering free fruit in schools and voluntary improvements to labelling on foods (7). This approach gives the impression that our environment, like our energy-conserving instincts, is something that we must battle against. But we have created our environment to reflect the values we have chosen as a society (7). The preservation and development of green space, plus a range of transport options including walking and cycling, will reverse this trend. The integration of parks, pathways, safe cycle track, allotments and public spaces into the urban fabric and the development of affordable housing in a wide range of locations accessible for work, needs to be pursued.

Planning for health

Achieving this is not such a fanciful notion. In recent years there has been a renewed interest in the links between public health, land use and spatial planning. This has been informed by research that suggests we now realise that how we design the built environment may hold tremendous potential for addressing the nation’s greatest current public health concerns, including obesity, cardiovascular disease, diabetes, asthma, injury, depression, violence and social iniquities (8).

Many of the major public health challenges will only be addressed if we engage with processes that shape our living environment. For example, the concerns about obesity, levels of physical activity, food and alcohol consumption, mental ill-health, heart disease and diabetes for example, can all be linked to decisions made as part of the planning process. This is not to suggest that planning is the source or solution to all such problems. Instead, it is recognition that we will not fully address many of these issues if we do not work alongside colleagues in planning and other professions.

In Lothian, we have pursued an approach which identifies the specific nature of the links through health impact assessment (HIA) and developing relationships with the planning authorities in the four local authorities. In this, we are seeking to ensure that we engage with major planning mechanisms that operate and the local plans that they produce – notably local Community Plans. We are also, with varying degrees of success, inputting to the planning processes for major new building developments planned across Lothian as new communities like these should, obviously, be healthy communities. In this way, HIA can be used as a tool to forecast the potential health impacts of policies and plans and how they may be distributed through the population. One of our problems however, remains the relatively limited value placed on health concerns within the planning process. It is very encouraging therefore, that the Royal Commission on Environmental Pollution recommended that the UK government and devolved administrations “develop a statutory framework for including Health Impact Assessments in the planning process” (9). Our most pressing need is to work with our local authority colleagues to highlight developments or proposals that have potentially significant health effects. When we think there may be significant health impacts, we try to carry out more detailed assessments of proposals and make suggestions about mitigation or improvements that will enhance the health benefits of proposals and make the plan itself better.

To date we have completed detailed HIAs of proposals for the regeneration of Craigmillar and the new town at Winchburgh in West Lothian. At present we are trying to engage with planners to ensure the major developments across Lothian are healthy and sustainable.

So what does a healthy and sustainable place look like? Perhaps the most important statement on this topic is the Egan Report from 2004 (10). This report was commissioned by the UK Government to inform the massive housing development proposals across south eastern England. Egan suggested a model for sustainable places that bears a striking resemblance to well established models for health. (See Figure 1). People are very clear about what they want from their communities – places that are safe, clean, friendly and prosperous, with good amenities such as education, health services, shopping and green spaces. These priorities are widely known, and have been shown to work in successful communities that have built up over hundreds of years, but in too many places our current approaches and systems are failing to deliver what people want. There are some good examples of where we get it right, principally in the renaissance of city centres and in some individual places. However, in general, development is not resulting in communities in which people can live wholesome and prosperous lives, let alone experience a sustainable twentyfirst century.

Figure 1: The Egan Model of Sustainabie Communities (top) and the Dahlgren and Whitehead Model of Health (bottom)

Figure 1: The Egan Model of Sustainabie Communities (top)
and the Dahlgren and Whitehead Model of Health (bottom)

The Sustainable Development Commission in Scotland has also produced research that provides clear guidance on how we should pursue this work. Of course, delivering such communities is easier said than done, but in the past 30 or so years there has been little formal health input into the design of our urban environment. Public health input into town planning processes has been confined to management of health hazards and risks. However, there are now reasons to be more optimistic that specific health issues will be included in development. Partly, this is because there is now concern about the health and economics of an obesogenic environment as well as the existing concerns about climate change and peak oil* that are also driving policy. Public health professionals have started to collate an evidence base for what constitutes a healthy place (see the section on transport for an example). Planners and health professionals have once again started to work together. The Royal Town Planning Institute has run a number of seminars in the past two years that have focused on health, and professional planning magazines have focused on health this year (11). One of the most exciting future developments is the proposal to develop sustainable communities in demonstration towns across Scotland. The Scottish Government is exploring how to extend pilot work from England and develop a number of Sustainable Travel Demonstration Towns in Scotland (12). Clearly, it is to be hoped that Lothian communities will be part of these exciting pilot schemes. And this could be only the start: imagine the opportunities for planning environments that help to prevent and reduce obesity.

* ‘Peak Oil’ is described in detail in the last chapter of this report.


key points

Lothian is not unique, the prevalence of obesity has been increasing over the last 20 years in most developed countries including Scotland.

Lothian has an opportunity to prevent and reduce obesity through approaches which take into account the complex environmental factors that impact on physical activity and consumption of food. The Foresight project (www.foresight.gov.uk):

  • The obesity epidemic cannot be prevented by individual action alone and demands a societal approach.
  • Tackling obesity requires far greater change than anything tried so far, and at multiple levels: personal, family, community and national.
  • Preventing obesity is a societal challenge, similar to climate change. It requires partnership between government, science, business and civil society.

This is the challenge that faces us all.