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" Tackling obesity is fundamentally an issue about healthy and sustainable living for current and future generations. This is only likely to be achieved if there is a paradigm shift in thinking, not just by Government but by individuals, families, business and society as a whole"

" In order to reduce excess weight in the population, we need a society where we eat fewer calories and are sufficiently physically active that we use more energy than we consume"

Where we are now?

Scotland has one of the highest levels of obesity among OECD (Organisation for Economic Coordination and Development) countries, second only to the United States. By 2003, 24% of men and 27% of women were obese, rising from 16% and 19% in 19951. Almost two thirds of Scottish adults and a third of children are now overweight or obese. In Lothian approximately 150,000, adults are clinically obese and we can already see increases in obesity amongst diabetics.

The rise in the number people who are overweight and/or obese has serious consequences for individuals' health and wellbeing and for society as a whole. Individuals who are obese have a 50 - 100% increased risk of premature death from all causes compared to people who are not overweight2. Their excess mortality is greater the more severe the obesity and the earlier in life it develops3. The disease burden of obesity is similar to that of smoking. It is estimated that 42% of type II diabetes, 36% of hypertension, 18% of myocardial infarctions, 15% of angina, 29% of colon cancer and 14% of endometrial cancer are due to obesity4.

Obesity is also linked to depression, anxiety and social isolation5. In addition, people who are overweight and obese are often stigmatised and bullied with an increased proportion of obese children having poorer educational and social outcomes6.

Existing approaches to tackling obesity - too little, too much, or the wrong sort

Evidence shows that a broad set of social and environmental changes have combined to promote consumption of energy-dense diets and a more sedentary way of life7. This has been termed the 'obesogenic environment' (see Box 1).

[ Box 1 ] Current advice for physical activity

Physical activity does not need to be strenuous to have significant benefits for health and wellbeing8:

  • Every adult should accumulate 60 to 90 minutes of moderate-intensity physical activity on most, preferably all, days of the week; and
  • Every child should accumulate at least one hour of moderate activity on most, preferably all, days of the week.

'Moderate intensity physical activity' is using about five to seven calories a minute - the equivalent of brisk walking9

Traditional approaches based on individual behaviour change or treatment provide, at best, a partial response. We need to be making changes to our physical, social, work and leisure environments so that individuals' physical activity is increased to a higher level than current guidance and our intake of energy-dense foods (such as fats and sugars) reduced so that we are using more energy than we are consuming. That way, we will start using up fat reserves to meet the body's energy demands.

To help us make progress as a population, the UK Government's Office for Science published a Foresight Report on Tackling Obesity in 20071. Foresight Reports provide an in-depth review of areas that require action cross government and across society to deliver an response to current and future challenges.

The link between increasing alcohol use, its impact on social cohesion and capital was outlined in chapter 3.2 - Mutual Aid and Alcohol Recovery. Alcohol use increases energy intake and the chronic low level excess alcohol intake that is common in Lothian increases the risk of obesity. It is hard to see an area for public health intervention which is more in need of a mutual approach to its resolution.

Eat, drink and be healthy

Most people know about the 'five fruit and vegetables a day' message with 65% of adults aware of it in 200510. The lack of progress in meeting dietary targets simply confirms that knowledge alone does not change behaviour. Implementing the Scottish Diet Action Plan10 is essential but is only one part of the policy response required. Expecting every individual to comply with it without tackling food price, availability, and composition is not a sustainable approach.

Many of the influences on what and how we eat are beyond the scope of the framework set out in the Scottish Diet Action Plan10. Current thinking supports a new approach to food and health work, one which builds on good, smallscale practice and establishes new areas of activity, alongside action by governments and the food industry. There are examples of interventions elsewhere that support the development of a local, sustainable and healthy food system11. These include work to grow and provide organic food to schools,12 develop local food chains,13 and make locally grown food accessible and affordable to local communities. In England, DEFRA has a programme supporting sustainable public procurement of food14.

[ Box 2 ] National Targets in the Scottish Diet Action Plan11:
  • Average intakes of fruit and vegetable consumption should double
  • Total complex carbohydrates should increase by 25%, including consumption of breakfast cereal to double and bread to increase by 45%
  • Total fat should reduce to <35% of food energy and unsaturated fat to <11%
  • Salt should reduce to <6g per day in adults with much lower levels in children
  • Consumption of added sugars should reduce by half in children and not increase in adults
  • White fish consumption should be maintained and that of oily fish should double; and
  • Breastfeeding should increase to a target of more than 50% at 6-8 weeks of age

At the local level, food co-operatives provide affordable fresh fruit and vegetables in low income communities and could develop into community food distribution systems. For example, Edinburgh Fareshare15 is one example of a new - more mutual - approach that provides food redistribution, and links emotional and social capacity building with food provision through volunteering and training in food hygiene and cooking skills11.

The procurement and provision of food by statutory organisations, including the NHS and Local Authorities, has a direct effect on the diets of the people eating the food, improving their diet, providing opportunities for social interaction and reducing sickness absence rates. As large employers of people from all sections of society, health and Local Authorities can increase the availability of healthier food for staff and their families, regardless of income, as well as providing a positive role model for other employers. The Health Promoting Health Service approach sees every healthcare contact as a health improvement opportunity and can reinforce this message16. NHS Lothian and other public bodies can also act to provide healthy foods in catering, retail outlets and prevent advertising of unhealthy choices in NHS or Council premises, including hospitals, leisure and sports centres, and schools. All healthcare premises are expected to achieve the Healthy Living Award plus by 2011. To achieve the award seventy percent of the food served is based on healthy choices, and these must make up at least half of each menu section. Healthy-living choices must be promoted and the promotion of non-healthy-living items avoided. The amount of fat, salt and sugar must also be reduced. From a public health perspective, every meal offered should comply with Scottish Diet Action Plan guidance as a minimum.

However, all of this will need to be supported at a Scotland-wide level if we are to address the issues such as:

  • The capacity of the food industry to produce cheap, energy-dense foods in high volumes;
  • The marketing of fatty and sugary foods and drinks to the public;
  • The way in which food and alcohol is labelled and priced;
  • Changing our approach to agriculture and fisheries policy, food production regulations, alcohol and environmental policies in line with the Health in All Policies17 approach; and
  • Using a range of financial and other incentives to increase access to world class produce and cuisine in Scotland by more vulnerable populations.

Implementation will require recognition that to be a less obese society we need to be a mutual one as well.

Key messages

  • In order to reduce excess weight in the population, we need a society where we eat fewer calories and are sufficiently physically active that we use more energy than we consume.
  • We live in an obesogenic society. Slowing the inexorable rise in obesity requires changes in the built environment, the commercial environment, the policy environment, and the socio-cultural environment. Reversing these trends to achieve the necessary health and economic benefits in the medium term will require some difficult decisions.
  • To fulfil its statutory responsibilities to improve the health of the population, the NHS must be an exemplar employer and public health organisation.
  • Work is underway to develop care pathways allowing appropriate, targeted interventions for those people who are overweight and obese. This can only make a minor contribution to the wider, societal changes needed to achieve a sustainable, lightweight future.