Overcoming policy cacophony on obesity: an ecological public health framework for policymakers
T Lang Professor of Food Policy, Department of Health Management and Food Policy, Institute of Health Sciences, City University, Northampton Square, London EC1V 0HB, UK. E-mail: firstname.lastname@example.org
Like others, we see the recent rise in obesity as the result of past decades of societal, technical and ideological change. The pace and scale of change may only now be gaining attention, but the evidence has been strong for decades (1). Part of the search for solutions must be the investigation of not just what the drivers of obesity over time have been but how they interact. Too many analyses of obesity are locked into disciplinary ‘boxes’ when, given the complexity and breadth of such drivers, it is likely that obesity requires a broader interdisciplinary analysis and a sustained, society-wide response. By implication, ‘quick fixes’ or single-factor remedies are unlikely to work.
On a positive note, political processes are beginning to emerge giving due priority to the obesity crisis. In the UK, after a National Audit Office report and the Chief Medical Officer’s clarion call about obesity being a ‘timebomb’, the issue climbed up the national policy agenda (2,3). A Parliamentary Inquiry spelled out the complexity of the issues and gave suggestions for direction of travel (4). All the devolved governments of the UK now have commitments to tackle obesity. However, even the briefest review of recent trends shows the scale of difficulties.
In Scotland, childhood obesity is rising rapidly, with levels of overweight and obesity among younger and older children at double the levels that might have been expected on the basis of data for the UK as a whole (5). Currently in Scotland, 26% of women and 22% of men have a body mass index (BMI) of >30 and 65% of men and 60% of women have a BMI of >25 (6). Data from the Scottish Health Survey 2003 reported that people living in the most deprived areas were more likely than those in the least deprived areas to be obese or morbidly obese, and morbid obesity was three times higher among women in the lowest-income households than in the highest.
In England, the 1992 Health of the Nation, the English national strategy for public health, introduced a target to reduce the proportion of obese men aged 16–64 in the population from 7% in 1986–1987 to 6% in 2005, and obese women from 12% in 1986–1987 to 8% in 2005. A 1996 review of the Health of the Nation by the National Audit Office showed that by 1993, the proportions of obese men and women in the population had risen to 13% and 16% (7). By 2003, 22% of men and 23% of women were obese (8) and by 2010, on these trends, obesity will rise to 33% of men and 28% of women. Childhood obesity in 2–10-year-olds has risen from 9.9% in 1995 to 14.3% in 2004. On current trends, 20% of 2–10-year-olds – more than 1 million children – will be obese by 2010.
In order to redirect these trends, the Government in England, through the Department of Health, is currently promoting a new initiative based on social marketing called ‘Small Change, Big Difference’. Although this differs from the US approach to social marketing, which focuses heavily on changing individual behaviour, it is nevertheless still framed in terms of the personalization of health choice (9). The Government in England introduced a new obesity target for children (‘halting the year-on-year rise in obesity among children aged under 11 by 2010 in the context of a broader strategy to tackle obesity in the population as a whole’) initially focusing on children aged 2–10 years, and their parents and carers. Given the shallow reach of the National Health Service (NHS) into local communities, growing attention is given to the role of local government, with obesity prevention inserted into Local Area Agreements (LAAs), the national-local framework for service delivery. One example of an LAA obesity target is for the northern town of Barnsley. Agreed in July 2005, this sets a maximum prevalence target for obesity of 15.5% for children aged 2–10 years (10). This figure is all the more striking given that the prevalence of obesity in 1984 among 4–12-year-olds in England was 0.6% in boys and 1.3% in girls (11). Other LAA targets relate to precursors of obesity, such as participation in sports or access to free school meals. The implication, perhaps, is that an ambitious target would not be likely to be achieved.
The figures for most of Europe may not be as alarming as for the UK. Nevertheless, they are moving in the same direction. In policy terms, there is manoeuvring and ‘testing’ of strength of feeling and options. Targets are also being set, but as yet – as in the UK – there are few strong interventions to deliver them. Currently evolving policy frameworks, including that of the European Commission’s obesity Round Table, which draws on its 1996 Amsterdam Treaty health powers, appear ‘soft’ rather than ‘hard’, and rely on goodwill and voluntary action more than structural, regulatory or fiscal change (12).
The problem of policy cacophony
There are many competing diagnoses of what ‘really’ matters in obesity generation. Different analyses and policy solutions have been developed and proffered, each clamouring for support, funding and adoption. The increasing sophistication of different positions actually adds to the complexity of the policy challenge. For policymakers, now worried about the cost of obesity (and the spectrum of ailments linked to it, such as diabetes), there is a situation we describe as policy cacophony – noise drowning out symphony of effort. This cacophony is not helpful because policymakers need coherent directions on which they feel they can deliver. Obesity policy is already weighed down by complexity, accentuated by the multi-level (global, European, national, regional and local) nature of modern systems of governance. It is also shrouded by ideological fears such as interventions being interpreted as ‘nanny-ish’ or restricting ‘personal’ choices in food and lifestyle.
Compounding this policy cacophony are two other difficulties which this review sets out to address. The first is time frame. Obesity is a problem that has taken decades to develop. Bar sudden external shocks to society, such as a massive oil shortage or price rises that make walking a necessity, it is likely to take many years to bring it under control. Yet, the political timetable demands quick results. Second, there is a difficulty about evidence. No country has managed to reverse obesity trends, or at least not so far. To some extent, part of the obesity policy problem is the evidence, or lack of it. Yet, the rise of obesity is literally visible and the explanation and ways forward are hard to pinpoint. This does not mean we favour disregarding evidence, but rather that we see obesity as a test case for policy changes in advance of perfect evidence. Faint hearts privately muse that obesity is too complex. But we see obesity as akin to that of climate change – complex, yes – and demanding firm action, however hard that might be.
What is the problem?
Why is obesity a problem? Who is it a problem for? Where did it come from? These simple questions have to be asked. Half a century ago, in the years following World War II, millions of UK citizens and other Europeans went hungry, and obesity as a medical condition appeared little more than as a curiosity. These events framed British determination – and, for that matter, on both sides of the Iron Curtain – to rebuild agriculture (albeit in different ways) (13–15). Even just a decade ago, with most of Europe more than adequately fed and European Union (EU) farming policy consuming almost half of the EU budget, the average politician might have remarked that obesity was an irrelevance. To find a comparable society suffering from obesity meant travelling to the USA.
Until just two decades ago, Britons flattered themselves that the UK, even with its constricted food culture, possessed factors that immunized it from US trends: smaller food portion sizes, cost-conscious purchasing habits, a less car-dominated society and, perhaps, too, a culture which supported personal resolve to maintain optimal body shape in a social environment less concerned with consumption volume. But the UK – and the rest of Europe too – appears to be steadily succumbing to what is sometimes unfairly called the ‘Americanization’ of diet and society: the rise and rise of car culture and other technical ‘advances’ marginalizing daily physical activity; widening distances between homes and work or shops; the over-consumption of food accompanied by its unprecedented, plentiful availability; the culture of clever and constant advertising flattering choice; the shift from meal-time eating to permanent ‘grazing’; the replacement of water by sugary soft drinks; the rising influence of large commercial concerns framing what is available and what sells; and more (16–19).
Today, the rise in population weight in the UK remains behind US trends, but only as a matter of degree. Copious evidence exists that both adults and children are affected by rising weight. The UK is now one of the leading countries for population weight gain, although there is still considerable variation in trends across Europe (20). Most worryingly, the biggest national weight increases among children have been in countries such as Greece and Spain, previously justly celebrated for their Mediterranean diets, high in vegetables, pulses and unrefined carbohydrates, culturally close to the land (21). While this needs to be researched, it is possible that a transition to a diet composed of energy-dense foods (high in fat and low in fibre) makes speediest headway in countries that have had high income growth and exposure to more commercialized food pressures. Obesity is emerging in places with supposedly strong and protective food cultures.
Although obesity is highly complex, there are some core truths on which thinking can be developed. We suggest the following:
- • Obesity is not just a phenomenon of the UK. Rates are rising across Europe but there is a particularly worrying acceleration of rates among children (22).
- • Obesity is known to lead to medical problems, long documented although only formally classified by the World Health Organization (WHO) in 1997 (1).
- • There are serious and rising social and financial burdens stemming both directly and indirectly from obesity (23).
- • Obesity is linked to other societal trends and risks, such as changed food production, motorized transportation and work–home and lifestyle patterns (1,4,24,25).
- • Policymakers have been slow to recognize the seriousness of the issue, which suggests the public health movement has been slow or ineffective in its advocacy work or that the evidence is not easily translatable into policy or lacks political champions (26,27).
- • Remedies based on individual action alone, whether diet plans, surgery or stigma, have limited effectiveness in population terms and often come at a high cost. Part of the difficulty in generating effective policy is having a policy package that will deliver a corrective population-wide shift (20,28,29).
- • There is a powerful temptation in Government to limit actions to a choice-based, personalization approach, in part because this style of intervention is aligned to the commercial sector’s own customer management and marketing methods, but also because a cross-society approach appears so big in conception that failure is assumed (30,31).
- • Both in the UK and more widely in Europe, and despite some welcome initiatives (9,32), there are, as yet, no comprehensive structures or set of policy models for what to do about obesity. There is as yet no Finland or North Karelia project doing for obesity what that country did for tackling premature diet-related ill health from the 1970s (33). We are generally still at the ‘talking stage’ of policy, albeit with some specific initiatives and a child obesity target, rather than well into implementation.
- • Food companies are not adequately changing their behaviour in response to the request to do so by the WHO under its Global Strategy on Diet, Physical Activity and Health. On the contrary, there is evidence that the big food companies are for the most part unconcerned (34).
The complexity that obesity raises for governance: who decides which policies?
For all the above reasons, obesity has to be seen as not just a technical, food, physical activity or healthcare problem but a challenge for what sort of society is being built. This is why obesity is beginning to engage social policy interest (30). The deceptively simple issue of how to encourage physical activity across daily life and modify dietary intake in fact raises complex questions about the need to reshape public policy across a number of areas. These include:
- • agriculture – because policy affects what is produced;
- • manufacturing – for ingredients, portions and products;
- • retail – for planning, prices, availability and location;
- • education – for health knowledge and skills;
- • culture – for the shaping of consciousness around food and physical activity;
- • trade – for product pricing and terms of trade;
- • economics – for differential taxation and subsidy of foods.
Part of this complexity is how to judge what is the appropriate level for policy action and intervention. Who is responsible – local, national or international governance? And how radical or limited should policy be? Small, incremental, publicity-driven (i.e. social market-based) changes might suit the existing balance of policy interests, but what if evidence suggests that a more extensive, co-ordinated, cross-sectoral action would be more effective? There may be little payoff from working on one aspect of obesity without tackling other determinants as well (4). The challenge is to produce policy analyses and solutions that work across policy boxes not just within them.
And, again, there is the problem of evidence. Despite the persistent calls for evidence-based policy, obesity illustrates the gap between policy and evidence (35). How much evidence of prevalence and impact will it take for policy to change? How might that be accumulated and interpreted? Where is the role model (again, Finland’s North Karelia project) for obesity that might encourage policymakers not to be fatalistic about obesity? (Might it be Sweden this time?) Is a beacon country even possible in a globalizing world? The Finns tell us they could not do today what they undertook 30 years ago; today’s policymakers lack control over media (advertising, lifestyle), agriculture, or the cultural coherence that they had then. And is modern policy reliance on consumer choice as a driver of change adequate to deal with obesity, especially given the vulnerabilities of social class, sex, age and genetics? Will better food labelling, despite all the attention given to it, have any sustained, positive effect? Or might prices that internalize currently externalized health costs be a better option (36,37)?
These and many such questions explain why obesity is a major challenge not just for European medicine and public health but for governance, the art and practice of government and decision making, let alone shifting food supply patterns. It is also the reason why the appeal for policymakers of taking a science-based, though in fact medicalized, route of individualized treatment through drugs, therapy and, at the most extreme, bariatric surgery, is still considerable. If obesity is caused by a matrix of factors and policies beyond health, how can health policymakers win sufficient attention to ask other ministers to drive change? There is a risk of appearing to be doing something through a scatter-gun of announcements; these may include targets, new guidance – even if by the National Institute for Health and Clinical Excellence (NICE) – or research grants in pursuit of wonder drugs or technical fixes such as functional foods or nutrigenomics. Obesity prevention could even evolve as a major research and policy intervention ‘industry’– with mounting expense to the public purse, but unable to deal with the fundamentals. It may only endlessly address symbols and symptoms rather than causes.
Even as the scientific understanding of obesity gets more sophisticated, the overall policy situation becomes potentially more muddled. The lack of solid evidence can lead to uncertainty over what action to take (4,38,39). Political leadership in the name of public health is sorely needed. It was effective in kick-starting debate (3), but the extent of change needed requires more than heroics. It requires an entire culture shift by society, supply chain and government. No wonder obesity is such a thorny problem for policymakers. The public health world’s divided and confused messages have not helped. More policy-oriented research and thinking is needed to help the policymakers (28). More research is also needed to demonstrate the consequences of leaving the situation to itself.
Culture: the ‘Cinderella’ public health dimension
At its simplest level, obesity policy thinking has to centre on the need to tackle diet and lack of physical activity. The scientific endeavour is about unravelling their complex interplay. We have argued elsewhere that the resulting policy focus on biology or social aspects of diet and physical activity has tended to underplay the cultural dimension that bonds diet and physical activity (30,31). Obesity is the manifestation of inappropriate societal structures framing what people eat and what they do. Such structures are expressed in terms of both physiological (body) and consciousness (mind) processes.
Among the conceptual models around obesity, the insightfully termed ‘Nutrition Transition’(40–42) appears the strongest. It has emerged as a central focus of research and policy thinking in the developing world and within the WHO. However, we think that, despite its strong merits, it deserves to be unbundled. The Nutrition Transition is not one process but, in our opinion, three transitions of:
- • diet;
- • management of, and human interface with, the physical environment;
- • culture.
These three transitions overlap, combine and amplify each other. We see reduced chances of any obesity policy being effective unless all three are tackled. We therefore argue that policy interventions should be judged from the perspective of these transitions, rather than in some isolated or disconnected way that has the potential allure of inoffensiveness or apparently quick results.
What wins the attention of policymakers? (Is it only monetary costs?)
We restate the question: why is obesity a problem, and who is it a problem for? The short answer is that obesity is an individual’s physiological and personal problem (which they may see as normal rather than as a problem) that becomes society’s problem. Although the media narrative often promotes tales of uncontrolled personal consumption and revels in the sheer visibility of obesity, the issue that consistently wins attention in policy circles is the issue of costs. Obesity’s burden on health care, health insurance (in the UK, tax) and pension systems is already under pressure in rich societies and is potentially unbearable for less rich societies.
The USA, as ever, sets the trend. Overweight and obesity afflicts respectively two-thirds and one-third of the US population, but a possible one-fifth of US healthcare expenditures will have to be devoted to treating the consequences of obesity in the future (43). The US Surgeon General notes obesity costing up to 6% of healthcare budgets, a figure now exceeding $100 billion (44). Obesity might soon overtake the toll of tobacco (45). Over and above direct costs, there is the impact of decreased household incomes, earlier retirement and higher dependence on state benefits, which overall are likely to exceed the medical costs alone (46). These trends will be compounded as the weight problems of children and teenagers converts into lifetime disease, mental health and other social costs (47).
Such calculations can be made for Europe too. Obesity was estimated to account for 2% of total French healthcare costs by 1995, long before obesity became a dramatized narrative (48). In England, the National Audit Office estimated in 2001 that obesity cost the NHS an annual £480 million (€720 million) and the wider economy a further £2.1 billion (€3.2 billion) (2). By 2004, that cost was estimated to have risen to £3.3–3.7 billion (€4.95–5.55 billion) for obesity alone and £6.6–7.4 billion (€9.9–11.1 billion) for obesity plus overweight (4). In the Netherlands, a 2004 study estimated that the proportion of the country’s total General Practitioner expenditure attributable to obesity and overweight was around 3–4% (49).
Alive to these EU member-state trends, the former European Commission (EC) Commissioner for Health and Consumer Affairs cited US evidence as a warning to Europe, stating in 2003 that ‘[i]t will take nothing short of a behavioural revolution to stop this epidemic in its tracks’ (32,50–52). Such statements are welcome signs of political interest, but how exactly is Europe’s behaviour to be changed dramatically enough? In these societies, is not the consumer sovereign? This is where social marketing’s rising appeal lies. It emulates conventional marketing, tailored to socially defined goals (53,54).
Policy advice: choose your theories carefully
Part of the difficulty of translating evidence into policy stems from cacophony. Obesity can be theorized in various ways and is fissured by significant ideological distinctions: individual/societal, physiological/psychological, economic/cultural, short-/long-termism and more.
Governments subscribing to the power of individualism tend to propose public health strategies nuanced around consumerist ethics. Hence, again, the attraction of social marketing. Social marketing, which has its core precepts in faulty individual behaviours and beliefs, contains the rhetorically uncomplicated appeal to consumers to make ‘healthy choices’ in the marketplace. While having considerable appeal – using market mechanisms rather than confronting or critically amending markets flows with the ideological times – even supporters are aware of limitations as to its effectiveness (55). Social marketing is not a panacea for inaction elsewhere in the policy world. If obesity is framed as an individual problem, the ‘solution’ will be focus on personalized interventions (56). In circumstances of free information circulation, people ‘choose’ to be overweight simply because they eat too much and do too little (57). The implication is that a vastly growing proportion of the population, from their own volition, are ‘choosing’ to gain weight. In fact, such propositions are deeply flawed. The existence of the diet industry (special foods, diet books, clubs, etc.) suggests the very opposite is the case. Population weight gain is occurring in conditions of growing ‘health consciousness’.
If the individual choice argument underlying social marketing incurs difficulties in analysing adult obesity, it fails spectacularly for children. While private choices are necessarily part of the total explanatory picture for adults, the well-documented rise in childhood obesity – nationally, regionally and globally – means that this highly individualized perspective cannot be applied so simply. Children’s choices are, for the most part, determined by features of the adult-framed environment encompassing diet, physical activity and culture (58,59).
Between individualist perspectives and environmental perspectives – or what we term the ecological public health approach (60) – lie a number of other theoretical approaches (30). Some have been devised explicitly to identify and help us comprehend the determinants of obesity. Some draw on other fields of inquiry. Some are heavily ideologically framed, even when couched in science. Table 1 summarizes some of these theories and examines their core arguments, evidence and proposed solutions. The problem for policymakers is that no single theory offers clear-cut solutions.
Table 1. The policy implications of some key obesity theories
|The predisposition to lay down fat is an evolutionary legacy||Predisposition by phenotypes is calculable (61). The GAD2 gene (on chromosome 10, human genome) may interact with and speed up brain neurotransmitters, which then activate part of the hypothalamus, stimulating people to eat (62)||Genomics, gene mapping and |
nutrigenomics. Functional foods might help play a part in tailoring diets to individual predispositions
|There is a danger of searching for pharmaceutical or bariatric solutions. Technological solutions are unlikely to resolve societal problems. At best, they are a ‘sticking plaster’|
|Lifestyle change is associated with development of a|
post-industrial consumerist society
|Fatty foods are relatively cheaper|
than health foods (20,63). There
is a spread of US-style fast foods.
There is oversupply of fats and
sugars compared with WHO/FAO guidelines (64–66)
|Once sufficiently affluent, people|
will be able to tackle obesity as
consumers, choosing or not,
as they wish. At the micro level,
fiscal measures such as ‘fat
taxes’ could be considered (37)
|There is some fatalism that obesity is an inevitable consequence of progress|
|Oil as a source of energy is replacing food as source of energy||Fossil fuels are replacing human/animal motor power (67). |
Human physical activity levels
decline with societal affluence (68)
|Build in more physical energy |
use into daily life. Design
technology to help keep intake
in balance with expenditure
|Food companies selling sugary, fatty foods tend to like this theory. They sponsor sports and physical activity|
|Cultural change||Marketing and advertising |
installs new cultural norms
about what and how to eat, and how much to eat
|There has been a worldwide |
growth in advertising foods and
soft drinks. Advertising changes
food cultures (69). Snacking
|Social marketing can |
emulate ‘business’ marketing
|Public health organizations lack sufficient budgets to compete with the food industry. McDonald’s and Coca-Cola’s marketing budgets are each twice the WHO’s full-year |
|Psychosocial||Food choice is intensely |
personal and expresses
identity. Obesity suggests
a schism within identity well-being
|Obesity has grown despite cultural obsession with thinness and beauty (71–73)||Family change. Counselling. |
This is required both individually
and on a mass scale (74)
|This has a tendency to become a solution on individualistic rather than population basis|
|Obesity is a normal |
to an abnormal or
|Physiology is developed to cope |
with under-supply, not today’s
coincidence of over-, mal- and
under-supply and decline in energy expenditure (60,75)
|Change the physical and dietary environments to allow normal physiological balance to |
|This approach is arguably the most attuned to social policy thinking|
|Rising income leads to dietary changes, leading to shifts in disease patterns||Many studies in developing countries suggest the transition |
does occur (76–78)
|It is probably too late to prevent rising obesity||The Nutrition Transition is a nutrition analysis of cultural, social and technical change|
Policy cacophony: the implications of different models
We view the policy complexity suggested in Table 1 as a critical starting place for analysis as the differences between the models help explain why obesity is so problematic and why an alternative, unified model is so necessary. Differences of cause attribution imply differences of strategy and solutions. And, vice versa, different interests are drawn to models that reinforce or suit their predilections. Commercial interests often (but do not always) favour individualized models, just as public health practitioners often (but do not always) favour population-oriented models. Each of the models has a reasoned basis and is backed by different academic, professional, commercial and civic sources. The net result is cacophony, with models competing for policy attention, dominance and funds. This cacophony makes policymakers cautious, demanding stronger evidence. This exposes the fact that evidence is only part of the problem – equally important is the thinking guiding how evidence is interpreted.
The key question is: which model provides the best, most practical way ahead? Surprisingly, comprehensive answers are scarce (28). To expect any might even be premature; strategies have not yet been applied for long or extensively enough for evidence of dramatic change to emerge. Even if, for example, a drug is proven to work at the individual level, its impact across the population cannot be assumed. Even if a ‘statin’ for obesity emerges, whose responsibility is it to implement a mass prescription: the state, the individual citizen (or civil society as a whole) or companies and the marketplace? Policy viability is not just a matter of what works, but what works in a manner that governments, business and people will find acceptable.
How good are policy responses so far?
Summary of intervention trials suggests some limited gains can be made (79). But, at the important population level, policy responses to obesity have generally been weak. Standing away from the politics, most obesity analysts agree that responses are implicitly fatalist (accepting inevitable rises), palliative or single-factor focused, or else drawn to crisis intervention (in extremis, recognizing the efficacy of bariatric surgery) (26). Variations between countries’ obesity rates are variations in speed of generally upward trends, although countries with significant regulation, especially of the food industry, appear to have had less of an increase. While a few societies – again Finland might be mentioned – have made significant efforts to intervene in heart disease (80), so far, obesity has received no such startling population-wide success. It may take decades for such evidence to emerge.
The few intervention trials in prevention of obesity that focus on children or schools [in Crete, Agita Sao Paulo, Singapore, Minnesota (20)] give little grounds for unalloyed optimism. It has been suggested that strategies like Epode in France, a national to local model giving an important role to local mayors, or the community development approaches in Australia may in some instances be halting obesity, but there is little indication – although full evaluations have yet to appear – that they are reversing its impact. Although there is a literature of action on different factors such as price, marketing, education, supply (81), no mass societal policy intervention has taken a ‘full spectrum’ approach (80). Yet, most policy overviews suggest that efforts to combat the epidemic have to be society-wide, extensive and deep (20,79). In any terms, refurbishment of health promotion and health development is required, demanding significant alteration of supply chains, daily existence, indeed whole cultures.
The International Obesity Task Force has reviewed possible preventive measures (1,20). The thinking appears to be that actions can be useful but without overall policy coherence and political drivers, atomised initiatives are unlikely to deliver requisite change. What, for example, is the point of a Ministry of Health recommending change in fat consumption if agriculture continues to pour out excess fat, if transport policies make it hard to build exercise into daily life, if trade and economic ministries have policies that cut across or even work against public health efforts? No wonder health professionals feel beleaguered by the subject of obesity. If farm policies produce copious fat and sugar, how can their health promotion compensate? If heavy advertising associates soft drinks with fun and sports, how can social marketing funded by restricted state sources compensate for, let alone defeat, it? And what is the point of forging policy directed mainly (or solely) through governmental agencies such as schools or hospitals (i.e. by public procurement) if no serious obligations are placed on business, or if there is a framework of mutual recrimination? In societies where commercial drivers are deemed of higher value than state action, this policy focus looks myopic; the state sector is being used as a policy ‘sink’.
Obesity policy reflects disciplinary and societal fragmentation
European Union member states, like nation states worldwide, are justly jealous of retaining control over their own public health systems. And some governments are fearful of neo-liberal accusations that health interventions constitute what the neo-conservative press refers to as the ‘nanny state’, a state that treats its citizens as though they were infants (82). Yet, even in individualistic Britain, parents state they want support and protection for their children (83). If the state refuses to apply some protectionist principles, dietary choices will increasingly be set by the rhythm of the marketplace; and this is dominated by large players with massive marketing budgets.
The most heavily marketed foods are those typically associated with weight gain. Key role models in sports, like the Olympics themselves, are sponsored by fast-food and soft-drink companies. Coca-Cola and PepsiCo spent respectively $2.2 billion and $1.7 billion on worldwide advertising in 2004, a combined level of spending exceeding the WHO biennial budget for the same period. Put differently, those two companies each spend annually on marketing their few products and services about what the WHO spends annually on its entire health work globally (34,84). This is the financial context for the WHO’s Global Strategy on Diet, Physical Activity and Health (85,86). The food industry has long been judged to be collectively enormous, politically well networked, a subtle lobbyist, and major employer. So what chance have public health agencies and arguments with their levers for health? The policy stakes are high indeed.
The roles of the state, business and consumers
The analysis we have presented so far does not single out any one key causal factor. Rather, we have sought to depict a collective, systemic, failure. In Table 2, we set out an analysis that links these failures with obesity and the three broad transitions shaping it. Table 2 conceptually unravels the three interlocking, if differentially paced, transitions shaping obesity (31). It represents the immediate changes shaping obesity as, first, physiological (the body) and in the consciousness (the mind), alongside the three broad transitions grouped here as changes in diet, physical activity and culture. Policymakers might find it useful to acknowledge three kinds of failure – of markets (all actors throughout the supply chain), government (at all levels and across the range of instruments) and society or consumers themselves, who ultimately are the ‘eaters’. Table 2 acts as a broad checklist for the range and focus that any policy actions must seek to address.
Table 2. Failures and factors shaping obesity in ‘wealthy societies’
|Markets fail |
because they . . .
|• Highlight and over-|
supply particular taste
receptors (sweet and fat)
• Invest in technical fixes and single-factor solutions
|• Appeal to pleasure|
• Build brand value over nutritional value
• Exploit vulnerable
groups (e.g. children
and low income)
|• Produce an excess of inappropriate, energy-|
dense foods cheaply
• Offer only limited
investments in workforce training
|• Promote fossil-based fuels|
• Glamorise private
motor transport rather
than expenditure of
|• Market and mould mass |
• Barrage consumers with
energy-dense food and
drink as entertainment
|Governments fail because they . . .||• Adopt inconsistent modes of protection (interventions on sexual protection but not nutrition)|
• Are unwilling to
modernise public health
scope and capacity
|• Limit health education to become a minor partner of market information, |
of information flow and
|• Subsidise overproduction of fat and |
sugar compared with
• Emphasize food safety while semi-abandoning nutrition
• De-emphasize nutrition and food education
|• Oversee decline of |
(transport, public spaces, sports facilities)
• Prioritise car use in retail and transport planning.
|• Permit genderized and |
inadequate food literacy and skills
• Promote rights of
• Facilitate media transmission by paid marketing
• Confuse citizenship with
(everyone is equal in the market)
|Consumers fail because they . . .||• Disconnect appetite from need and satiety||• Adopt distorted images of body acceptability|
• Accept temporality (short-termism) of
|• Eat a price-led rather |
than nutrition-led diet
• Respond individually rather than en masse
to identity crises about
meaning and values
|• Bow to the ubiquity of the non-energy-expending material world (e.g. in travel to work/shop/school)|
• Are disinclined to build exercise into daily life
|• Consume rather than |
expend energy as the norm of consumer culture
• Participate in physical
activity by proxy (TV sports)
• Accept inequalities or indulge in victim-blaming
However, Table 2 is a simplification. Failures in the supply chain have occurred because of both market and extra-market factors. In the case of foods, a battery of policy measures that made sense in the 1940s and 1950s (subsidies and policy encouragement to increase output, measured by output per unit of capital or labour) today help create price signals that are inappropriate for health. The Common Agricultural Policy, for instance, has led EU countries into delivering excessive fats and destruction of fruit (87). The policy of encouraging the marketization of food supply has been a boon for processed product development and the creation of multiple ‘niche’ food items, but it has not built health into the heart of supply (88,89). Studies have shown how, if agriculture was to meet the dietary guidelines such as the those of the WHO or Eurodiet, there would have to be considerable change in what is produced: less sugar, fat, meat, oils, etc. Interestingly, no calculations are yet available on what the good news is – i.e. more fruit and vegetables – but a Rural Economy and Land Use project is underway at Reading University (64,65,90). The assumption in supply chain policy is that health is left to individual choice and information, despite, in the case of obesity, this model clearly having failed.
Governance failure has occurred mainly because public health policy has been marginalized in the face of other priorities (e.g. promoting a successful food industry, raising private funds for education). To some extent, obesity is a jolt to the state about its priorities, just as food safety crises were in the late 1980s. This led to considerable efforts to improve food safety, with some success. A similar push is now required with nutritional health. Children are being exposed to low-quality foods in institutional settings and by the insertion of food marketing and advertising into the interstices of their everyday lives, sometimes in government-approved cause-related marketing projects, although work is now ongoing to address this (91). On the one hand, there is advice to take more exercise, but, on the other, transport policies still centre on car use. The normalization of car transport to school in place of walking illustrates the point (4). Walking to school remains in decline, despite ‘walking bus’ initiatives. In its defence, Government – and health professionals within it – face a significant delivery challenge compared with food industry advertising or marketing budgets (69).
Turning to consumers, failure here also has to be acknowledged, as it is in many popular explanations for obesity. ‘No one forces people to eat’ can slip into blaming the obese for their obesity. People choose the wrong foods and therefore, in effect, choose to be overweight. However, consumer failure might properly be seen as a consequence, at least in part, of the two other forms of failure already considered. That said, there appear to be additionally genetic/evolutionary, social and psychological dimensions, some of which were considered in several of the models presented in Table 1, such as treat culture, peer pressure and cognitive dissonance (e.g. pleasure but guilt). There appears to be a social gradient applying here. In these conditions, only individuals having higher levels of ‘social power’ are likely to be able to consistently make healthy choices. It is no surprise therefore that patterns of obesity are linked to other societal inequalities and vulnerabilities, whatever the genetic factors. But, that said and mindful of the dangers of victim-blaming, policymakers have to acknowledge that for adults, at least, there is some level of volition involved. Consumer failure requires policy to re-emphasize both rights and responsibilities. Obesity policy could usefully draw on the debate about behaviour change to promote sustainable consumption (92), and the ‘happiness’ or well-being debate (93,94).
A new policy framework is needed
Having explored why obesity is rising so fast, and suggesting that, powerful though it is, the Nutrition Transition is, on its own, inadequate, and that in fact there are three transitions and three forms of failure, what would a new policy framework guiding prevention implementation look like?
We propose that if obesity prevention becomes a genuine policy, engaged with and delivered across government, society and supply chain, its accomplishment will require a paradigm shift, based on principles designed to (95):
- • take a whole-system rather than a partial approach;
- • reshape not just the physical and dietary environment but also the social and cultural environments;
- • adopt a long-term strategy by asking what an anti-obesogenic environment might look like and then draw out the policy changes needed to deliver it;
- • recognize the fundamental nature of the challenge posed and give due political priority to building alliances that could overcome the obesogenic social forces (as was done for tobacco in a long 50-year process);
- • reformulate the roles of government, markets and consumers to shift them away from reinforcing obesity;
- • deliver a situation where prevention is the norm, where victim-blaming is unacceptable but responsibility not avoided;
- • engage multi-sector, multi-agency action within and beyond the public health professional discourse.
This combination requires vision with pragmatism, leadership with collective action.
What needs to happen in order to deliver this policy framework?
As with climate change, pessimists argue that only a ‘system shock’ such as an oil crisis might shake people out of their cars (67,96). But even with such ‘tipping points’– moments when societies agree that enough is enough – strategies are needed to cushion the impact (97). Planning for systemic change without external crises is preferable but still requires political will, good evidence, alliances of pro-public health bodies committed to the long-term reorientation of societies, superb organization and commitment, and a long-term perspective. In part, such thinking has already been tabled in the UK by Sir Derek Wanless in his reviews for the Treasury of national healthcare funding and of public health (23,98). The Wanless reviews presented a ‘fully engaged’ scenario as the optimal basis for action. Carefully couched, this is more radical than it appeared because it actually made the case for demand management in place of ‘laisser faire’. Obesity is nothing if not a problem requiring demand management.
No one can foretell the future. Britons may start increasing physical activity just as they seemingly adopted aspects of US-style fast-food culture. Escalating oil prices may shock societies into change, as peak oil analysis predicts. Walking or biking long distances to work and school might become fashionable. Societies might decide to narrow the gap between the very fit and the very fat. If such change does happen, it is likely to have been helped by society-wide coalitions pushing, publicising, researching, sharing successes and failures, and organizing that change. Although some such public health coalitions have emerged, they currently lack momentum, and tend to be locked into the professional mode of policy discourse.
Scenario planning might help galvanize the necessary inter-sectoral thinking and work. Taking the current prognosis that obesity is rising, below we present a number of different but plausible policy scenarios. Each of these to some degree implies failure in that it will either perpetuate current obesity levels or marginalize routes to success or result in further complexity. At the end of this review, we present another, more ideal, scenario. It too requires a managed transition.
- • Policy as usual. This scenario offers continuation of today’s small-scale, incremental, piecemeal change. There is investment in endless short-term projects. These offer tantalizing visions of change, building expertise but not transferring to society at large. The result is palliative. Initiatives are encouraged, such as local health and physical education programmes, rather than a national advertising moratorium. There are once-a-year sporting activities (fun-runs) rather than policy delivering daily physical activity (biking to school or work daily, subject to weather). Vast attention is given to prime sporting events, like the Olympics, where elite athletes compete and others watch. Ministers are able to produce reports showing they fund this or that ‘success’ (projects), but society continues to produce divided obesity rates. The paradigm is individualized, personalized, health.
- • External shock. In this scenario, we envisage extensive and radical change following external shock to society. This comes from an oil crisis or a fiscal crisis over rising healthcare costs. Or an international outcry emerges over childhood obesity. Any of these can deliver a tipping point, and car transport has to be reduced, people use bicycles daily, etc. Policymaking requires co-ordinated, cross-cutting themes. Existing institutions are audited for their obesity (health) impact. The drive is for food to be ‘fuel’, rather than using fossil fuels to drive food around the continent of Europe.
- • Targeting ‘at risk’ groups. In this scenario, policymakers abandon any pretence at addressing population health, instead aiming to tackle ‘at risk’ groups. The poor, the already fat, those with a predisposition, are given (‘offered’) special programmes – therapy, drugs, exercise regimes, weightwatchers schemes, one-to-one trainers, etc. – mediated, for instance, by healthcare professionals or contracted to new companies offering wellness and fitness packages. The incentive to enter such programmes is either hard (shame) or soft (enticement and encouragement – in the style of private physical fitness mentoring – as in Celebrity Fit Club). The value of this policy scenario is that it focuses attention on the social groups that cost most. The problem is that few measures show more than limited success and do not tackle the underlying reasons why these groups are at a higher risk, and therefore this approach is unlikely to prevent other people from joining the ‘high risk’ groups.
- • Generational focus. In this scenario, policymakers judge that the ideological complications of tackling adult obesity are too great, despite the emerging focus in government reports on health among the 50-plus. There is not enough political support. Instead, they focus on children only, assuming that parents are more likely to do things for their children than for others. Radical ‘walk to school’ programmes and bans on children’s food advertising (and other marketing, e.g. texting, product placement) are gained at the European level because they are undertaken in the name of children. In half a century’s time, obesity rates fall and the new generation’s norms are worked through in a new demographic transition.
- • Business (almost) as usual. In this scenario, governments abandon state responsibility to shape responses to obesity. The focus here is on individual solutions, serviced by the food and sports industries. Cultural industries sponsor achievers, backing sports ‘winners’, presenting physical activity as something an élite undertakes. Society splits into watchers and doers. Corporate social responsibility becomes the core policy ethos, a substitute for government leadership. Commercial bodies take a lead in offering new product ‘choices’. For example, governments encourage industry-partnered public advertising or social marketing.
These are all plausible future scenarios but they all have more or less undesirable features and consequences. More ideal would be a scenario that genuinely delivered population health improvement. The problem is that policymakers and public health practitioners are not all that clear about what this might be or even, for that matter, what public health is. In his speech on public health on 26 July 2006, the Prime Minister stated that ‘questions of individual lifestyle – obesity, smoking, alcohol abuse, diabetes, sexually transmitted disease’ were ‘not, strictly speaking, public health problems at all’ (99).
Re-specifying what is meant by public health for obesity policy
Obesity, as the Prime Minister’s statement shows, exposes the weaknesses of public health as a scientific and political force. In large part, it is caused by social change and an image of public health as collective measures of the past. Advances in medical science mean that far more is known about disease, including the role of genetic factors, and more can be done to treat them. Single-factor classifications of disease have given way to multifactoral theories, emphasizing multiple, cross-cutting factors. In part, this acknowledges the fact that the disease burden has shifted. Infectious diseases, while recently undergoing signs of resurgence, have given way to chronic diseases not just among the older part of the population (as predicted by Omran’s theory of Epidemiological Transition) (100–102) but in younger age groups too, with significant growth of non-communicable diseases (NCDs). Even in the case of infectious diseases (HIV and other sexually transmitted infections come to mind), some of the old mechanisms for control and disease management have broken down. If we know more now about disease, we appear less able to stop its spread.
Much of the contemporary policy debate about obesity is framed by the state supposedly being powerless to know what to do. The litany of arguments about restrictions on governance adds to the policy cacophony. In an age of globalization, it is said, how can levers of influence be pulled? Obesity, being a multifactor disease, is so complex to address. And so on. This analysis is, of course, partly true. Proponents of public health tend to look back fondly on eras like the 19th century, when grand social engineering such as Sir Joseph Bazalgette’s sewage system for London (tackling the Great Stink) or individual heroic public health interventions such as Dr John Snow at the Broad Street pump (tackling cholera) were not only possible but effective (103,104). But romance should not cloud our judgement (27). Even then, the policy context was furiously complex, with class-interest-led politics deeply entrenched, opposition to action (as in the case of Bazalgette) immense, and citizen rights far fewer. It could even be argued, to follow the Prime Minister’s thinking, that these measures were not, strictly speaking, public health responsibilities either; rather, they were due to industrialization, population growth and urbanization.
We are more optimistic about what can be done today, but it means rethinking what we mean public health to encompass, from the physical engineering of the environment – the principal achievement of the Victorians – to our proposals to reshape the social, economic and cultural environment today. Part of our analysis is that, if the dynamics sketched in Table 2 are followed through, key actors, institutions and processes can be discerned, with realms of influence. The 2001 National Audit Office and 2004 Health Select Committee reports both mapped many of them (2,4). But the fact remains that public health requires a stronger mandate and champions. The term ‘public health’ is used to denote a population condition, an activity, a set of disciplines, a profession (or rather competing professions), an infrastructure, a set of policies, laws, a philosophy, even a movement. Given this fragmentation of meaning, methods, institutional forms and profile, it is not surprising that public health is poorly represented in government, misunderstood, and only momentarily achieves some limited degree of power during perceived emergencies (avian flu being the latest). Advocates of public health, as we are, we nonetheless think that obesity requires a return to basics. Currently, public health can be thought of as composed of action on (at least) three essential elements:
- • Health protection encompasses all forms of disease prevention in terms of its control and regulatory elements, including dimensions of healthy public policy. Health protection in its institutional forms was boosted by the creation of the Health Protection Agency (HPA). However, the purview of the HPA is limited to infectious diseases, hazards or bioterrorism preparedness, while health protectionism in terms of NCDs is diffused through a variety of bodies, some of which do not even have health in their remit. The Food Standards Agency does; Ofcom, for example, does not, yet it regulates advertising which, though not a magic bullet, some critics argue is nonetheless a not insignificant factor in the cultural transition or systematic framing of mass consciousness indicated in Table 2. Unsurprisingly, from a health perspective, the regulatory aspects of the control of the determinants of NCDs are poor.
- • Health development (sometimes called health promotion) is the promotion of healthy communities. In professional forms, these span school nursing to health visiting. Increasingly, the focus is on the role of local authorities in obesity strategy (through, as noted, LAAs, but also through healthy schools, health scrutiny functions, etc.). In its institutional form, the establishment of a national programme of health development, with its focus on putting good health evidence into practice, occurred through the Health Development Agency (HDA), now part of the NICE.
- • Health education involves the promotion of what the WHO calls ‘health literacy’, in other words the creation of a population informed about its health and how to maintain it. Health education has been progressively weakened in its institutional forms both nationally (the Health Education Council/Authority became the HDA) and locally (most health education departments in NHS Primary Care Trusts have withered). Health education has given way to the rival theory of social marketing – to the delight of the advertising industry, which switches between formulating campaigns for crisp manufacturers to activities on behalf of the Department of Health.
These streams have also been conceptualized in terms of the ‘three domains of public health’ by the Faculty of Public Health (105):
- • health protection – clean air, water, food; infectious diseases; radiation; environmental health protection, etc.
- • health and social care quality – service planning, clinical effectives and governance; research, etc.
- • health improvement – reducing inequalities; employment; housing; lifestyles, etc.
Valuable as this latter model is, it lends itself to a professional-centric and NHS/Primary Care-based approach to public health, with the Director of Public Health role at its core (106). In practice, despite the copious energies of many departments of public health, and in some cases the establishment of joint local authority/NHS appointments, it is easier to work within boundaries than across them and far easier to document problems than to deal with them. The other side of the equation has been the relative deskilling of local authorities in public health, which naturally interprets the term as something to do with the NHS rather than local government – despite the fact that local government – for more than a century –was public health.
The deeper reality is that the societal transitions referred to earlier – diet, the physical environment and culture – which once produced, in conditions of erratic but generally spreading economic benefit, a serendipitous relationship with health improvement, have now turned against public health. A conventional model may be adequate for many things, but it is quite inadequate to deal with the complexity exposed by obesity, which requires societally systemic, population-wide change (26).
In its place, we propose a more fundamental analysis, which addresses the long-term societal transitions in diet, physical activity and culture, the multi-level nature of causation and the disparate range of levers needed for change.
This has the advantage of seeing agents outside conventional public health as key agents for (and barriers to) change. Too often, obesity interventions are conceived of as the responsibility of a few public health professionals, when in fact it requires much wider, cross-sectoral and concerted action (3). This does not mean that local actors are irrelevant. On the contrary, we suggest they need more power and resources. People will not be able to alter diets or take more exercise unless these goals are primary drivers at the local level.
Towards an ideal scenario for public health success
The failures of market, government and consumers presented in Table 2 need to be recast in order to deliver success by changing diet and physical activity. At the heart of the obesity problem is the simple fact of mismatch between energy input and output. As Nobel Laureate Robert Fogel has pointed out, Britain in the early 19th century – at that time the richest country in the world and consuming a diet that was then comparable in energy terms to that of India today – did not achieve an average calorie supply designated as that of low-income economies by the World Bank today until the middle of the 19th century (107). Today, the calorific intake of an average citizen can be purchased almost infinitely more cheaply. Fogel notes that the supply of calories per equivalent adult male available for work was about 848 per day in 1800; today a confectionery, once advertised on the basis of helping the consumer to ‘work, rest and play’, provides almost 500 calories – almost a quarter of a woman’s daily calorie needs – for 50 pence. Although much of the world still suffers dietary insufficiency, as the Food and Agriculture Organization (FAO) and the WHO have shown, there is a systemic over-supply of fat, particularly in Europe and North America (see Table 3) (86).
Table 3. Trends in the dietary supply of fat. Source: World Health Organization/Food and Agriculture Organization (86)
|Latin America and the Caribbean||54||65||73||79||25|
|East and South-East Asia||28||32||44||52||24|
Re-engineering the world of food today requires, we think, the re-categorization of public health within four dimensions of human existence:
- • the physical world, by which we mean the world of nature and transformed nature – the built environment, urbanization – and the extractive relationship with the environment, i.e. nature as the reserve on which existence draws;
- • the physiological world, by which we mean the importance of the bodily processes that transform food – not just calories but micronutrients too – into bodily manifestation; the food can be either expended or translated into ‘thermodynamic overload’, i.e. obesity;
- • the social world, by which we mean human relationships and all the societal institutions and interactions that frame how humans live;
- • the cognitive world, by which we mean the interpretive structures within the human mind that are necessarily personally experienced and yet have meanings that others may share.
This four-part distinction helps reform what is meant by public health. The oft-quoted modern definition of public health is that it is: ‘[t]he science and art of preventing disease, prolonging life and promoting, protecting and improving health through the organized efforts of society’ (108).
We propose a modification. In an era that is having to face the consequences of mining nature, the material infrastructure for human health has to be recognized. In an era of massive culture shifts, when product marketing saturates the human consciousness, health education is largely the domain of the private, self-interested forces. So, in place of the common definition of public health, we believe that the true art and science of what we would rather term ‘ecological public health’ is:
to comprehend the composite interactions between the physical, physiological, social and cognitive worlds that determine health outcomes in order to intervene, alter and ameliorate the population’s health by shaping society and framing public and private choices to deliver sustainable planetary, economic, societal and human health.
This approach allows policymakers in ‘health’ to link actions with others focused on apparently different policy problems and objectives. This ‘ecological public health’ perspective is closely aligned to the policy goal of sustainable development, grouped around the core foci on society, economy, environment (109).
In Table 4, we present a forward-looking set of indicative goals for each of the three domains indicated in Table 2: markets (supply chains), government (state) and the public (consumers). Each of these needs to be translated into practical terms, which is a separate task. Whereas in Table 2 we linked the failures in terms of three transitions of diet, physical activity and culture representing the evolution and interpretation of obesity as a policy problem to date, we now propose that future policy might more usefully be cast around the four, more fundamental, dimensions of existence emerging from our discussion of the dimensions underpinning what is meant by public health: the physical, physiological, social and cognitive. For each of these, policymakers must consider which actors – in supply chain, society and government – are needed to deliver change both within the four dimensions and across them, and on what terms they could deliver change across the other sectors.
Table 4. Ideal indicative actions to shape healthy and sustainable futures
|Making markets work for health by . . .||• Reducing over supply and |
cheapness of calories
• Linking profitability to
healthier food ranges
• Making food acquisition
costs reflect environmental
• Reducing reliance on fossil fuels to encourage
physical activity in daily life
• Ensuring health targets
are built into wastage
• Making environmental
indicators (e.g. food miles) meaningful for obesity policy
|• Changing price signals of food to favour fruit and vegetables|
• Shopping more often for less
and using ‘person power’ to
burn energy from food rather
• Promoting smaller portion sizes
• Farmers producing less fat/
|• Promoting good, wholesome food to all, but especially to low-income social groups |
• Aligning companies’ success with consumer health
• Accepting restrictions on the commoditization of relationships in food marketing
• Promoting self-regulation and Key Performance Indicators that work for health
|• Agreeing not to target children • Supporting honest consumer information|
• Promoting more flexible and diverse social role models
• Teaching the joy of eating ‘excess’ only as feast day rather than everyday experience
work for health by . . .
|• Making people feel secure|
to walk or bicycle to work/
• Aligning sustainable
consumption targets with
public health targets
• Incorporating health
into food industry
sustainability strategy targets
• Using planning functions to
routinize physical activity
|• Setting incentives for better-quality food for all socioeconomic groups and ethnic minorities|
• Focusing subsidies and
setting taxes to promote
healthier food ranges
• Using public procurement
and other fiscal measures to manage demand
• Setting and paying for high standards of public sector catering
• Ensuring Public Service
• Agreements and Local Area
• Agreements fully reflect
government obesity targets
|• Setting minimum income |
standards for a sustainably
produced, wholesome diet
• Ensuring all citizens have a
requisite level of food choosing, sourcing and preparation, and general food literacy
• Supporting the strengthening of social rituals when people bond through food
• Redefining what is acceptable and unacceptable (norms)
|• Setting clear, long-term cultural goals • Helping educate ‘taste’ to be more discriminatory|
• Changing desirability of foods and behaviour by fiscal measures such as aligning taxation of
marketing expenditures with the health properties of food and drink
• Providing more remedial
support for overweight people • Supporting media analysis in schools and supporting commerce-free schools
|Making the public |
live healthily by . . .
|• Demanding an extension of ‘defensible’ public space |
beyond home and protected malls, etc.
• Enabling children to play
in streets and parks
• Getting out of their homes
more to reclaim civic space
• Accepting fewer parking
spaces for cars and im proving safety of walkers, bicycles and riders
|• Altering the composition of |
• Building exercise into daily life to promote energy balance
• Creating new cultures of daily activity, e.g. accepting less car use
|• Accepting and promoting new social norms on diet and physical activity|
• Using food as an affirmative social engagement, e.g. eating together
• Establishing overt social norms that support people to be of health-desirable weight.
• Create incentives for healthy weight
• Reverse the long-working- hours culture
|• Accepting the need to eat less unless people exercise more|
• Building a food culture which is more health- discerning about when, how often and what to eat
• Being prepared to redefine parental responsibility for long-term benefit rather short-term ‘peace’
The criticism of this approach is that it might take public health policy away from practicality into abstraction. We would argue, conversely, that the test of practical strategies and interventions, in toto, is the capacity to address these different dimensions of existence. Current policies are failing because they do not cover the range and depth of interventions needed. Policymaking has to move beyond the realm of tick boxes and unrealistic targets and, instead, face the world of real power, culture, consumption and the well-springs of consumption. More realistic targets should promote cultural change processes and other change processes linked to more sophisticated target setting. Similarly, the determinants of health must also be understood as working at multiple levels and across multiple policy terrains.
Policy about obesity must engage with economic drivers – not just the costs of obesity. Dietary change is shaped as much by the affordability of and mixed messages on a healthy diet as it is by the financial implications of national (or European) farming policy that currently troubles Government. The Treasury’s desire to reform the Common Agricultural Policy is likely to win more support if other member states see it as health-oriented, for example, tapping into the WHO European Region’s summits on obesity, which culminated at Istanbul in November 2006.
Our point is that the new policy on obesity has to cover the entire terrain, or continued drivers in one dimension might undermine positive action in others. Thus, children should be not only provided with school meals (tackling the physiological dimension directly) but also introduced to the culture of food and the means by which food is produced (the cognitive dimension of norms and expectations about food). Equally, social marketing, more correctly seen as more rigorously applied health education (oriented at the cognitive), should not disseminate ‘healthy’ beliefs about food or physical activity without allowing ‘regulators’ (who might be schools as well as parents) to have the power and the incentives to block ‘antisocial marketing’. Of course, policies have to address the means of access to healthier, affordable food or promote the normalization of physical activity as part of everyday life; but this aim, if taken seriously, implies a radical move away from the ideology of ‘choice’, particularly in the case of children.
Who should be responsible for policy and process co-ordination? The rapid and continuous upward trend of obesity might demand that new policy is led from the higher reaches of government but, if so, it should also be ‘owned’ by everyone. It is a long-term vision that demands copious financial and political resources. The point must be to catalyse new forms of leadership, but of the many rather than the few, engaging people who currently feel powerless or who do not understand that obesity is a shared societal problem (‘everyone’s business’) that breaks down policy segmentation and genuinely seeks the participation of the public.
The argument presented here is the need to tackle not just the manifestations of obesity but the forces that shape it. This review has tried to reconceptualize the basis on which attempts to tackle obesity are and could be made. We have suggested that obesity is the public health equivalent of climate change. This is a striking analogue in at least five respects. First, failure to act at an early stage is already having immense and undesirable consequences. Second, the policy discourse about obesity – vibrant although it is among the problem-watchers – is not yet being matched by requisite, measurable changed direction of travel by society, governments and economy. Third, obesity is being normalized, even as the trends accelerate and the evidence grows. Fourth, as Jain has remarked, the environmental determinants remain misunderstood and under-researched, while policy drifts towards individualized responsibility (26). Fifth, there is a danger that the political moment to act radically and coherently will be missed, and that the possibility of reversing population obesity will be lost. A tipping point will have passed – both adiposally and metaphorically. Already too many actors and institutions feel powerless.
In sum, we think it highly unlikely that obesity rates will be reversed by small steps or reliance on single solutions being offered in conditions of policy cacophony, as outlined earlier, or by unwarranted emphasis on individualized change with limited societal support. From our analysis, obesity change is more likely to be delivered by ‘big thinking, many changes’. Coherence and optimism are needed, with firm political leadership across government, supply chains and civil society.
The systemic analysis offered here suggests that policymakers should be wary of making quick-fix promises and offering ‘light’ solutions. If obesity is a systemic failure – the understandable bodily and psychological response to an inappropriate set of signals from the physical, physiological, social and cognitive worlds – then obesity’s solutions must lie in addressing all of these dimensions. The extent and depth of the policy shift required should not be underestimated.
To conclude on an optimistic note, it should be stressed that many governments worldwide, led by health ministries, are beginning to realize the enormity of the obesity challenge. Although economic ministries do have a tendency to see ‘health’ as expenditure on health care, this reflex is beginning to be shifted by initiatives such as Wanless’s ‘fully engaged scenario’ and the realization that food supply chains must be rebuilt around sustainable development. Obesity is not the only challenge in the early 21st century. From the ecological public health perspective offered here, investment in prevention and building capacity will have pay-offs not just in massive reductions to health care but also by turning broader societal costs into improved well-being and quality of life.
Conflict of Interest Statement
No conflict of interest was declared.