“It’s been very hard over many years to persuade governments of many different political persuasions that we should invest in preventing and treating obesity,” said University of Oxford professor of diet and population health Dr Susan Jebb.
Prof Jebb was the science advisor for a report published in 2007 by the United Kingdom’s Government Office for Science under its Foresight programme titled Tackling Obesities: Future Choices.
The report was meant to “produce a long-term vision of how we can deliver a sustainable response to obesity in the UK over the next 40 years”.
She was subsequently seconded to the UK Department of Health as a science advisor on obesity and food policy from 2007 to 2015.
During the recent Addressing the Global Health Challenge of Obesity in Malaysia and Beyond workshop organised by Academy of Sciences Malaysia (ASM) and The Academy of Medical Sciences, UK, in Kuala Lumpur, Prof Jebb shared the highlights from the report via video call from the UK.
The report, she said, involved four work packages. “They were really the underpinnings for us coming up with a series of principles as to how government might put together what we hoped to be an effective obesity strategy.”
She added: “It’s important to note that from the outset the intention was not to develop specific recommendations; rather, the way Foresight operates is to come up with a series of guiding principles.
“One of the benefits of that is that it then allows politicians of any particular party to tailor the strategy to meet their political ideology.”
The four packages were:
Short science reviews
“This was interesting because we asked probably 20 of the UK’s leading scientists, not to conduct long, complex systematic reviews, but rather, just to tell us in a couple of thousand words, what they thought we really needed to know about their topic.
“So we asked experts to synthesise all the evidence they had in their head and to give us the nuggets, the real gems, which they felt would be vital for policy-making.”
This proved to be a quick way for the team to gain an understanding of the science behind obesity, and also helped to inform the systems map they developed next.
Obesity systems map
“Essentially, if you ask 100 scientists about the causes of obesity, I think it’s not entirely surprising that you get about 200 different explanations.
“What we tried to do was to synthesise those into a system which allowed us to understand something about the aetiology of obesity.”
While the heart of the map revolves around the concept of energy balance, there is also a bias towards food accumulation.
“We’re designed to seek out food – it’s a basic biological drive. And that means that in an environment of plenty, it’s very possible for us to consume far more than we actually need,” explained Prof Jebb.
The first impression most people, including policymakers, had when they saw the map was that it is very complicated, and Prof Jebb feels that that was its first success.
“Suddenly, policymakers could see how, if they just had an isolated initiative to tackle obesity – perhaps just addressing one of the nodes in this map – it probably wasn’t going to be sufficient to fully address the problem.”
A crucial point the map helped make was that an individual’s food choices are shaped by the wider system of food production, supply and distribution, while their physical activity is shaped by their wider physical environment and how possible it is for them to be active.
In addition, there are also psychological influences, like an individual’s self-esteem and ability to take control of their environment, as well as social and cultural norms that affect how we live our lives.
Using the map, the team could also quickly assess the impact of suggested interventions, to see how much, or little, a programme could actually affect obesity.
“There is a real danger in obesity that we not only become paralysed by the range of potential options, but also by the lack of specific evidence that any one of them would actually work.
“The reality is, if we wait until the evidence is complete and perfect, we may be waiting for a very long time.
“And so we recognised that there was a need to take action now, and then to gather the evidence as the policy programme rolled out, so that we learn as we went along,” said Prof Jebb.
One of the challenges for policymakers is that a policy implemented now might not be suitable a few years down the road.
Therefore, what the team did was to develop four different future scenarios through expert workshops that revolved around how much or how little individual and societal responsibility for the causes of obesity would be emphasised.
A variety of policies were then developed and their effectiveness in each scenario was determined through expert opinion.
Five policies were deemed the most effective through all four scenarios. They were:
• Investment in early life interventions
• Controlling the availability of, and exposure to, obesogenic food and drink
• Increased walkability/cyclability of the built environment
• Increasing responsibility of organisations for the health of employees
• Targeting health interventions for those at high risk
“I can’t emphasise how important this piece of work was, because this was really the mechanic which engaged government.
“And what we sought to do with economic modelling was to demonstrate the cost of inaction,” she said.
Their projections then were that if nothing was done, by 2010, obesity would take up 6% of the total UK National Health Services (NHS) expenditure, and that would increase to 13.9% by 2050.
More crucially, the UK NHS costs would be but a fraction of the estimated £50bil (RM280bil) total cost to the UK economy in 2050, including the cost of loss of productivity and incapacity of obese patients.
She added that a few years ago, management consulting firm McKinsey also looked at this area and estimated that obesity is the third most negative impact on a country’s economic output.
“I think in the past we have tended to underestimate the impact of obesity on the economy because we focused only on the direct healthcare costs.
“In fact, it’s the indirect costs of obesity that are particularly important,” she said.
Developing an obesity strategy
At the end of the day, the team came up with six strategies to tackle obesity:
• Interventions at different levels: individual, local, national and global.
• Systemic change across the system map.
• Interventions across the life-course.
• A mixture of initiatives, enablers and amplifiers.
• Short, medium and long-term plans for change.
• Ongoing evaluation and continuous improvement.