The obesity epidemic: why we need an independent agency to tackle it
Ireland should be spending €15-20 million annually on a top-down and bottom-up approach to obesity
‘Governments don’t feel compelled to invest in a problem over which there is considerable apathy.’ Photograph: Getty Images
According to the McKinsey Global Institute, the cost of obesity to the UK National Health Service problem equals the combined costs of the entire policing, fire, prison and court services in the UK. There is no reason to believe that the pro rata costs here are any different.
The largest UK government investment in obesity management (Change4Life) has an annual spend of £14 million. The comparable figure for the Royal Society for the Protection of Birds amounts to £90 million annually. When it comes to obesity, the fifth largest cause of global mortality (physical inactivity lies fourth), governmental commitment across the globe is grossly inadequate.
There are several explanations for this failure to make a significant national investment in tackling a problem, which now equals that of tobacco. The first reason lies in the mindset that public health medicine has developed following decades of campaigning against issues such as tobacco, alcohol or road traffic fatalities. In all of these instances, the main initiative is within the regulatory realm. We ban, restrict, license and otherwise regulate social behaviour to minimise the impact of these public health scourges on society. Having done so, the main investment is in policing the regulatory framework. That won’t work for obesity and in a series of six high level papers on obesity in the prestigious medical journal, The Lancet the main message was that obesity needs both a top down and bottom up approach.
The top-down approach is currently the dominant one to tackling obesity: whether through soft drink taxes, advertising restriction, the regulation of vending machines in schools, regulating the location of fast food outlets or food package labelling restrictions. Almost nothing happens here in Ireland by way of significant programmes to help people to better manage their lifestyles in the struggle to contain the obesity and physical inactivity epidemic.
It is worthwhile considering the reasons for this imbalance. Extensive research has shown that people fear only those public health threats that are (a) dreaded, (b) unfamiliar and (c) largely outside of their personal control. Ebola and BSE, for example, meet these criteria and because of voter concern, there is considerable governmental action to combat these perceived risks to our health.
Obesity, on the other hand, doesn’t meet these criteria. We all know lots of overweight people (familiar), we see them leading normal lives (not dreaded) and at any time, each individual could, if he or she chose to, manage their weight (control). Thus voters are not so concerned and indeed research shows very significant social ambivalence to overweight.
Governments don’t feel compelled to invest in a problem over which there is considerable apathy. The lack of any visible governmental action to tackle obesity allows the concerned citizens to take the initiative, participating in non-governmental organisations (NGOs), and they tend to drive policy, largely focusing on the top-down approach. Almost always, they drive single issues such as soft drink taxes, advertising and so on.
Governments are more than happy to facilitate this low cost “action” to tackle obesity. The UK government’s Foresight Report on Obesity writes thus about the solutions to the obesity problem: “The complexity and interrelationships of the obesity system described in this report make a compelling case for the futility of isolated initiatives. Focusing heavily on one element of the system is unlikely to bring about the scale of change required. There are as yet no concerted strategies or policy models that adequately address the problem.” But unless there is significant investment in properly financed, independent structures with a long-term vision to combat overweight and physical inactivity through bottom-up action programmes, obesity will continue to be a major public health problem.
In Ireland, in or around 90-110 people are killed on our roads annually and the annual budget of the Road Traffic Authority is about €40 million. Based on the spend on road traffic accidents, the McKinsey Global Institute’s report on obesity estimates that a realistic investment in obesity prevention should be about 1.2 per cent of the costs of obesity to the health service. My calculations suggest that this should translate into about €15-20 million annually for Ireland. That would be the first decision for the long-term control of the problem of overweight and physical inactivity but that spend would require the Government to bite the bullet and go further to establish an independent agency to oversee this spend and to put in place both evidence-based proposals for the regulatory framework (top-down) and more importantly, programmes that help people adopt a healthier lifestyle (facilitating bottom-up approaches).
The reason for an independent agency is best seen from the history of food safety. Once upon a time, the same branch of government (and of the European Commission) that assessed risks to health from the food chain, also managed that risk. That was found, most notably in the BSE crisis, to create a conflict between risk assessment and risk management. In the case of obesity, a national agency would be independent of the powers that walk the corridors of Hawkins House.
Unpopular opinions have to be uttered and that will never happen when risk assessment and risk management lie within the same governmental structure. Independence does not mean that national agencies currently attempting to contribute to obesity reduction, such as the Food Safety Authority of Ireland (calories on menus), the Department of Health (regulations) or SafeFood (TV campaigns), would lose out. They would be empowered through proper financing to enact agreed bottom-up approaches, which have been clearly agreed by all partners as the most practical approach to both the prevention of obesity and the management of the ill effects of this condition (hypertension and diabetes).
The problem of obesity is incredibly complex. As the UK Foresight Report on Obesity states: “What quickly becomes apparent to anyone who examines the body of evidence from several different disciplinary sources is that the answers are neither straightforward nor, as is popularly supposed, necessarily known. Although a great deal of research has been done into the problem, much of the evidence is not integrated”.
Without a long-term commitment to a properly financed and independent structure to help people manage the issues of overweight and physical inactivity through bottom-up national and local solutions, we might as well whistle Dixie to this huge public health issue.
Michael Gibney is Professor of Food and Health at UCD