Without wishing to sound critical or mean spirited, my week’s holiday surfing and relaxing on the English coast this summer came as quite a shock, and it wasn’t the weather. On reflection, I felt it worth sharing what I see as the naked truth – from a healthcare communications point of view: Beach holidays reveal a lot about the state of the nation’s health, albeit a view from the exterior with no medical diagnostic tools to hand. Britain is in the thick of an obesity crisis, with diabetes rising in parallel, but we still aren’t talking about it nearly enough.
You need only compare photos of beach life taken in the 1970s and 80s (main photo: my brother and me in Devon, 1985) with those of today to appreciate the scale of change that’s taken place in relatively few years. My week of admittedly unscientific polls ‘from behind the windbreak’ consistently put the rate of overweight or obese people holidaying on the South West coast at around 60%. Now, even though I keep up to date with health issues, and am acutely aware that I live and work in the ‘bubble’ that is London, within the affluent South East, I was shocked by ‘in the flesh’ evidence of the drastic change in the shape of men, women, and children.
Seeing the rise in children who are overweight or obese is particularly depressing, given the likelihood that their BMI won’t fall, and knowing how the related psychological and physical burdens can compound to bring about many disadvantages in life. We’ll come to those later, suffice to say there are 4.5M children and young people in the UK who are overweight or obese. This includes over a fifth (22.5%) of Reception year children aged 4 – 5, with boys being more likely to be obese than girls in both Reception and Year 6 (age 9 – 10). As experts in healthcare communications, it’s a pertinent fact that most parents of an obese child are in denial about it.
The speed of change is daunting. A 2013 study saw hospital admissions for obesity and related health problems in children and young people rise more than four-fold from the previous decade – particularly among girls and teenagers. We also know that being an overweight child is linked to bullying – nothing new there – but consider this: In 2003 a US study concluded that the health-related quality of life of obese children and adolescents was similar to those diagnosed with cancer. It seems ironic that we read far more in the media about extremely underweight girls being admitted to hospital, than overweight girls (which is not to underplay the former).
Obesity is strongly linked to anxiety, eating disorders, depression and other mood disorders, especially in women. Aside from its well-documented effects on cardiovascular health, obesity affects women and girls in ways that are profound. It causes girls to start having periods earlier because adipose tissue (fat) contains aromatase – an enzyme that converts androgen precursors to oestrogen. (Conversely, in boys, obesity may cause delayed puberty, which can in turn cause psychological problems.) It also causes menstrual, fertility and pregnancy problems, including pre-eclampsia, eclampsia and miscarriage – as well as increased maternal and infant mortality, and gestational diabetes. (Curious PR predicts we’ll be hearing more about these less well-known obesity side effects in the future.)
But no discussion of obesity is complete without considering the Type 2 diabetes epidemic; they are two sides of the same coin, yet nobody has found a solution to reverse these unwelcome and costly trends. The chief executive of the NHS, Simon Stevens, has talked of the potential for diabetes to bankrupt the NHS eventually: “Obesity is the new smoking, and it represents a slow-motion car crash in terms of avoidable illness and rising health care costs.” According to the NHS, If current trends persist, 1 in 3 people will be obese by 2034 and 1 in ten will develop Type 2 diabetes. It is finally sinking in that one pound in every 10 spent by the NHS goes towards treating patients with diabetes, so It will be interesting to watch how the NHS Diabetes Prevention Plan is launched in April 2016, from a PR perspective.
THE FAT OF THE LAND
The Plan will attempt behavioural interventions that support people to maintain a healthy weight and be more active. But some obesity crisis observers call for ‘less nanny state’ and more ‘short, sharp shock’ to encourage behaviour change. Whilst controversial, the hard-hitting TV advertising campaign of 1987 narrated by John Hurt – ‘AIDS – Don’t die of ignorance’ – did terrify many into reducing risky behaviour overnight (albeit that HIV affects only around 0.15% of the UK population compared to 25% for obesity and 6% for diabetes.)
Back on the beach, and feeling depressed about ‘our fat future’ black humour stepped in and I headed to buy an ice cream from the café despite the long queue. Reaching the front of the line for elderflower sorbet, I was asked, “Child or adult size?” Having glimpsed an adult departing with 3 huge scoops in a large cone, I opted for “child ” – a portion that easily weighed 200g. One solution being tried by the food industry and other stakeholders is reduced portion size, but clearly, this café was having none of it! What I was more struck by however was that the queue hadn’t shortened all day: This beach – and countless others – may once have provided sunbathing, swimming and surfing, but it was now a grazer’s paradise.
Grazing is everywhere and it’s constant. Snacks are usually conveniently packaged for long shelf lives, so are often high calorie, low nutrient foods with high sugar levels, much like fizzy drinks. On the sugary drink front, certain nations are attempting to tackle their obesity via a sugar tax. Amongst these is Mexico which has set the levy at 10%, and public health experts report it’s having positive effects, but on the whole though, the jury is still out on this policy. Closer to home, chef-turned-campaigner, Jamie Oliver, has ruffled feathers via Channel 4 documentary, Jamie’s Sugar Rush, during which he witnesses surgical removal of children’s teeth made rotten by the white stuff. On the subject of obesity, he is clear: “Every clever person I have met realises we’re all aligned in the same catastrophe.” For sure, Jamie’s work is cut out. Snacks have become so much part of our culture, our leisure and lifestyle that mealtimes have taken a back seat. I was intrigued to hear one of our French clients note that the difference between how people ate in France versus the UK lay not in what was eaten: “French girls don’t snack”. (Only 12.9% of the French are obese, versus our 25%. (Smoking as a substitute for snacking was not discussed…) So, could Britain’s ‘snacking culture’ somehow be reversed? Afterall, evolution cannot move anything like as fast as cultural change, and it’s evolution that is winning out: High energy food is irresistible to most of us, because our ancestors were biologically adapted to survive times of famine. This renders willpower essential for maintaining a healthy weight in today’s times of plenty.
As mammals, we have a predilection for high calorie foods, with a particular penchant for a 50:50 mix of sugar and fat. Think donuts, ice cream and chocolate. (Intriguingly, this combination of nutrients is found nowhere in nature.) When it’s on offer, our neurological reward systems are set ablaze, and it’s hard to stop eating, even if our conscious brain taunts, ‘A moment on the lips, a lifetime on the hips!’ Indeed, lab experiments involving rats which are given separate bowls of sugar and butter don’t gorge on one or other food, whereas their fury counterparts offered a blended 50:50 mixture rather than separate bowls of fat and sugar tend to gorge until they become overweight, obese, and possibly insulin-resistant (pre-diabetic or diabetic). Such observations have lead to over-eating being labelled as an ‘addiction’. In an article entitled ‘Obesity is an incurable disease’ for The Guardian, George Monbiot notes in a somewhat crude analogy that only 10-20% of people who use crack cocaine become addicted, whereas a study of 176,000 obese people saw 98% fail to reach a healthy weight. Monbiot points the finger sharply at the junk food industry and at advertisers, but in fact there are multiple stakeholders involved. Labels, semantics and blame aside, we need solutions, and we need them fast.
THE ELEPHANT IN THE ROOM
In attempting to know why our obesity epidemic isn’t budging, we see one clue in a recent study that analysed the records of several thousand obese patients, and found 80% had never talked to their GP about their weight. This would suggest GPs are reluctant to discuss ‘the elephant in the room’ for fear of offending patients, and in a way, who could blame them? Or perhaps they are too focussed for various reasons on treating symptoms – not causes or solutions. Either way, experts point to the need for primary care professionals to seek training in obesity care. With the leading causes of morbidity and death being largely preventable these days we believe behaviour change is the crux, and healthcare needs to factor it in further. Perhaps, as with depression, over time, obesity will become less of a taboo subject to HCPs, with the upside that more cases can be identified and treated through a range of interventions. What is clear is that multiple stakeholders need to get together to find practical solutions – for all of us – and for the long term. The sheer size of this issue means a fatalistic attitude is not going to work – for any of us.