What should nanny do next? The government and obesity Episode 2 of the Health Foundation podcast

Jennifer Dixon: Who'd have thought before the pandemic hit, that the state would have intervened to pay the wages of a nation for up to a year? Who would have thought that the government would be restricting our lives for months in a lockdown? We accept this level of state action in an emergency to protect our health but health is also affected by slow burn threats, which actually kill more of us than any virus. One of these slow burners is obesity.

The UK is the most obese nation in Western Europe. We know that people who are obese are twice as likely to be killed by COVID. Did you also know that obesity now causes more cancer than smoking?

The human cost is huge and so is the impact on the NHS and the economy. But is it really any of the government's business? If it is, what should it do next? Just how much state interference would we put up with? Joining me to pore over these issues today, I'm really delighted to welcome three expert guests; Dame Sally Davies, now Master of Trinity College, Cambridge, and as many of you know, stepped down just last year as Chief Medical Officer for England and Chief Medical Advisor to the UK Government.

Dame Sally Davies: This is a very important moment where you can get away with things that normally you couldn't.

Jennifer: Harry Rutter, who is professor of Global Public Health at the University of Bath.

Harry Rutter: We're doing worse than anywhere else in Europe. We're up there with the very highest level and worst trends of any countries around the world.

Jennifer: Finally, James Forsyth, who is political editor at The Spectator, and he also manages to squeeze in a column for The Times newspaper.

James Forsyth: Skinny people lecturing people with weight issues, saying you've got to lose weight, you've got to do this, can be very jarring.

Jennifer: Welcome, everyone. Sally, let me start with you, more than a quarter of us adults in the UK are obese and one in three children aged 11 are overweight or obese. Just why, in your view, is that such a problem for the government?

Sally: Well, I would say this is a problem for our whole society, not just our government. We know that this leads to mental ill health, particularly in children, but also in adults. We know it is one of the common causes, as you said, of cancer. We know that 50% of premature deaths and morbidity in the UK relate to modifiable risk factors and poor diet and physical activity are part of that or physical inactivity.

Jennifer: Harry, are we really a nation, as The Sun put it, a ‘nation of fatties’?

Harry: First off, I'd start by challenging the language of a nation of fatties. I don't think that stigmatizing language is helpful to anyone. But in terms of the prevalence of obesity, and the direction of our trends, places like the United States are ahead of us. Some of the Pacific island states are doing worse than us, but in general, we're doing worse than anywhere else in Europe. We're up there with the very highest level and worst trends of any countries around the world. Importantly, we also have enormous problems with inequalities in childhood obesity. In particular, if you're from the poorest 10% in the country, you're more than twice as likely to have obesity as a child from the least deprived 10% in the country. These gaps are getting worse. They're widening.

Jennifer: A big challenge for any government it sounds like. James, is it fair to say that COVID has pushed obesity right up the government's agenda?

James: Yes, I think it has. I think Boris Johnson before this crisis was a classic anti-nanny state conservative. Remember, he overshadowed David Cameron's first party conference as Tory Leader by defending mothers who are pushing pies through the railings to their children in defiance of their attempts to make them eat healthier school meals. I think what people have realized, though, is the link between COVID and obesity, and I think changed the balance of thinking about government action. I think Boris Johnson is a particularly interesting politician on this point because he also has a personal experience that allows him to speak about it.

He was 17.5 stone when he went into hospital with COVID. He is convinced that his weight is one of the reasons why he ended up being hit so badly by the virus. I think that there's, obviously, I think anyone would know, I think skinny people lecturing people with weight issues, saying you've got to lose weight, you got to do this, can be very jarring. I think he probably as someone who has had his own battle with weight, probably has more permission to speak and is probably more likely to be listened to than the average politician on this subject.

Jennifer: That leads us on to looking a little bit more about obesity as an issue. Harry, it's a very complex thing, isn't it? Do we know about what is driving this dramatic trend?

Harry: Gosh, that's a podcast in its own right, Jennifer. I guess, one of the places to start is a reflection on something James just said about skinny people lecturing the overweight. I think what that highlights is the idea that obesity is fundamentally down to decision making by the individual. Of course, the decisions that we all make is an important part of ultimately leading to what goes into our bodies, what we eat, and how much physical activity we engage in. The context within which those decisions are made is one that has shifted enormously over recent decades. So the dominant idea that obesity is down to individual willpower or a lack of individual willpower, is one that's not borne out by the facts.

If it were the case that individual willpower was driving obesity, then surely the thing that would have driven the obesity epidemic is a reduction in willpower over the last 30, 40, 50 years. Now, I'm perfectly happy to accept that I'm weak-willed, and I enjoy my food but I don't accept that my generation is weaker-willed or enjoys its food any more than my parents' generation, or that my kids' generation fits along the same lines.

What's happened is not that we've changed as individuals over time, it's that the world around us has changed. What we've seen is the development of what's called an obesogenic environment in which we can do these things but it's just that much harder. What we see is that many, many ways, across our daily lives, we are inclined, we're pushed to consume that much more energy and to expend that much less energy. Those behaviors ultimately are socially patterned.

Jennifer: Sally?

Sally: Well, think about a child, that what do they see? They see in the spotlight unhealthy food and drink. They are drowning in a flood of unhealthy food and drink. It is very difficult to make the healthy choice as an easy choice. We have a society that is structured around commercial drivers and profit, rather than around the long term health of our people.

Jennifer: You've written a lot about this in various reports, and you've been close to government advising them on an obesity strategy. How difficult was it for you to convince government that to act on the obesogenic environment as opposed to something which is about individual agency?

Sally: Well, it's not easy for anyone, is it? I mean, you come into government, and you've got various levers, you want to pull them and something to happen. As Harry has explained beautifully, this is not a single lever and this isn't about willpower or one thing that politicians can do. They have to slowly understand that and it seemed, on average, to take prime ministers a year also to understand that. First, you've got to understand the complexity, then they have to think so which bits will they take on, unless we can persuade them that in the interest of the nation they should take on the whole lot. But it takes time to get politicians there and I do understand that.

That's why you've seen what are called Chapters One, Two, from Cameron, from May and now a new Chapter Three, new obesity strategy, from this prime minister. Bit by bit, they're adding to the jigsaw of what needs doing. But even if we delivered everything that they have promised, we wouldn't be there in doing what needs doing and getting our weight as a nation to a healthy level, we are going to need to do more.

Jennifer: James, you were talking earlier about the Prime Minister's own brush with COVID and the fact that he's 17.5 stone and always struggled with his weight, and when the government published the obesity strategy last July, he did say that their efforts will be "supportive rather than excessively bossy or nannying." What appetite do you think, if you forgive the pun, they might have for acting a lot more radically on this obesogenic environment that Sally and Harry are talking about?

James: I think in Boris Johnson's ideal world, he sees exercise, particularly cycling, as the answer to this problem. Get everyone moving around more, and the state won't have to tell people what they should and shouldn't eat, what they can and cannot eat, and all of that. Politically, it's certainly far easier to put money into supporting exercise than it is to put taxes on unhealthy foods. I think that will very much be at the heart of his attempt to deal with. I am personally skeptical of how much effect that that can have. I think the Nigel Lawson argument that exercise alone isn't going to fix this problem is probably right-

Sally: It is right.

James: -but then I think the problem then comes down to this, which is putting taxes on unhealthy foods is politically difficult because of, A, the moralizing element to it, and B, that it would tend to be regressive. I think this is a particular worry, which is how do you come up with a situation where you don't look like these tax rises are essentially hitting the people with the least money to spare hardest?

Jennifer: It's interesting because it's certainly true that our polling shows that if you ask who has responsibility for helping people stay healthy, actually 51% think the government has a great deal of responsibility to help, so in a sense, the government in its current policies, which do rely a lot on that personal agency, that doesn't really reflect that does it, James?

James: I think the biggest single difference that could be made would be to get GPs more involved in this strategy. I think at the moment, GPs are very reluctant to tell people that either they or their children are overweight. There is a lot of fear that this will affect the doctor-patient relationship, but it won't be helpful. I think the research details that this is perhaps one of the most effective interventions, that is one of the things that I think the government should do. I think it should become much more the responsibility of GPS to be very frank and direct with people about when their weight is putting their overall health at risk.

Jennifer: Harry, I think I heard you say at that point, GPS and the action by the NHS, how efficacious do you think pushing that would be?

Harry: There are all sorts of things, there are hundreds of things that need to be done, which absolutely include individual-level decision making, absolutely include the role of health services, the advice from GPs, and so on. If we're really looking for the keys to unlock this, I think it's important to understand that obesity is not a knowledge deficit disorder. Obesity is not fundamentally driven by people failing to understand that if you consume too much energy, and you expend too little energy, you won't put on weight. People get that.

But they exist in an environment where there are all sorts of cues, focusing on things that appeal to them, other than just their long-term health status. They might be about convenience, they might be about price, which we're all weighing up all the time. From a health perspective, we might think everyone should be focused on health all the time, but we're not. That's human nature. Pretending that all we need to do is give people more information really misses the point. It's not going to solve the problem.

Jennifer: The government last year published its obesity strategy. One aspect of that was policies to try to support individuals to help them lose weight. But another strand was to try to influence people's behavior through taxes and advertising and price deals. Some people have talked about the food and drink industry and advertising as the commercial determinants of health and everyone.

I think, agrees there's huge scope, potential, scope to act here, especially, for example, as we know that spending on junk food is nearly 30 times what the government spends on healthy eating advertisements through Public Health England. Sally, do you think the government's gone far enough on some of the price deals and including the quaintly named BOGOF which is buy one get one free deals?

Sally: Funnily enough, every week, I buy a BOGOF but they're packets of spinach. I'm all in favor of BOGOFs as long as they're for healthy food. I think the July announcement of three things to do banning TV and online adverts before 9:00 PM ending BOGOFs of unhealthy food [unintelligible 00:14:41] salt, sugar and fat and calories displayed on menus are useful. But even added to what has already been put on in place, is not going to deliver the change we need. We are going to have to look at some other things because the healthy choices are difficult.

The government needs to consider more things like the soft drinks levy, which was very innovative. It reduced, in a three-year period, sugar by 21.5%, which was over 30 tons of sugar a year in England, but sales went up 10%. What's the harm of that? The commercial people did very well out of it if they innovated. The people who bought the drinks didn't do badly. Everyone won. We've got to stop saying we're taxing regressively and look at how to use incentivization for innovation so that the public can lead good lives and enjoy treats, but that there is low calorie as can be made, and we're thinking about the whole environment.

Jennifer: I was looking at going to turn to Harry about the government's obesity strategy published in July, in terms of the extent to which it talks about restricting promotions for high sugar, fat, salts products. Given the fact, and I think we all agree that something more radical is going to have to happen for these trends to be dented in future trends in obesity, where do you think the government could go next?

Harry: Restrictions on promotions are, as you've said, as Sally has said, are important, but they're necessary, but not sufficient as are so many other factors here. If we look at just the title of the latest obesity strategy, it's called Empowering Adults and Children to Live Healthier Lives. This yet again, brings it back to the idea that this is about a decision made by individuals, a set of decisions made by individuals and empowering is all very well for people who have the power to control those aspects of their lives.

But many of us live in environments where, for example, the street outside where I live is not a particularly pleasant place to cycle. We live in environments where there are all sorts of offers on in the supermarkets. Allowing companies continue to sell their products that cause harm without making them pay for it, these corporations that sell products that impose harmful externalities without those externalities being internalized into the price, effectively means that were allowing companies that sell products that cause harm, we're giving them a subsidy and we're giving them a benefit over companies that sell healthy products.

Jennifer: Where are the really good international examples where you think countries have got the balance right or at least they've pushed further, more radically on this agenda without necessarily become excessively bossing or nannying in the way we've described?

Harry: I'm really pushed back against this idea of nanny. If we--

Sally: Thank you. I was hoping someone would.

Harry: I think there is very, very good evidence that obesity is driven by environmental factors, and those factors are shaped by all sorts of things but predominantly by commercial determinants. It is not nannying to say that the environment should not be one that drives unhealthy behaviors, should not be one that promotes obesity. I don't think that's nannying in the slightest.

Jennifer: James, what mechanisms do you consider to be or do you think the PM, the government would consider to be bossing or nannying if I can use that term? Sorry, Harry. What mechanisms might actually be legitimate nudges that actually there could be more political support for?

James: I think, taxes on unhealthy foods is still something that there would undoubtedly be political resistance to. I think it is always easier to promote something so, e.g, exercise, healthier eating, all of those things are, I think, easier to do. Personally, I think that the daily mile, for example, getting primary school-aged children to walk at least a mile every day, that is a good first step in the issue. I think, sounds rather old-fashioned, but I would be all in favor of bringing back home economics in schools.

Jennifer: I think what we're all agreeing on is that there's a comprehensive range of things that need to happen. You mentioned one of the things there, which was the daily mile, James, which I think was piloted first in Scotland. Harry and Sally, I know you've been in contact with many of your colleagues in Scotland. Do we have anything to learn from how the other UK nations have addressed the balance between intervention more or less.

Sally: It's much easier to do directions like the daily mile if you're a small country. Interestingly, James, and I share that we don't want a nanny state. What we want is something where there are nudges and an environment where it's easy to be healthy. That's why I was listening with interest because I was remembering the debates about tobacco, which caused all these deaths from cancer and lung disease, and thinking it was only when people understood the secondary effects that we really got movement, and what have we done? We've taxed it so that it has become much less common and we've set up wonderful NHS stop smoking services and things that can really make a difference.

We did do that by making it less and less attractive. I think we're going to have to do something like that with unhealthy food and drink. In the end, I would predict we will get there. What we're debating is the best ways of getting there and the fastest way of getting there.

Jennifer: What do you think is going to provide that extra velocity that we now need if we're not going to, in the words of Simon Stephens, bankrupt the NHS through obesity, or worse for the economy?

Sally: Well, I'm much more interested in children growing up into being healthy adults and full members of society. As I said in my book, we talk about health as a primary asset individually for happiness, but also for employment, let alone the impact on the economy of this nation. I think we're going to have to take a big step change. I've suggested that we actually need to start the debate properly around an index, a national health index that measures things and makes us have the debate.

I've suggested that we need a public health investment fund that actually looks at return on investment in 10 and 20 years because that thing allows you to work through and find the evidence for what really works, and do things differently. The moment we can see there aren't enough nudges to help people take the healthy choice, we can see the network effect of once you've got some overweight and obese people in your social network, it normalizes and then it becomes that other people join them.

We've got to really make a step change. I've also argued that we need a national bank for health that looks at our stock of health, and actually balances how we fund and where we fund. I think we need a dramatic upgrading of how we regard these issues.

Jennifer: If you say that we do need a long-term commitment to public health over 10 to 20 years to get incremental change that seems intelligent, how do we bind governments into that pathway? Sally, you and I were on a webinar recently where we talked about commitment devices for long-term policymaking. Why would any government commit itself to that pathway?

Sally: Well, I appreciate it's difficult, but COVID has woken people up to the impact of chronic diseases and overweight being underpinning many of those, and then what happens when you get an infection? I think people are primed to do something different.

James: I think it is possible. If you have cross-party agreement, think of the net-zero by 2050 target. That's an example of something where I think whoever wins the next election, you're not going to see a radical shift in strategy on that. I also think that, frankly, you've seen in this COVID crisis, how potent the arguments about protecting the NHS are. I think one argument that needs to be made more is that unless we as a country get a grip on this issue that is going to place ever-increasing burden on the health service that the health service will really struggle to deal with. I think that is an argument that I think would resonate with people.

Harry: Can I chip in here? I think one of the things we're really bad at in public health is thinking long term and there's a whole load of reasons for that. One of them is that we have a research system, an evidence generation system that is focused on short-term research projects, that give us approximately short-term answers to proximal risk factors. We have an evidence-based that is telling us about things that might or might not work quickly. We don't have much of an evidence base about things that might take 10 or 20, or 30 years to take effect. It's just much harder to do that. It's harder to get funding for it.

One of my little mantras is 20-year vision, five-year strategy, one-year plan. Let's think where we want to be in 20 years time. Let's get some broad agreement on it. Then what are the things that are realistic, feasible, and appropriate within any political cycle in this country, five years, whatever it might be. But the minister does need to know what he or she should do now. That's also entirely appropriate. You have a one-year plan for what ought to be done. What we tend to do is just say, what's our one-year plan, rather than thinking through how can that one-year plan sit sensibly within a five-year strategy, and help us to achieve that 20-year vision.

Jennifer: What we've got in front of us is a government with a leveling up agenda. I was going to turn to James next to ask whether or not you thought that health played any role in that agenda? Indeed, is the leveling up agenda still on the agenda? Is health part of it or is it really mostly about the economy and infrastructure investment?

James: I think the extent to which health is part of the leveling up agenda is probably limited in the current thinking to building new hospitals in these places. Obviously, the health challenge is part of what determines the quality of life. Obviously, a healthier society is a happier society.

Jennifer: Sally, where do you find that there's inspiration? You talked about the well-being index ONS I think are going to be publishing soon, which tries to measure progress, not just by GDP, but also on looking at Green issues on health and other things as well as the economy. Clearly, New Zealand is trying that now. Do you look to them for inspiration?

Sally: Well, I think we do need it. After all, I recommended the Composite Health Index. They've gone from the areas that we suggested social determinants of health modifiable risk factors and outcomes and rename the layers very well, I think, into healthy people, healthy lives, healthy places. I think that's good. It'll start a debate. But where would I look? Well, I think that Amsterdam have done some very good work. What I think has not yet been internalized by society is that unhealthy people not only have higher levels of mental ill-health and distress, they have higher levels of sickness, and they are not as employable.

Our economy and our employment prospects would be greater, which then feeds through to individual contentment and families and community well-being, if you want to use that. It's multifaceted. It isn't just about using the NHS. It's about our mental health and it's about our community health and our financial, economic health as a nation. I'm sure that this government are going to want to look at health in a big way once they understand all of this in their levelling up agenda. It has to be central.

Jennifer: James, the number of issues being faced by the government, big issues, legion, aren't they? There's Brexit. There's COVID. There's the long-term in fact of the economy. Have they realistically got the bandwidth over the next one to three years to be able to even make any inroads in this agenda that we're talking about?

James: Public Health is going to shift massively to pandemic preparedness. I think that's going to become a much, much bigger issue. People are going to be much more interested in a public health infrastructure that can deal with those problems. I think, though, there is almost certainly a window of opportunity. I know I risk irritating Harry by saying this.

I think a lot of people have become more concerned about their own weight during this crisis because it has been flagged up so regularly by the media as a risk factor. I think there is probably an opportunity to try and promote healthier lifestyles now. Again, I think the tone of it will have to be a more positive and more upbeat tone than, perhaps, some of the campaigns of the past have been.

Harry: You're not irritating me at all in that, James. I agree with you and I think we should absolutely go with that. I guess, what I'm saying is that there are enormous opportunities here. There's a lot of very optimistic and I think rather over-optimistic rhetoric around this concept of build back better, but there really are opportunities for win-win-win scenarios. We've got to create safe environments for people to be able to get to work using active travel. Even if everyone could afford a car we wouldn't have space for everyone to get to work in them. Healthier food creates a healthier population. A healthier population makes lower demands on the NHS is more resilient to this pandemic and will be more resilient to future pandemics.

There are win-win-win opportunities here that will help us to meet our climate goals, that will help us to meet our air pollution goals, that will help us to meet our health goals, and will help to reduce costs and burdens on the NHS.

Sally: I think, for me, the issue is this is a moment in time with COVID when everyone has woken up across the nation across the world, to the damage that obesity is doing to our health. This is a very important moment where you can get away with things that normally you couldn't, and it would be a pity to squander it.

Jennifer: This has been a fascinating discussion and one will doubtless return to. For now though, a very big thank you to our three guests today. Dame Sally Davies, James Forsyth and Harry Rutter. In our show notes, you will also find a link to the recent polling by Ipsos MORI for the Health Foundation, looking at the public's views on the government's role in managing our health. Join us next time when we'll be exploring how the NHS should move forwards in 2021, in the light of the pandemic, and, hopefully, its then aftermath.

Do join us for that one, and in the meantime, thank you for listening.