Obesity strategies ignore obese people

Some time around 1990 I was involved in some work for Bradford Health Authority that touched on the use of data to improve the impact of public health messaging - we were looking mostly at HIV/AIDS and diabetes. The difficulty for the health authorities came when we pointed out that AIDS really wasn't an 'all population' risk except in the very broadest of definitions. There were some groups in Bradford - gay men, intravenous drug users, African immigrants - where the risks were far higher. We suggested profiling and targeting so as to get the best value from the limited pubic health funding available (especially since there were extensive national media information campaigns about AIDS at the time). This was rejected because of 'stigma' or a risk of being perceived as racist or homophobic.

The consequence of this refusal to use profiling is a belief that, not only are the risks equal across society, but that public health strategies should be directed to the whole population regardless of the truth about those risks. This 'whole population' approach has been widely debunked with alcohol consumption (although its advocates continue to use models to pretend that the merest sip of the demon drink lead inevitably to ill health) and we see it also with obesity where the public health focus is on what they call Tier One Intervention - stressing the 'social determinants of health'.

With obesity, the result is that health funding is directed primarily to seeking behavioural change in the whole population - weighing children, getting shouty chefs to bang on about school dinners, browbeating restaurants to make portions smaller or offer salad, banning kebab shops anywhere near children and getting Lucozade to make their core product taste awful. This is despite the fact that 95% of the population isn't facing any serious health risk from our weight. We use 'scare statistics' about how two-thirds are 'obese or overweight' and then illustrate this with images of a 25 stone person rather than the reality that 'overweight' (BMI 26-30) really isn't anything that 'a little more exercise and fewer puddings' wouldn't sort out and probably isn't unhealthy either.

At this point the Guardian notices that the UK, compared to other places, doesn't do much bariatric surgery on obese people:

What’s going on? The procedure is the most effective way of helping people who are obese to lose weight and can have a radical impact on their quality of life. At approximately £6,000 per operation, it’s relatively cheap and saves the NHS significant amounts of money on more expensive procedures such as hip and knee replacements further down the line. But here in Britain, it is being reserved only for the most extreme cases.

This situation is entirely a consequence of stressing Tier One rather than looking at higher tiers. You could call this 'fat shaming' but I prefer to call it massively stupid public policy. There are around 5% of the population with a serious, health-threatening weight problem but public health is too busy making out that obesity is the biggest health problem in society (and getting schools to write unpleasant letters to parents about their children's weight) to do its job of helping those people who really do have a problem with their weight.

None of this Tier One effort makes a blind bit of difference to levels of morbid obesity. If you take the sugar out of fizzy pop, obese people just switch to another calorie-loaded drink or food. Campaigns about fizzy pop, pizza or burgers result in thin people changing their diets (and talking endless rubbish about 'low carb' or 'clean diet') but do not look at the reasons why some people - maybe one in 20 - are very fat. And the same goes for exercise - it's probably a good thing that active living promotions have helped shift a further 3-4% of the population into regular (the approved 30 minutes a day) physical activity but it isn't working for the 50% of folk who do next to no exercise.

For all that the NHS bosses say obesity is their number one priority, we see that actually doing something to help people who really are obese isn't included within that prioritisation. Instead we get an increasing pile of pointless and intrusive fussbucketry masquerading as an 'obesity strategy'. While all this righteous lecturing about food (and attempts to make out that it's not fat people's fault that they're fat by blaming the food industry) is going on, the option of targeting efforts on the very obese is ignored. Public health wants to change the behaviour of the whole society - despite most folk's behaviour not seriously risking their health - rather than help the people who, for whatever reason, are riskily overweight. It's perhaps time we started talking about the problem - and helping those with it - rather than making up a sort of moral panic about lots of people being a few pounds heavier than they used to be.

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