You don’t need scales and height-weight charts to realise that people are fatter than they used to be. It’s clear that obesity is already damaging patients, and that in years to come it will take a huge toll on the nation’s health.
As GPs we have always tackled our patients’ obesity. Now we are going to be commissioning. What obesity services should we commission?
Homo sapiens evolved to exploit any opportunity to eat. Humans are not programmed to exercise restraint. But now food is abundant, our lives don’t demand physical exertion, and restraint is out of fashion. So is drudgery. The food industry has responded to provide immediate gratification and foster a culture of grazing and snacking at all hours – and not on raw carrots.
It’s not just what we eat outside the home. Apparently 75% of the nation’s diet is now processed food, carefully formulated to increase the desire for more … and more … and more. It slips straight down so it doesn’t stimulate satiety, so we buy super-sized portions, bolstered with salt and sugar to increase both customers’ satisfaction and companies’ profits. And now around 60% of the population are overweight.
What can be done? There is no putting back the clock – mother in a pinny serving up a home-cooked roast meat and two veg to husband and two children, forks at the ready at the family dining table – those days are gone. The British have given up cooking. Thirty years ago, people on a budget stewed root vegetables with the extremities of quadrupeds. But these days, economic stringency isn’t driving people back to the kitchen stove. Rather, they choose cheaper pizzas.
It has been suggested that GPs should use every consultation to advise patients about obesity. It would certainly sour relationships if patients knew that consulting over a sore toe would include a nag about their diet, but it wouldn’t do much for the obesity problem. Kernels of information have to fall on fertile ground. If everyone behaved logically no-one under the age of 60 would smoke. Even doctors seek comfort in chocolate.
Sensitively given, information is important. Most people still have a sense of what is good for them, or they wouldn’t tell the practice nurse that they eat tons of fresh greens when in fact they buy all their food at Iceland. So advice which seems to fall on deaf ears may bear fruit (and veg) later on. Food labelling is useful, but reading labels takes time and literacy and commitment. How many people bother, unless they are worried the contents might make them ill? Similarly, only the motivated will stick with a weight management programme, and only if it works. A recent BMJ editorial reported that NHS services have a lot to learn from Weight Watchers about the value of regular group sessions, intensive support and incentives.
If we can’t change people, perhaps we can change environmental factors which influence food choices. Kids don’t like queuing for school dinners because it cuts into playtime. As well as banning fast-food vans, some enterprising councils provide vans which serve up food from the school canteen so that pupils can grab a fast but healthy lunch.
There is also what is now called nudging – changing social norms. It worked with drink-driving. Nudging the British public into choosing healthier foods is a bigger challenge, but serving burgers with salads instead of chips would be a start. More exercise would also help. Selling off playing fields was a nudge in the wrong direction.
But this is tinkering. We have to tackle processed food. Not easy. We are up against an industry that has the power to get pizza reclassified at a vegetable. Yes, the food industry pressured the US authorities to take this Alice in Wonderland decision! And we are up against the Daily Mail, ever poised to rage against the nanny state – which gives consumers a cop-out.
‘Make the healthy choice the easy choice’, says WHO. It can be done. Regulation plays a part – restricting advertising to children and reducing trans fats in processed food. It has been suggested that increasing the price of sugar would both please farmers and encourage manufacturers to cut down the sugar in their products or switch to cheaper, healthier sweeteners. The tax system could be used to make the healthy choice the cheap choice. Financial incentives could enable corner shops to offer fresher, healthier food.
Surprisingly, it appears that voluntary agreements can work. Over some years, several big manufacturers have reduced the salt content of foods, so slowly that consumers don’t notice. Such products aren’t advertised as ‘low salt’. That would kill sales. But they are always changing unobtrusively, and this change has lasting health benefits.
What about the 25% of food eaten outside the home? It’s a challenge; takeaways have very low margins and customers want to know the price, not the fat content of their fish and chips. But in Belfast, following workshops in Cantonese and a Masterchef competition, 68% of Chinese takeaways improved their food. Lincoln has a similar project with Indian takeaways. And even something as simple as providing salt shakers with five holes instead of seventeen can make a difference.
So what can we do, as clinicians and commissioners? Here are some suggestions.
- Continue to inform and remind patients, sensitively, about the risks of obesity and how to eat healthily.
- Know about effective dietary advice, support groups and weight loss programmes in our area.
- Set up partnerships with councils and other local organisations to improve the availability of healthy food. Spread information about it.
- Then doctors can offer real-world advice. We can direct patients to the healthiest pizzas, tandooris, Chinese takeaways. And after a long evening surgery, we might follow our own advice.
For further information go to The Food Network