This article by Dr Dolly Theis, then a PhD student with the Unit’s Population Health Interventions programme, was shortlisted for the 2022 Max Perutz Science Writing Award. You can read all ten shortlisted and winning articles here.
It’s April 2020. The Prime Minister Boris Johnson has just left hospital where he was in intensive care with serious Covid-19-related health problems. Evidence about who is more vulnerable to Covid-related complications and death is still emerging. However, one thing that appears to be clear is that people living with obesity are at a greater risk of Covid-19 related hospitalisations, serious illness and death. Having been sceptical of strong government intervention on diet and obesity just one year prior, the Prime Minister’s close encounter with death is catalytic and he decides that the government must do something about obesity. In July 2021, his government publishes an obesity strategy.
This year, 2022, officially marks three decades of government obesity strategies in England. The first was published in 1992 and it included some ambitious population obesity reduction targets. Needless to say, these were not met. In fact, in this time the obesity prevalence has actually increased from 13% of men and 16% of women living with obesity in 1993 to now more than a quarter of adults (27% of men and 29% of women) in 2019. How and why has this happened? How can government obesity policy have failed so badly after all these years? And what are the consequences of this epic policy failure?
Fuelled by these questions, I analysed the 14 obesity strategies for England that have been published since 1992, which collectively contain no less than 689 policies. My research found that successive governments have failed to successfully reduce the obesity prevalence and related inequalities not only because of the policy ideas proposed, but also because of the way they have been proposed.
The hundreds of different policy ideas to tackle obesity and the related inequalities include school food and curriculum changes, guidance and standards for the food industry, provision of healthy food vouchers for low-income families, and a weighing and measuring programme for primary school-aged children. However, research shows that the largest proportion of the policy ideas are unlikely to be effective or equitable. For example, information campaigns have remained very popular with the government. The thinking being that government publishes dietary advice, people engage with it, they change their behaviour, and then ultimately their health and weight improves. However, this is unlikely to work for most people because individual behaviour change is tremendously difficult, especially long-term and especially when you live in conditions or face circumstances that make such change very hard. Evidence shows that shaping the environment and other key external influences to make it easy for people to enjoy a healthy life is much more likely to be effective and equitable. And yet, a much smaller proportion of the government’s obesity policies have focused on doing this.
My research also found that the government has tended to propose policies in a way that makes it unlikely they will be implemented. I identified seven key pieces of information necessary for effective implementation, but only 8% of policies fulfilled all seven criteria, versus the largest proportion of policies (29%) that were proposed without a single one. Only 9% of policies were proposed with a cost or allocated budget, 19% with any cited scientific evidence upon which the policy was based, and just 24% were proposed with a monitoring or evaluation plan.
The above has led to an obesity policy merry-go-round where the same or similar policies are proposed again and again by different governments or different secretaries of states, and yet are largely unlikely to be effective and equitable or get progressed fully from implementation right through to monitoring, evaluation and beyond. For example, there has been a Conservative Party Government since 2015, which has published not one, but four obesity strategies containing many of the same or similar policies. New prime ministers have come in and instead of seeing through the policies already proposed or in progress, they have all published new strategies. But it’s not just new governments that can come in and start again. In the last year, Prime Minister Boris Johnson has scrapped or sought to delay or revoke some of his own 2020 obesity strategy policies.
Meanwhile, problems such as poor diets and rising obesity rates are getting worse. The Covid-19 pandemic revealed how serious the consequences of failed obesity policy can be, as the Prime Minister Boris Johnson so personally experienced. The Global Burden of Disease (2017) found that poor diet is a factor in one in five deaths around the world. Four of the top five risk factors for healthy years of life lost to disease, disability and death are related to poor diet and physical inactivity. The evidence is writ large that poor diets have devastating consequences and there is increasing evidence on likely effective and equitable interventions. So, why does government obesity policy not reflect this?
One major barrier is that governments have tended to favour a less interventionist approach to reducing obesity, regardless of political party. Political decision-making is a primary arena in which scientific evidence comes up against ideology. The influence of neoliberalism, which advocates broad notions of individual responsibility, choice, a market-driven economy, and anti-government intervention, has been found by previous research to clash with more interventionist public health policies. Governments may have avoided stronger interventionist policies, e.g., legislation and fiscal measures, for fear of being perceived as controlling what people eat. The vilification of such intervention is commonly referred to as “nanny-statism” – the unwelcome interference of the state in people’s liberties and choices. Since politicians rely on the electorate to vote them back into power and Government relies on Parliament to support and facilitate policies, maintaining public and political popularity and avoiding potentially unwelcome policies are important. The question that remains is can scientific evidence be viewed as being more compatible with a neoliberal ideology? And if so, then how?
Through my research, I am trying to understand how government policy can more effectively, equitably and rapidly solve major problems like rising obesity rates. Breaking the decades-long cycle of ineffective obesity policies not only has profound implications for population health, but for government and the way it works too. A 2021 National Audit Office report found that the Department of Health and Social Care did not know how much it spent tackling obesity and yet it continues to spend billions of pounds treating the consequences. From our own health to the way that our country is run, improving government obesity policy matters to us all.