Overcoming policy cacophony on obesity: an ecological public health framework for policymakers

Like others, we see the recent rise in obesity as the result of past decades of societal, technical and ideological change. The pace and scale of change may only now be gaining attention, but the evidence has been strong for decades (1). Part of the search for solutions must be the investigation of not just what the drivers of obesity over time have been but how they interact. Too many analyses of obesity are locked into disciplinary 'boxes' when, given the complexity and breadth of such drivers, it is likely that obesity requires a broader interdisciplinary analysis and a sustained, society-wide response. By implication, 'quick fixes' or single-factor remedies are unlikely to work. On a positive note, political processes are beginning to emerge giving due priority to the obesity crisis. In the UK, after a National Audit Office report and the Chief Medical Officer's clarion call about obesity being a 'timebomb', the issue climbed up the national policy agenda (2,3). A Parliamentary Inquiry spelled out the complexity of the issues and gave suggestions for direction of travel (4). All the devolved governments of the UK now have commitments to tackle obesity. However, even the briefest review of recent trends shows the scale of difficulties. In Scotland, childhood obesity is rising rapidly, with levels of overweight and obesity among younger and older children at double the levels that might have been expected on the basis of data for the UK as a whole (5). Currently in Scotland, 26% of women and 22% of men have a body mass index (BMI) of >30 and 65% of men and 60% of women have a BMI of >25 (6). Data from the Scottish Health Survey 2003 reported that people living in the most deprived areas were more likely than those in the least deprived areas to be obese or morbidly obese, and morbid obesity was three times higher among women in the lowest-income households than in the highest. In England, the 1992 Health of the Nation, the English national strategy for public health, introduced a target to reduce the proportion of obese men aged 16–64 in the population from 7% in 1986–1987 to 6% in 2005, and obese women from 12% in 1986–1987 to 8% in 2005. A 1996 review of the Health of the Nation by the National Audit Office showed that by 1993, the proportions of obese men and women in the population had risen to 13% and 16% (7). By 2003, 22% of men and 23% of women were obese (8) and by 2010, on these trends, obesity will rise to 33% of men and 28% of women. Childhood obesity in 2–10-year-olds has risen from 9.9% in 1995 to 14.3% in 2004. On current trends, 20% of 2–10-year-olds – more than 1 million children – will be obese by 2010. In order to redirect these trends, the Government in England, through the Department of Health, is currently promoting a new initiative based on social marketing called 'Small Change, Big Difference'. Although this differs from the US approach to social marketing, which focuses heavily on changing individual behaviour, it is nevertheless still framed in terms of the personalization of health choice (9). The Government in England introduced a new obesity target for children ('halting the year-on-year rise in obesity among children aged under 11 by 2010 in the context of a broader strategy to tackle obesity in the population as a whole') initially focusing on children aged 2–10 years, and their parents and carers. Given the shallow reach of the National Health Service (NHS) into local communities, growing attention is given to the role of local government, with obesity prevention inserted into Local Area Agreements (LAAs), the national-local framework for service delivery. One example of an LAA obesity target is for the northern town of Barnsley. Agreed in July 2005, this sets a maximum prevalence target for obesity of 15.5% for children aged 2–10 years (10). This figure is all the more striking given that the prevalence of obesity in 1984 among 4–12-year-olds in England was 0.6% in boys and 1.3% in girls (11). Other LAA targets relate to precursors of obesity, such as participation in sports or access to free school meals. The implication, perhaps, is that an ambitious target would not be likely to be achieved. The figures for most of Europe may not be as alarming as for the UK. Nevertheless, they are moving in the same direction. In policy terms, there is manoeuvring and 'testing' of strength of feeling and options. Targets are also being set, but as yet – as in the UK – there are few strong interventions to deliver them. Currently evolving policy frameworks, including that of the European Commission's obesity Round Table, which draws on its 1996 Amsterdam Treaty health powers, appear 'soft' rather than 'hard', and rely on goodwill and voluntary action more than structural, regulatory or fiscal change (12). There are many competing diagnoses of what 'really' matters in obesity generation. Different analyses and policy solutions have been developed and proffered, each clamouring for support, funding and adoption. The increasing sophistication of different positions actually adds to the complexity of the policy challenge. For policymakers, now worried about the cost of obesity (and the spectrum of ailments linked to it, such as diabetes), there is a situation we describe as policy cacophony – noise drowning out symphony of effort. This cacophony is not helpful because policymakers need coherent directions on which they feel they can deliver. Obesity policy is already weighed down by complexity, accentuated by the multi-level (global, European, national, regional and local) nature of modern systems of governance. It is also shrouded by ideological fears such as interventions being interpreted as 'nanny-ish' or restricting 'personal' choices in food and lifestyle. Compounding this policy cacophony are two other difficulties which this review sets out to address. The first is time frame. Obesity is a problem that has taken decades to develop. Bar sudden external shocks to society, such as a massive oil shortage or price rises that make walking a necessity, it is likely to take many years to bring it under control. Yet, the political timetable demands quick results. Second, there is a difficulty about evidence. No country has managed to reverse obesity trends, or at least not so far. To some extent, part of the obesity policy problem is the evidence, or lack of it. Yet, the rise of obesity is literally visible and the explanation and ways forward are hard to pinpoint. This does not mean we favour disregarding evidence, but rather that we see obesity as a test case for policy changes in advance of perfect evidence. Faint hearts privately muse that obesity is too complex. But we see obesity as akin to that of climate change – complex, yes – and demanding firm action, however hard that might be. Why is obesity a problem? Who is it a problem for? Where did it come from? These simple questions have to be asked. Half a century ago, in the years following World War II, millions of UK citizens and other Europeans went hungry, and obesity as a medical condition appeared little more than as a curiosity. These events framed British determination – and, for that matter, on both sides of the Iron Curtain – to rebuild agriculture (albeit in different ways) (13–15). Even just a decade ago, with most of Europe more than adequately fed and European Union (EU) farming policy consuming almost half of the EU budget, the average politician might have remarked that obesity was an irrelevance. To find a comparable society suffering from obesity meant travelling to the USA. Until just two decades ago, Britons flattered themselves that the UK, even with its constricted food culture, possessed factors that immunized it from US trends: smaller food portion sizes, cost-conscious purchasing habits, a less car-dominated society and, perhaps, too, a culture which supported personal resolve to maintain optimal body shape in a social environment less concerned with consumption volume. But the UK – and the rest of Europe too – appears to be steadily succumbing to what is sometimes unfairly called the 'Americanization' of diet and society: the rise and rise of car culture and other technical 'advances' marginalizing daily physical activity; widening distances between homes and work or shops; the over-consumption of food accompanied by its unprecedented, plentiful availability; the culture of clever and constant advertising flattering choice; the shift from meal-time eating to permanent 'grazing'; the replacement of water by sugary soft drinks; the rising influence of large commercial concerns framing what is available and what sells; and more (16–19). Today, the rise in population weight in the UK remains behind US trends, but only as a matter of degree. Copious evidence exists that both adults and children are affected by rising weight. The UK is now one of the leading countries for population weight gain, although there is still considerable variation in trends across Europe (20). Most worryingly, the biggest national weight increases among children have been in countries such as Greece and Spain, previously justly celebrated for their Mediterranean diets, high in vegetables, pulses and unrefined carbohydrates, culturally close to the land (21). While this needs to be researched, it is possible that a transition to a diet composed of energy-dense foods (high in fat and low in fibre) makes speediest headway in countries that have had high income growth and exposure to more commercialized food pressures. Obesity is emerging in places with supposedly strong and protective food cultures. Although obesity is highly complex, there are some core truths on which thinking can be developed. We suggest the following: Obesity is not just a phenomenon of the UK. Rates are rising across Europe but there is a particularly worrying acceleration of rates among children (22). Obesity is known to lead to medical problems, long documented although only formally classified by the World Health Organization (WHO) in 1997 (1). There are serious and rising social and financial burdens stemming both directly and indirectly from obesity (23). Obesity is linked to other societal trends and risks, such as changed food production, motorized transportation and work–home and lifestyle patterns (1,4,24,25). Policymakers have been slow to recognize the seriousness of the issue, which suggests the public health movement has been slow or ineffective in its advocacy work or that the evidence is not easily translatable into policy or lacks political champions (26,27). Remedies based on individual action alone, whether diet plans, surgery or stigma, have limited effectiveness in population terms and often come at a high cost. Part of the difficulty in generating effective policy is having a policy package that will deliver a corrective population-wide shift (20,28,29). There is a powerful temptation in Government to limit actions to a choice-based, personalization approach, in part because this style of intervention is aligned to the commercial sector's own customer management and marketing methods, but also because a cross-society approach appears so big in conception that failure is assumed (30,31). Both in the UK and more widely in Europe, and despite some welcome initiatives (9,32), there are, as yet, no comprehensive structures or set of policy models for what to do about obesity. There is as yet no Finland or North Karelia project doing for obesity what that country did for tackling premature diet-related ill health from the 1970s (33). We are generally still at the 'talking stage' of policy, albeit with some specific initiatives and a child obesity target, rather than well into implementation. Food companies are not adequately changing their behaviour in response to the request to do so by the WHO under its Global Strategy on Diet, Physical Activity and Health. On the contrary, there is evidence that the big food companies are for the most part unconcerned (34). For all the above reasons, obesity has to be seen as not just a technical, food, physical activity or healthcare problem but a challenge for what sort of society is being built. This is why obesity is beginning to engage social policy interest (30). The deceptively simple issue of how to encourage physical activity across daily life and modify dietary intake in fact raises complex questions about the need to reshape public policy across a number of areas. These include: agriculture – because policy affects what is produced; manufacturing – for ingredients, portions and products; retail – for planning, prices, availability and location; education – for health knowledge and skills; culture – for the shaping of consciousness around food and physical activity; trade – for product pricing and terms of trade; economics – for differential taxation and subsidy of foods. Part of this complexity is how to judge what is the appropriate level for policy action and intervention. Who is responsible – local, national or international governance? And how radical or limited should policy be? Small, incremental, publicity-driven (i.e. social market-based) changes might suit the existing balance of policy interests, but what if evidence suggests that a more extensive, co-ordinated, cross-sectoral action would be more effective? There may be little payoff from working on one aspect of obesity without tackling other determinants as well (4). The challenge is to produce policy analyses and solutions that work across policy boxes not just within them. And, again, there is the problem of evidence. Despite the persistent calls for evidence-based policy, obesity illustrates the gap between policy and evidence (35). How much evidence of prevalence and impact will it take for policy to change? How might that be accumulated and interpreted? Where is the role model (again, Finland's North Karelia project) for obesity that might encourage policymakers not to be fatalistic about obesity? (Might it be Sweden this time?) Is a beacon country even possible in a globalizing world? The Finns tell us they could not do today what they undertook 30 years ago; today's policymakers lack control over media (advertising, lifestyle), agriculture, or the cultural coherence that they had then. And is modern policy reliance on consumer choice as a driver of change adequate to deal with obesity, especially given the vulnerabilities of social class, sex, age and genetics? Will better food labelling, despite all the attention given to it, have any sustained, positive effect? Or might prices that internalize currently externalized health costs be a better option (36,37)? These and many such questions explain why obesity is a major challenge not just for European medicine and public health but for governance, the art and practice of government and decision making, let alone shifting food supply patterns. It is also the reason why the appeal for policymakers of taking a science-based, though in fact medicalized, route of individualized treatment through drugs, therapy and, at the most extreme, bariatric surgery, is still considerable. If obesity is caused by a matrix of factors and policies beyond health, how can health policymakers win sufficient attention to ask other ministers to drive change? There is a risk of appearing to be doing something through a scatter-gun of announcements; these may include targets, new guidance – even if by the National Institute for Health and Clinical Excellence (NICE) – or research grants in pursuit of wonder drugs or technical fixes such as functional foods or nutrigenomics. Obesity prevention could even evolve as a major research and policy intervention 'industry'– with mounting expense to the public purse, but unable to deal with the fundamentals. It may only endlessly address symbols and symptoms rather than causes. Even as the scientific understanding of obesity gets more sophisticated, the overall policy situation becomes potentially more muddled. The lack of solid evidence can lead to uncertainty over what action to take (4,38,39). 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