Action on obesity

There are over 190 individual established determinants of obesity. These are mainly environmental and account for the increase in obesity we have seen over the past 30 years. While there has been a doubling of the population with a body mass index (BMI) over 30kg/m2 in the US, there has been a 1,200% increase in the prevalence of BMI over 50.¹ This, coupled with the understanding that weight gain is 90% irreversible for 90% of people, has to put prevention at the core of our societal efforts around overweight and obesity. 

The gains in life expectancy over the past 60 years are now clearly threatened by the diseases that obesity causes and makes worse – which in reality is every disease – including type 2 diabetes, cancer, dementia, sleep apnoea and asthma. While the recently launched Government policy and action plan prioritises prevention and has a clear plan of action, it will be the vitality with which this is driven that will determine its success.

National Obesity Policy and Action Plan

The main positive aspects of the plan are its focus on prevention and its clear recognition of the need to reach beyond health for meaningful cross-sectoral action. Development of the policy also included a consultation with children and young people as part of the groundwork to inform it and looks at approaches led by government (a sugar tax). It also involved consulting people in local communities (the Wicklow ‘No-Fry Zone’ campaign being a good example). 

There was also very strong engagement with the Royal College of Physicians of Ireland (RCPI) Policy Group on Obesity. This included representation from patients as well as healthcare providers involved in primary, secondary and tertiary care. 

Significant information from the RCPI obesity report is reflected in the Department of Health Obesity Policy and Action Plan, including the majority of the high-level recommendations. This level of interaction between the Department of Health and RCPI in the area of health policy is one of the most positive developments I’ve seen in Irish health planning in recent years.

Target of the National Obesity Policy

There is a five-year target of a 0.5% reduction per annum in level of excess weight in both children and adults; and a 10% reduction in the gap in obesity levels between the highest and lowest socioeconomic group. Progress toward these targets will be measured by the Healthy Ireland survey.

Overall, the targets appear in line with, if a bit more modest than, the targets specified in the Healthy Ireland Framework published in 2013. The Healthy Ireland Framework set a target of an increase of 5% in the number of adults with a healthy weight and a 6% increase in the number of children with a healthy weight by 2019. 

The 10 steps forward

The Obesity Policy and Action Plan sets out 10 interdependent steps towards preventing overweight and obesity between 2016 and 2025. Each step also has a number of priority actions associated with it:

• Step 1: Embed multi-sectoral actions on obesity prevention with the support of government departments and public sector agencies

• Step 2: Regulate for a healthier environment

• Step 3: Secure appropriate support from the commercial sector to play its part in obesity prevention

• Step 4: Inform and empower change through a clear communications strategy

• Step 5: Leadership will be provided by the Department of Health

• Step 6: Mobilise the health services with a focus on prevention

• Step 7: Develop a service model for specialist care for children and adults

• Step 8: Acknowledge the key role of physical activity in the prevention of overweight and obesity

• Step 9: Allocate resources according to need in particular for children and disadvantaged groups

• Step 10: Monitor, research and review.

Many of these are actions that the RCPI has actively called for. For example, priority actions under step 1 include a whole-of-school approach to healthy lifestyle programmes – including, but not limited to the curriculum. 

This recognises the unique opportunity inherent in the education setting to promote healthy diet, physical activity and to influence the lifestyle habits of tomorrow’s adults for the better. In particular, we would hope to see arising from this action initiatives such as the teaching of nutrition, cooking and budgeting skills for all students. 

Another priority action under step 1 relates to fiscal measures to support healthy eating. We have been very explicit in our support for a tax on sugar-sweetened drinks. These calorie-dense, nutrient-poor drinks have no place as part of a healthy diet, and there is a sound body of literature indicating that consumption of such drinks contributes in a significant way to weight gain.^2,3,4

The sugar tax

This is only one of a number of measures needed to respond to a problem that has so many underlying drivers. The RCPI feels it is a vital piece of the puzzle. 

Getting the sugar tax on the political agenda was no small achievement, but there are some concerns: initially, the sugar tax was billed to be introduced in Budget 2017. Delaying it until 2018 and putting a further public consultation process in the mix ahead of its introduction is a worry, and may cause a loss of momentum. 

All of us who are concerned with prevention of obesity need to engage with the public consultation on this – there is sure to be fierce resistance from industry and the public health argument cannot be lost, this is far too important. 

A healthier environment 

Changing the obesogenic environment is key. Educating children in schools on healthy eating and physical activity is not going to change anything if outside the school gates, they face a food environment centred on the promotion of high-calorie, high-sugar products. Education is not going to change anything unless the built environment supports physical activity and especially active travel.

I’ve seen in the past year or so, how in Greystones, a strong campaign was initiated by parents to introduce a ‘No-Fry Zone’ around schools, under the local development plan. The recent final ruling in favour of this is a potentially invaluable precedent. 

Such a measure must not be a once-off occurrence, and it should not take such efforts from parents and health professionals to draw attention to this – protecting health has to become everyone’s business and should be a fundamental aspect of local development planning. 

Calorie posting

Legislation for calorie posting is another priority area under this step, and has already been adopted by many restaurants. This, along with review of labelling of food products, is aimed at giving consumers the information they need to make informed decisions around the food they consume.

I hope this will translate into a front-of-pack traffic light system in addition to reference intake, as there is positive feedback from Irish consumers on the ease of use of this system.⁵

The Department of Health has also committed to making a submission to the Broadcasting Authority of Ireland’s review of the Children’s Communications Codes. Such submissions from health bodies are vital to limit children’s exposure to advertising of unhealthy foods (high fat, salt and sugar). 

Both in an individual capacity and as chair of the RCPI’s Policy Group on Obesity, I’ve been very outspoken on the issue of advertising and promotion of unhealthy food to children. I feel very strongly that this is a child protection issue. 

The UN Convention on the Rights of the Child states that children have the right to “nutritious food, a clean and safe environment and information to help them stay healthy” and the World Obesity Federation has identified commercial marketing of foods and beverages to children as a major driver of the obesity epidemic.

Support from the commercial sector

The appropriate support that the commercial sector can provide for the reduction in obesity levels is outlined under step 3 of the report. Targets for industry reformulation that would see widespread reduction in consumption of calories/sugars is to be welcomed. Strong codes of practice for food promotion, marketing and sponsorship with appropriate oversight is also critical. 

The National Obesity Policy seeks to capitalise on where the food industry has made positive contributions to prevention of obesity. What needs to be remembered is that ultimately, the commercial food companies have a primary responsibility to shareholders. 

A keen awareness of this has to underpin any dialogue with the commercial sector on reformulation, development of codes of practice and other related measures.

Service model for specialist care

Steps 6 and 7 outline actions within the health services to address overweight and obesity. Obesity prevention and care is foreseen as part of GP contracts. Combined with actions to strengthen capacity of primary care teams and implementation of the ‘Making Every Contact Count’ brief intervention model, this will go a long way towards ensuring that issues are identified and responded to at the earliest stages of contact with the health services.

Stigma associated with overweight and obesity presents a challenge for health professionals in addressing the issue with a patient, or with parents of a child. The training colleges will play a role here in addressing this head-on in courses on overweight and obesity. 

The specification of development of a service model for specialist care for adults and children is a particular strength of this policy. Current specialist service provision in Ireland is low compared with other European countries and needs strengthening – both in terms of surgical and non-surgical services. 

Appointment of a national clinical lead for obesity, who can oversee the development of a model of care, is a crucial step that will allow obesity to be addressed on a par with chronic conditions such as diabetes, heart failure and stroke among others. 

In the same way that national clinical leads in those areas have improved outcomes for patients through development of standards and models of care, the clinical lead for obesity, adequately supported and resourced, will drive improvements in services for people who are currently overweight and obese.

Funding and implementation

This Obesity Policy and Action Plan will only be as good as the energy and resources put behind it. It is our ‘next 10-year shot’ at addressing the biggest public health issue of our day that as it currently stands is contributing to every overrunning budget, every overcrowded emergency department and almost every waiting list. 

The policy is good, the action plan is set out, but as of going to press there is no identified budget to implement the action plan. The Department of Health is pushing hard for money, and some has been identified for a Healthy Ireland Fund. That will address only a small part of the overall Obesity Policy and Action Plan. 

The original Obesity Taskforce which reported in 2005 did not receive the funding required to implement its action plan. Let’s not let another good and comprehensive obesity policy and action plan go to waste. We cannot afford another lost decade.

The action plan can be accessed on: http://health.gov.ie/wp-content/uploads/2016/09/A-Healthy-Weight-for-Ireland-Obesity-Policy-and-Action-Plan-2016-2025.pdf

References

1. Sturm R, Hattori A. Morbid obesity rates continue to rise rapidly in the United States. Int J Obes 2013; 37(6):889-91
2. Vartanian LR. Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. American Journal of Public Health 2007; 97(4): 667-75
3. Te Morenga LA, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ 2013; 346: e7492
4. Malik VS, Pan A, Willett WC, Hu FB. Sugarsweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. American Journal of Clinical nutrition 2013: 98(4): 1084-1102 
5. RED C Research & Marketing (2010. Food labelling research. Commissioned by the Irish Heart Foundation (IHF), National Youth Council of Ireland and Irish Cancer Society. Retrieved from http://www.youthhealth.ie/sites/youthhealth.ie/files/Food-Labelling_Research.pdf on the 25/06/2014