Although professional confidentiality might make us feel uncomfortable debating the personal illnesses of our politicians, case examples and personal accounts can be highly effective learning tools, helping us understand the realities of illness and the importance of health messages. The public reflections of our Prime Minister, Boris Johnson, about his obesity status being a significant factor in his torrid and serious COVID-19 experience opens up a set of important considerations.
Is this an example of anecdote influencing policy? Boris’s “get on your bike” message is viewed by many as an overly simplistic and potentially stigmatising response to such a widespread, complex and serious illness. In reality, this personal responsibility message fits a long-practised and opaque narrative of shifting blame away from government policy – and all the costs thereof – but also away from the food industry, who clearly have such a vital role to play in resurrecting the economy through our deepening recession.
That’s not to say that bikes are not a great idea – for those able to ride and who have access to one. Indeed, healthcare professionals can do much to support people with obesity in getting fitter, developing healthier eating habits and exploring motivational triggers to remain engaged over time. The deeper concern is how such simplistic sound-bite policies skim straight past the well-known problems illustrated by the Inverse Care Law (Tudor Hart, 1971). Boris’s big bike push will trigger action in some people but risks further expansion of the gap between the readily engaged and the hardest to help.
But does this new policy paper offer more? The document, Tackling Obesity: Empowering Adults and Children to Live Healthier Lives, published on 27 July (Department of Health & Social Care, 2020), outlined much that we already know, such as obesity’s links to long-term conditions, and our expanding knowledge about the COVID-19 virus’s ability to tap into and amplify co-existing metabolic weaknesses. It seeks to understand reasons behind the stark COVID mortality rate differences seen in different ethnic backgrounds. Office for National Statistics data from March to May 2020 show that the COVID-19 mortality rate was highest among males of black ethnic background, at 255.7 deaths per 100,000 population, and lowest among males of white ethnic background, at 87.0 deaths per 100,000 (Office for National Statistics, 2020).
“… some people from black, Asian and minority ethnic populations are susceptible to obesity-related diseases, like type 2 diabetes, at a lower weight status compared to white populations.”
Details remain sketchy as to whether this policy proposal will drive genuine change, or if the financial investment required for genuine change will be forthcoming in such economically constrained times. The Obesity Health Alliance, a strong supporter of the effective Sugary Drinks Industry Levy, calls clearly for further environmental change and a change in food culture, beginning with limits on junk-food advertising, which is particularly impactful for children.
“There is overwhelming evidence that junk food advertising works. So, when adverts for unhealthy food and drinks dominate prime-time TV and social media, while the nation struggles to maintain a healthy weight, this is a problem. A 9 pm watershed on junk food advertising would put healthier foods in the spotlight and provide an incentive to the food industry to reduce sugar, fat and salt from their products, which would benefit everyone.”
The new policy tentatively begins on this journey, suggesting further consultation, but aiming to address both television and online promotions of high fat, salt and sugar foods by end of 2022. Similarly, cautious plans to improve front-of-pack calorie labelling and encourage calorie labelling in restaurants and out-of-home sites mentions further consultation rather than advocating bold immediate action.
Other stated ambitions of the policy include extending existing plans for NHS Tier 2 weight management support for anyone living with obesity, not just those with type 2 diabetes and/or hypertension. Further NHS Diabetes Prevention Programme expansion will be targeted at areas of particular high COVID-19 prevalence.
It is unclear what level of funding, training or standards of care will accompany the policy’s aim of “supporting Primary Care Networks to equip their staff to become healthy weight coaches though training delivered by Public Health England.” Let’s hope that the existing useful suite of patient resources, such as the Better Health app (www.nhs.uk/better-health), the ever-popular Couch to 5K and the NHS 12-week diet and exercise plan, continue to be invested and maintained online.
In view of successfully embedding stop-smoking messages into healthcare, the role of primary care teams is highlighted, with plans to incorporate incentives through the Quality Outcomes Framework (QOF) in England to ensure everyone living with obesity is offered support for weight loss. Key to this being impactful is that “appropriate” support is offered and backed up with comprehensive obesity service availability (including metabolic surgery), rather than tokenistic nagging triggered by yet another tick box, which might otherwise generate harm (Lewis, 2015).
An additional aspect that is rarely considered relates to “disease prestige” or disease hierarchy. Qualitative research indicates that brief interventions on health promotion topics are perceived as low-priority/low-prestige topics and are, therefore, not worthy of major focus, particularly when there are competing pressures within a time-limited consultation (Haldar et al, 2016). Even with QOF incentives, training to promote the value and impact of supporting weight management will be crucial in tackling existing “personal responsibility” attitudes, reducing stigma and promoting integrated patient-centred care. This matters particularly for people with several comorbidities, where care should begin with “What matters most to you?” Otherwise, we risk repeating the general practice physical activity questionnaire (GPPAQ) disaster of 2014/15, where a profoundly evidence-based brief intervention was rolled out through QOF, then rapidly retired due to poor communication about its value to GPs (Robinson, 2013).
To complicate our understanding of how this policy statement might progress care for people with obesity, we now hear that Public Health England is to be disbanded, rebadged and “repurposed” (BBC News, 2020). What will that mean for an embryonic policy statement that has barely emerged and now sits blinking at its parent organisation that is now morphing into…? Well, we’ll have to wait and see.
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