An open letter to Boris Johnson on his war against fat

Inevitably your proposals grabbed the headlines but, on reading the small print, the strategy lost gravitas. Put it this way, sir: the whole thing could be read over a quick cuppa. True, it does list seven measures you want to introduce – and refers to another eight that are not yet “oven-ready” – but what is missing is the raft of measures which, if not addressed urgently, may well mean that you will never achieve your legacy, your pledge to halve childhood obesity by 2030. In a much more impressive document which England’s outgoing Chief Medical Officer, Dame Sally Davies, sent you last October (Davies, 2019), she detailed 49 measures to tackle the epidemic – and she was not just flying a few kites. She had, simply, reviewed the enormity of the task before us and, inevitably, specifically highlighted the issues that we need to take.

You will of course be pleased that the magnificent seven – the banning of buy-one-get-one-frees, sweets and other treats from checkout aisles, slapping calorie labels on food menus and alcohol, etc. – got a good generalist press, as did your Damascene moment of ditching libertarianism in favour of some tough nannying. However, you might not have welcomed specialist commentators bombing your idea that a bike ride or two would speed up weight loss and, at the same time, being told that your historical opposition to “sin taxes”, such as the Sugary Drinks Industry Levy – was pretty dumb (Gallagher, 2020). It is now widely accepted that levies to cover a range of other drink and food products are actually a rather sensible idea.

It is your abandonment of obesity prevention, however, that really prompts this letter. Though you begin promisingly, by saying that your aim is to “make prevention at the heart of this Government’s health agenda”, you come a cropper by omitting any measure that could be honestly described as preventative. Hopefully you will have had time in August to reflect on this omission whilst camping out with your three-month-old son and make amends now that you’re back in London. I refer to Wilfred deliberately to emphasise that, at his age, he is going through a period that is crucial to thwarting anyone becoming fat. Quite simply, the first year of a child’s life is a critical time to act even though it is already halfway through the first “1000 days” (Health and Social Care Select Committee, 2019).

Although this 1000-day period traditionally begins at conception, it realistically should begin with pre-conception counselling. Indeed, the seeds to avoiding obesity should be sown even earlier: in secondary school. Here, every schoolgirl should be taught how to get herself in shape before conceiving in order to give her child the healthiest start in life. Though she may not get round to parenthood for a decade or two, she might just remember this vital lesson throughout her childbearing years. Tragically, in Britain, the lesson seems not to be taught well – or even ever – as some 50% of mothers-to-be attend their booking-in weight check already heavily unhealthy. So job number 1 is to whisper in the ear of whoever happens to be the UK’s Education Minister at the time to get PHSE (Personal, Social, Health and Economic education) properly taught and excess weight in mothers sorted.

Job number 2 is to give a piece of midwifery (mal)practice a shake-up. Currently midwives put ladies on scales at their pregnancy booking-in to confirm how heavy they are. It’s a time-honoured practice, but one weight check is not enough. There should be mandatory checks at both second and third trimesters in order to ensure that mums are keeping to a healthy weight gain and not upping their risk of delivering a child that is uncomfortably large. There are even guidelines to show what healthy weight gain in pregnancy looks like (Centers for Disease Control and Prevention, 2019), but they are not universally used in the UK because they are American, which perhaps makes them appear “primitive” in the eyes of our midwifery establishment. Where these are used, they are used best with mothers who are overweight to begin with and gain excessive weight in pregnancy, and are thus in danger of producing macrosomic (very large) infants, of which the UK produces far too many.

You may recall that a female Conservative Public Health Minister once famously declared in Westminster Hall that it was “bonkers” not to weigh mothers-to-be routinely and thus pick up if they are incorrectly “eating for two”. She was roundly castigated for her view by the establishment but, actually, she was right. There is a mountain of literature to confirm that obesity in the mother makes it three times more likely that the newborn will grow up obese (NHS Digital, 2019). If both parents are obese, the chances increase even more. Given this, wouldn’t it be a good idea if you also encouraged both parents to be weighed at booking-in and have the risks of obesity outlined really early?

Once the baby is delivered, routine weighing is a must at each planned baby check in its first year. The fact that infants are being referred to obesity clinics by their first birthday is proof that the earliest signs of excess weight gain are not being identified – because these measurement episodes are being overlooked. All too frequently, a baby’s “chubbiness” is lauded as being the model of good upbringing when regular assessment of their progress might suggest the opposite.

And whilst you’re about it, you should insist that the child’s Personal Child Health Record, which has growth charts from birth, also features BMI charts to check the toddler’s weight annually from age 2. Some 25% of 4–5-year-olds enter primary school overweight or obese, and for this the Government should be ashamed. It’s ironic that animals in zoos get measured annually yet children – the country’s future – do not.

Breastfeeding would go some way to mitigate early obesity, but your strategy and the UK Government does nothing to encourage it. In the good old days there used to be regional breastfeeding coordinators and Breastfeeding Awareness Weeks to remind mothers that exclusive breastfeeding for the first six months is a child’s optimal source of nutrition. But no more. Exclusive breastfeeding rates at 26 weeks hover around 1%, and all too frequently children are not breastfed at all (Unicef, 2020). Of course, many mothers are physically unable to breastfeed – formula milk will always be needed – but an unforgivable number of mothers are not supported to give their infants the best milk they can get and thus bequeath them a protective cloak against obesity. You could do worse than revamp the nation’s breastfeeding.

The above jobs are just for starters but, if you value your legacy, they will go some way to helping you achieve what no other British Prime Minister has this century, by taking obesity seriously. Today would be an excellent time to start. To quote a well-known Conservative saying: “On yer bike!”