Obesity: we need to move beyond sugar

The Lancet
In January, discussions about diet, food, and obesity usually dominate the media. This year is no exception. New figures released last week by Cancer Research UK and Diabetes UK underline the current, and likely future, effect of the obesity epidemic. Around 700 000 new cancers caused by being overweight or obese are predicted by 2035. And the estimated number of people living with diabetes worldwide has topped 4 million for the first time, an increase of 119 965 compared with the previous year, and a rise of 65% during the past decade. These are well known associations and unsurprising figures. Obesity has been on the public health agenda for more than a decade in many countries with little effect. There are now loud calls for a so-called sugar tax in the forthcoming national UK childhood obesity strategy. The strategy has already caused some furore after the publication of Public Health England’s report—Sugar Reduction: the evidence for action—was delayed last year and finally published in October.

We know taxing works to reduce purchases of unhealthy products from many other examples and some concrete country evidence for sugar sweetened beverages. We know we have an unabated epidemic of adult and childhood obesity in many high-income countries and an emerging one in low-income and middle-income countries based on present trajectories. We know our current approaches don’t work. We know obesity is the result of an obesogenic environment maintained by large global food and drink companies with a vested interest to provide ultra-processed, energy-dense, nutrient-poor food as cheaply as possible, and of an increasingly sedentary lifestyle. And we know that obesity prevention and treatment needs urgent, serious, and multifaceted action, beyond just a sugar tax. And yet, even that small and insufficient step is hotly debated and governments are dragging their feet.

One reason, undoubtedly, is the undue influence of the food and drink industry and other lobby groups on governments and policy makers. The reliance on voluntary deals, such as the UK’s Responsibility Deal, which has been quietly shelved, is an anticipated failure. The new 2016 Global Access to Nutrition Index, released on Jan 14, which ranks the 22 largest companies on contributions to tackling obesity and undernutrition, showed that the industry as a whole is moving far too slowly. The new dietary guidelines by the US Department of Agriculture and Health and Human Services, released on Jan 7, were quickly criticised by nutrition experts for not going far enough. Although they mention a Mediterranean-style diet, they still mainly focus on sugar reduction and just cover much old ground (some suspicion of influence by lobby groups exists). The private sector with vested interests will react only if strong and impartial science-based guidance and clear policies leave them no choice.

So, although national obesity strategies are welcome and much needed, they need to be comprehensive by involving all relevant government departments and also covering both prevention and treatment. In addition to the health sector, the education sector is a vital role model, empowering children and adolescents with the relevant knowledge about food and nutrition and the opportunity to do physical activity beyond competitive sport. Transport and urban planning departments need to ensure that cities and environments support easy and preferred access to healthy food and physical activity. Economic, business, and enterprise departments need to be held accountable for the health effects of their policies. Addressing obesity in both children and adults is difficult. Treatment strategies are multifaceted, and begin with the need to recognise overweight and obesity and their consequences, and range from nutritional information and advice to bariatric surgery. Interventions for childhood obesity only work if the whole family is engaged. Any national strategy should have clear guidance on treatment of established overweight and obesity.

Obesity is a form of serious malnutrition. The Scientific Report of the 2015 Dietary Guidelines Advisory Committee notes that the US population has a shortfall of vital nutrients, such as vitamins A, D, E, and C, folate, calcium, magnesium, fibre, potassium, and iron. If two-thirds of a population had serious undernutrition or anorexia nervosa, there would be a recognised national emergency. Obesity needs much more serious attention than countries and global health organisations are currently prepared to give. The goal of sugar reduction by introducing a sugar tax is a small step in the right direction. Nevertheless, it should not distract us from the need for far deeper and broader measures.

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