Social, economic and industrial changes have changed the patterns of life globally. Changes in diet and physical activity patterns have been central to the rise of obesity among many of the world’s population. Obesity was traditionally seen as a disease of high-income countries only, but it is now replacing malnutrition and infectious diseases as a problem transcending social divides. Obesity carries a higher incidence of chronic illness including diabetes, heart disease and cancer. This paper will critically evaluate the current UK and NI policies aimed at addressing the obesity epidemic. There will also be a discussion around definition of policies, role of government in healthcare, previous and current healthcare policies regarding obesity in both Britain and Northern Ireland.
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The official calculation for defining obesity was set by the World Health Organisation (WHO) where adults are registered overweight and obese using a formula of Body Mass Index or (BMI), that is a person’s weight in kilograms divided by the height in metres squared (DWP, 2012). The main restraint with using body mass index as an indicator is that it does not distinguish fat mass from lean mass; so a person could be healthy and have a low body fat, but be clinically overweight if they have a high enough BMI. A person is thought to be overweight if they have a BMI of 25.0 or more and obese if the BMI is 30.0 or more. Obesity has three classifications:
• Class 1 BMI 30 to 34.9 (waist perimeter 102cm plus for males and 88cm plus for females). Person is categorised as overweight
• Class 2 BMI 35 to 39.9. Person is classed as obese
• Class 3 BMI 40 and over. Is when a person with a BMI of 40+ is said to be morbidly obese (WHO, 2012).
Policy originates from the government that are in power, who are also the legal authority and have a status and guidance over all policy whether they be private or public (Crinson, 2009). According to Crinson 2009 Health policy is hypothesised in terms of macro and micro social developments, with the macro level reading the working of social and formal structures, such as the economic context of the state and the market, and the National Health Service (NHS). The micro side focuses on the influence of policy from the level of the healthcare professionals and the experience of the users (Crinson, 2009).
Policy making, according to a White Paper published by the Labour Government in 1999 states that it is a method in which a government interpret their political vision into programmes and actions in order to make changes that are required and wanted by the population (Cabinet Office, 1999). It was also focused on modernising the government schema (Cabinet Office, 1999a) and the need for more inclusive and reactive policy’s linked to people’s demands. It planned to guarantee that policy making was to become more forward thinking and evidence-based, as well as correctly assessed and based on best practice. It went on to note the need for improved evidence when addressing policy making and to ensure a more joined-up approach across government departments and agencies (Cabinet Office, 1999).
According to the World Health Organisation health policy signifies decisions, plans and actions that are started in order to reach detailed health care goals within a society. It goes on to note that and clear and string policy can outline an idea for the future whilst helps to establish objectives and points of orientation. A health policy can also help to design a framework and build agreement in addition to informing people (WHO, 2006).
There are three key policies areas within the Department of Health and they are National Health (NH), Public Health (PH), and Social Care (SC) (Kouvonen, 2012). The current theory has two dissimilar backgrounds; the first is a public policy analysis that is favoured by the United States and Northern Ireland. The second is favoured in the United Kingdom and is a social policy theoretical structure (Kouvonen, 2012).
Policies are intended to improve on current provisions in health and social care in the UK and aim to guarantee services that are funded or supported by the Department of Health are delivered in an open and patient-centred way (www.dh.gov.uk). This was not always the case, as according to Crinson governments were indifferent to the type of care delivered within the healthcare service; that was the concern of the doctor. This was to change in the 1970s when the economy declined and tax revenue was reduced (Crinson, 2009).
The roll of the state in providing health and welfare to the public according to Crinson 2009 takes the view that there are five diverse conceptualisations and they echo differences between political and conceptual actions of the role that the state should play when delivering health and welfare services (Crinson, 2009). The writer goes on to give examples of these conceptualisations one of which is the neoliberal prospective that influenced the change in the health and social welfare policies of the Thatcher Government in the 1980s (Crinson, 2009). In the Political-Economic Critique, according to O’Connor et al welfarism serves to build consent for capitalism through the process of dividing the population into groups with specific needs. This he notes had the effect of individualising what are widespread social and health problems associates with living in a capitalist’s society (Gough, 1979).
In a paper by David Berreby in which he asks the question, why do people get fat and risk major health problem?, He believes the answer to this question is capitalism and sites it as the main cause of global obesity (Berreby, 2012). Conversely in a programme series aired on the BBC on the 11th July 2012 the reporter Jacques Peretti reports that our eating habits were changed by a decision made in America 40 years ago. Peretti travelled to America to examine the story of high-fructose corn syrup (HFCS) a calorie-providing sweetener used to sweeten foods and drinks, chiefly processed and shop-bought foods. The sweetener was backed in America in the 1970s by Richard Nixon’s farming administrator Earl Butz to use additional corn grown by farmers. Inexpensive and sweeter than sugar, it rapidly found its way into nearly all convenience foods and soft drinks. HFCS is not only sweeter than sugar; it also inhibits leptin, the hormone that controls hunger, resulting in the inability to stop eating (BBC, 2012). This was backed up by evidence from Robert Lustrig an endocrinologist, who according to this report, was the first to identify the dangers of high-fructose corn syrup (HFCS). His findings however, were discredited at the time. and a US Congress report sited fat, not sugar, for the alarming rise in cardio-vascular illness and the food industry responded with a series of low fat and ‘heart healthy foods in which the fat was removed. (BBC, 2012). Policy makers encouraged farmers to overproduce corn and soy with the promise of foreign trade (Philpott, 2008).
It was also in the 1970s that Britain’s food manufactures used advertising drives to encourage the idea of snacking between meals. A fast food culture also developed and fast food chains offered tempting foods and customers served themselves, and according to Ritzer this was the beginning of McDonaldization of Society. He goes on to write how fast food restaurant contribute to the development of obesity and it emphasis on supersizing its portions (Ritzer, 2004).
Conversely poverty increased in the 1970s under Thatcher Government and according to the Institute for Fiscal Studies in 1979 13.40% of people in Britain lived below 60% on median income before housing costs. With this came a big rise in inequality and under the gini score for Britain was up to 0.339 from 0.253 (Crib, et al 2012).
Due to the comorbidities associated with obesity and their increasing cost to the NHS, the consequences of obesity are currently and will continue to be important public health challenges globally and in the UK. It impacts through society and across all life courses, and can increase the risk of life threatening disease (Kouvonen, 2012).Appendix 1.
Currently there is a framework in Northern Ireland titled ‘A Fitter Future for All’, this agenda spans from 2012 to 2022. Within this paper it explains that in Northern Ireland 59% of adults are either overweight (36%) or obese (23%) (DHSSPSNI, 2012). This policy addresses the need to act from childhood based on evidence from the Foresight Report 2007, and is now a cross sectorial cohesive life course agenda that will address obesity over the next 10 years (Foresight Review, 2012). The Department of Health has published a follow-on document to the Public Health White Paper called ‘Healthy lives, healthy people: A call to action on obesity in England’, which sets new national drives for a descending trend in excess weight by 2020. The Tackling Obesities: Future Choices project presented its findings on 17 October 2007 and the Project aims to deliver a feasible response to obesity in the UK over the next 40 years. It also sets out examples of what is intended on a national level to help challenge obesity, one of these is called Change4life programme. In this programme it states it will help consumers make healthier food choices (www.dh.gov.uk). This could be linked to Professor Marmot point, when he discussed behavioural choices as individuals such as where to shop for food, and how these decisions are dictated by the individual’s socio-economic circumstance, and if they can afford the recommended good food (UCL Institute of Health Equity, 2012).
‘A fitter Future for All’ and ‘Healthy Lives, healthy people’ are policies that both the British and Northern Ireland government support, but there are wider determinants of poor health such as poverty and inequalities that play an important role in obesity (HM Government, 2010). It could be argued that while policies such as these are targeting the causes of obesity, they are not actively seeking out realistic solutions to the problem; people may know they need to eat healthier, but simply cannot afford to buy the better food.
In developing countries rates of obesity are inclined to rise, and this is associated with growing social disadvantage; addressing social deprivation and material disadvantage is likely to reduce obesity (Kouvonen. 2012).
Socio-economic class as a factor in health is not a new phoneme in the United Kingdom, as it has a history of many hundreds of years. According to Edwin Chadwick’s report on sanitary conditions of the labouring population in Britain in 1842 showed that in Liverpool the average age of mortality for people in the upper classes was 35 years, and 15 years for labours and servants (Richardson, 2008). Inequalities still exist today, but have improved and in the Black report published in 1980 it states that there are still inequalities with regard to life expectancy and the use of medical services (Whitehead et al, 1992).
According to the Foresight report (2007) a government science think tank reported that most adults are already overweight. It goes on to note that modern living will ensure that upcoming generations will be heavier than the last, and by 2050, 60% of men and 50% of women maybe clinically obese. The report also states the obesity is a multifarious and there is no evidence anywhere in the world where obesity has reversed. Social policy frameworks are paramount according to this report (Foresight Review, 2012).
The Marmot Report the third such officially approved analysis in as many decades probing the link between health and wealth. The findings confirmed an alarming social incline, the poor not only die seven years earlier than the rich, but they can expect to become disabled 17 years sooner. Professor Marmot continues to discuss behavioural choices we make as individuals are part of our social and economic settings. He believes that people born into more affluent milieu tend to adopt a healthy lifestyle, resulting in healthcare differences between the social classes (UCL Institute of Health Equity, 2012).
In 2011 the Chief medical Officers (CMOs) from across the UK published new strategies for physical activity, and they addressed a life course methodology, and included guidelines for early years (www.ic.nhs.uk). It could be argued this is a blanket policy and it is widely known that poorer people have limited choices with regards to lifestyle choices such as gym memberships. Also the report appears to place the responsibility of exercise on the individual. People from poorer socio-economic backgrounds have poorer housing and environments that don’t encourage physical exercise which could be due to social culture of where these people live and lack of resources (UCL Institute of Health Equity, 2012). Addressing overweight children that become obese in later life was issue raised by Dr Hilary Jones on Good Morning Britain, when he stated that obesity begins in childhood. He went on to say that the National Health Service and the Government know causes of obesity but actively preventing it in childhood needs to be addressed (www.gm.tv).
Prevention of obesity is more achievable goal than addressing obesity when it becomes established, as some health problems that are acquired through obesity remain an issue even after weight loss. Therefore government policies are mostly directed at primary prevention of obesity such as eating well, exercise and no smoking (Kouvonen, 2012).
Social determinants of health are also a key factor in obesity in both children and adults. According to the World Health Organisation the social conditions in which people live are paramount to their health. It goes on to note that lack of income, poor housing and lack of access to healthcare facilities are just some of the factors leading to inequalities (www.who.int).
Medical care on its own cannot adequately improve individual’s health and addressing where people live and work is also important The social determinants of health are the “upstream” social, economic, and environmental factors that affect the health of individuals and populations, including income, social support, education and literacy, employment and working conditions. Downstream determinants, which include physical activity, clean air and water and healthy housing. These factors can influence health inequalities difference between social groups that can result in obesity in poorer areas (Kouvonen, 2012).
Incidents of Childhood obesity are higher in areas with a lower socioeconomic population according to National Health Service Information Centre report on obesity. It also states that obesity is more widespread in schools in disadvantaged areas. It also noted that with Reception children (children in the primary school age group) 6.9% of those in least deprived areas were obese, in comparison to 12.1 percent of children in most deprived areas (www.ic.nhs.uk).
In Northern Ireland statistics show that 8 percent of children ages between 2 and 15 years are obese, according to the Health Minister Edwin Poots. The health Minister went on to say that the likelihood of obese children become obese adults was probable; this would put greater strain on the health and social care services due to the comorbidities associated with the condition (Northern Ireland Executive, 2012).
Governments state that health policies are micro driven, but in reality it could be argued that they are macro driven as ultimately obesity will cost more in the long run due to obesity related illness such as diabetes and heat disease, and according to NHS website the cost will be £4.20 billion per year (HM Government). Tackling obesity is a challenge for not only the UK, but globally and according to the Department of Health and Social Services Northern Ireland website, overweight and obesity will overtake malnutrition and infectious disease in terms of their cost to the health services and people suffering from the condition (www.dhsspsni.gov.uk). Appendix 2.
It was not until 1999 that obesity was declared an epidemic in America and was considered to affect all racial groups and across all ages in United States (National Medical Association, 1999). According to the information published there was an increase from 12% to 18% over a seven year period using a body mass index (BMI) that was greater than 30 (National Medical Association, 1999). Historically obesity rates were low and unaffected until 1970s and 80s, and the obesogentic environment (an environment that encourages and leads to obesity in individuals that relates to the influence that contribute towards obesity such as food, physical activity and environment. Many broader determinants of poor health such as health inequalities, poverty and deprivation play a significant role, and these factors have not swayed over the years. In pre-war Britain large differences in mortality and morbidity levels between rich and poor were recognised as the norm by policy makers. It was the introduction of the National Health Service in the 1940s that brought with it hope that the social class differences affecting health would decline. It wasn’t until the 1970s that the Marmot Report stated people’s lifestyle and circumstances have a direct effect on their health (Crinson, 2009).
The health implications from obesity are immense and can ultimately result in a premature death. Although obesity is caused by intake of more energy through food and drink than needed and the resulting excess stored in fat in the body, the view that obesogenic environment also plays a part in obesity is becoming widely accepted. Social and economic circumstances are also evaluated in this paper as are the role of governments and policy makers, both in the United Kingdom and Northern Ireland. The overall view of this paper would be that policies are made by individuals that have no insight into what part of society they are directed at such as deprived and socio-economic areas that lack the means and facilities whereby individuals feel that their contribution to society is valued and important enough for them to care about their own wellbeing. Policies are not directed at one specific group such and the one size fits all doesn’t appear to be working as obesity is now a global epidemic.
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