Adapted from BMJ 1 April 2023
Surgeon Scarlett Mc Nally writes: In the 30 and more years since I qualified, England has had 14 obesity strategies including 689 policies. In that time the prevalence of obesity has almost doubled from 15% in 1993 to 28% of the adults in the UK in 2019. This spectacular failure of policy is probably due to a misplaced focus on individual behaviours rather than social, fiscal, or regulatory policies.
High body mass index is the fourth leading risk factor for disease in the UK and a major risk factor for 13 cancers. People with obesity are 7 times more likely to develop type two diabetes, contributing to worsening health and the risk of amputations, sight loss, kidney dysfunction and complications of surgery.
Several aspects of physiology are not widely understood or applied. First, starchy carbohydrates such as bread, pasta, rice and potatoes, are rapidly converted to sugars that are preferentially stored as fat.
Release of the hormone insulin is triggered by high sugar levels, helping to store sugar as fat and leading to the post meal dip in blood sugar around two hours later. Fats, proteins and fibre cause a lower insulin spike, leaving us feeling fuller for longer. This is the basis of low carbohydrate diets.
Second, the balance of hormones means our bodies are either storing fat or using it. Any food intake reduces fat loss for some time. This is the justification for intermittent fasting routines.
Third, it takes 20 minutes to feel full after eating. Slower eating helps us to avoid overeating at meals, helps us consider portion sizes more wisely and helps us resist second helpings.
Fourth, exercise help the body to burn fat by lipolysis.
So what do we do with this knowledge? Perhaps suggesting what and when to eat is a better option than new, expensively promoted semaglutide injections, which mimic a hormone that decreases appetite.
Replacing carbohydrates means that more protein, fat, or fibre is needed. This can be difficult in a cost of living crisis, as obesity is highly related to social deprivation. A person is twice as likely to experience obesity (37%) in the most deprived areas as in the least deprived (19%).
Tackling obesity then should include social initiatives to fight deprivation such as healthy school meals.
Our environment needs to change, through improved funding and regulation. It should permit physical activity, with play parks, walkable neighbourhoods, cycle lanes, and low traffic areas.
Commercial food companies should be subject to the full weight of regulations, which should be applied to any junk food advertising. We need initiatives to improve access to affordable, high quality food, which is shamefully poor in many deprived areas.
Obesity should not be considered a “lifestyle” problem. It requires a whole community approach focused on environments, regulation, and funding.
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