Sunday, November 20, 2011

Overweight: is there a population solution?

First, let me be bold and honest. The answer to the question is “No”. Not while we live in an affluent democracy with abundant, relatively cheap food. You may have your own idea for a solution. Certainly there have been many espoused – tax cakes, confectionery and soft drinks, tax fat people, ban advertising of foods you perceive to be evil or just plain ban every processed food. Simple. It seems that we favour controlling the environment to educating and encouraging people to eat intelligently. The public weight loss campaign is a favourite solution offered by governments.
Does anyone listen & act?
Obesity Reviews published a paper that considered 60 interventions or policy proposals since 1980. Although presumed to be useful, may public campaigns have uncertain benefits and, indeed, many aren’t even evaluated for effectiveness. The [ last Australian campaign] showed 55% awareness among adults. So what? I’m aware of many things too but do stuff-all about it. I know I should turn off appliances and not always have them on standby like I do. I know Mugabe is not good for Zimbabwe but haven’t got around to assassinating him. Evaluating awareness and asking people questions about their intentions is irrelevant to success or failure.

The review also suggests that there can be unintentional consequences, such as some adopting unhealthy diet practices to achieve a goal weight. The Singaporean Trim and Fit program was criticised because it might contribute to eating disorders.

Stigmatised sub-class
Being fat is stigmatised, linked to stereotypes of stupidity, ugliness, weakness and laziness. I would imagine that every campaign directed at their weight can’t make them feel better about themselves. In 2008 it was reported that the US state of Mississippi planned to [ ban fat people from restaurants], presumably to keep them away from temptation. Bet that would have been helpful. Is this form of discrimination healthy? Should we fire health professionals, airline staff, police or firemen once they are judged to be fat? For some, I would say “Yes”. A 140kg fireman may be a risk to himself. Yet an overweight dietitian may be a more credible voice about healthy eating than one that can barely throw a shadow.

The review argues that public campaigns focus solely on the kilojoule and health benefits of foods and completely forget the social context of food. If you are told to cut out cheese and wine would you be welcome at your grandparents who left Italy in the 1950s to start life in your country? I now refuse to do media interviews about what to eat over Christmas. Hey, no-one listened in the 1980s, the 90s and frankly I no longer care what you eat for Christmas. Overindulge like most do, enjoy it and do some activity to balance things out.

Although I feel that it is my responsibility, and mine alone, to look after my weight and health, not everyone has that capability. If you are unemployed, have a lousy job, live in a threatening household, hospitalised with a severe injury, feel alienated, or can’t speak the local language then I suspect that looking lean may not be a priority; may not even be on the first two pages of your priority list. I doubt if a weight loss campaign offers them anything more than guilt.

Public weight campaigns have a shot-gun strategy – send out a few messages and hope some will stick. That makes them ineffective. The last Australian public weight loss campaign cost you $45 million, a lot of it on commercial TV. There has to be a better use of the money. That campaign is being written up for a science publication. Hopefully the data will prove me wrong.

It has been suggested that we reward “good behaviour” and give bonuses for weight loss such as the police in one Mexican city who received 100 pesos bonus for every kilo they lost. How would you feel if you were a lean local and heard about that? I would gain a kilo in December, lose it in January, gain it back in February, on and on. Nice little earner. Healthy?

What does it all mean?
Frankly, I think you can have any viewpoint on a population solution to overweight, and justify it however you want, but you would be hard-pressed to show that it was effective, and by that I mean effective in permanently changing eating or activity habits to create weight loss in more than, say, 2% of the population over a five year span.

I’d love to see the stairs full of people and the escalator used by only those over 90, parents carting young children or those recovering from a sports injury. I would also love to see people encouraged to eat well for their health, well-being and longevity while never once mentioning their weight. Public health campaigns should be about health, fitness and well-being. Forget weight – too difficult, too dangerous and nobody listens.

Reference: Obesity Reviews 2011; 12: 669-679