Approaches, attitudes and attributes
As in HIV–AIDS, and cigarette smoking, lifestyle interventions are essential to addressing globesity. Prevention, screening and interventions around weight, food and exercise for obesity, must be closely coordinated, as has been the case in HIV-AIDS. Aggressive information campaigns, legislation, restrictions on sale and taxation, have worked effectively and cumulatively in combating tobacco and so should, we feel, be implemented in some form for obesity. Taxing ‘bad’ foods, and making access harder at the same time, seems a reasonable first step, and is now being adopted.
Further powerful stimuli are required to effect and sustain change. It is undeniable that biomedical interventions (e.g. generic statins, antihypertensive and anti-diabetic medications, or aspirin) benefit people at significant risk of, or already suffering from, cardiometabolic diseases, yet this ‘over-medicalized’ approach should not be the primary way to approach the problem – just as it should not be the case for smoking-cessation that the only way to quit is through a clinic, using prescribed interventions (either because it is too ‘late’ in the life-cycle of the disease, or, the medicalization leads to alienation for some, or, would mean very widespread use of medicine such as a ‘polypill’ used on a global scale). Table compares all three health contexts.
Comparison of cigarette smoking, HIV-AIDS and overweight-obesity
Weight gain is particularly an issue for adolescents and young adults – moving from home and school to colleges and universities means exposure to alcohol, cheap high GI foods, and the desire to ‘shake off the shackles’ and enjoy life. These all conspire to promote rapid accumulation of body fat in many young people; this is often accepted as ‘normal’.28
Fat parents are more likely, for both genetic and behavioural reasons, to produce fat children, and fat children are more likely to become fat adults, and fat parents themselves. Breaking this ‘inevitability’ and ‘passive acceptance’ we feel is the key to success in the prevention of obesity.
We feel that the main ‘preventive’ priority in the ‘fight against fat’ is to target adolescents and young adults who are not yet obese, but close to, or already achieving overweight, and intensively to try to persuade them to adapt their behaviours. Lifelong weight charts, with mandatory yearly weight checks in school, university, workplace, and with each health service interaction, will help focus attention on this obvious risk factor. This, however, needs vigorous re-enforcement with calibrated, accessible and digestible information on the risks of overweight-obesity, strongly promoting exercise and good food choices. Here we believe that a number of exciting IT-based, readily accessible products could be of real value, as these are more likely to be acceptable to, and drive engagement with, at-risk younger cohorts. These should also of course include good advice on smoking and safer-sex.
The difference between ‘smoking’, which is driven through short-term nicotine-dependency induced craving-relief, and has no health benefit, and ‘eating’ which self-evidently is essential to maintain vitality, is obvious. But, some behavioural, genetic and societal factors in the overweight-obese may well produce similar behaviour-sets as we see in smokers.29
Nicotine-replacement, or substitution, is acceptable and successful in weaning nicotine-addicted people off cigarettes; getting people to make good food choices, and keep away from making bad ones, is a similar concept we feel. Ensuring that poorer-quality sugar-rich foods cannot be distributed so cheaply and readily by avaricious food companies is essential (thus mirroring societies' increasingly disapproving attitude to the major tobacco manufacturers, which set the scene for the deployment of legal instruments). Just because the battles with centralized conglomerated food manufacturers over the addition of salt, and phosphate, to food have not yet been won is no reason to stop trying – it arguably took four decades to ‘cow’ Big Tobacco, at least in many parts of the world. Provision of personal financial incentives to choose better foods, taxing less wholesome foodstuffs, providing free gym membership for those who attend, and who lose weight, all could all be important components of a successful strategy.
Of course, it may well be that with current and growing economic challenges to cheap food production, food distribution, and personal transport, there will be a necessary ‘rowing back’ in people's habits, choices and behaviour, as food and nutrient security and over-abundance may become less obvious. But it would be complacent to rely on this happening soon enough. It is also surely not right to leave these matters entirely to ‘market forces’, as these same forces have helped produce the abhorrent outcome of 20% of the world's population suffering from over-nutrition at the same time as 15% suffer from under-nutrition.30
If we employed measures which were a genuine marker of a societal ‘zero tolerance’ to obesity - as was seen with smoking – it would not be so easy (or desirable) to get fat, nor so easy to stay fat. This stricter approach of course still recognizes that behaviours are often complex and complicated, driven by many factors such as genetics and addictions, and judgmentalism per se has no value in providing solutions. All interventions, at the levels of the individual, family, community, country and internationally, need to be carefully coordinated and applied with precision. Overall though, we strongly advocate a much more ‘dirigiste’ approach to overweight-obesity over more subtle, gentle approaches; the sheer size and scale of this obesity pandemic now mandates urgent, concerted and co-ordinated action – the time for indecision has long gone.