Erik Millstone - Epidemics of Obesity: narratives of 'blame and 'blame' avoidance. Presentation given at STEPS Centre Epidemics workshop December 8-9 2008

1. Epidemics of Obesity - narratives of ‘blame’ and ‘blame avoidance’ by Erik Millstone

2. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) No Data < 10% 10%-14% 15-19%  20% Source: Mokdad AH.

3. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. No Data < 10% 10%-14% 15-19%  20%

4. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. No Data < 10% 10%-14% 15-19%  20%

5. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. No Data < 10% 10%-14% 15-19%  20%

6. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. No Data < 10% 10%-14% 15-19%  20%

7. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. No Data < 10% 10%-14% 15-19%  20%

8. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. No Data < 10% 10%-14% 15-19%  20%

9. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. No Data < 10% 10%-14% 15-19%  20%

10. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad AH, et al. J Am Med Assoc 1999;282:16. No Data < 10% 10%-14% 15-19%  20%

11. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 2000;284:13 No Data < 10% 10%-14% 15-19%  20%

12. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI  30, or ~ 30 lbs overweight for 5’4” woman) Source: Mokdad A H, et al. J Am Med Assoc 2001;286:10 No Data < 10% 10%-14% 15-19%  20%

13. Prevalence of Obesity in Scotland & England by Local Health Authority District Females Scotland 1995 England 1994-96 In Scotland the maps are based on Scottish Health Survey data. Areas were defined by Health Board. In England maps are based on the Department of Health, Health Survey for England data. The data was produced by the National Centre for Social Research, February 2004. Areas were defined by Strategic Health Authority. The maps is for illustrative purposes only. The areas defined by Health Boards in Scotland and the Strategic Health Authorities in England do change. For further information contact Rachel Leach email: rleach@iaso.org Greater London (see Insert) Greater London Reproduced by kind permission of Ordnance Survey © Crown Copyright NC/2005/32578  30% 28-29.9% 26-27.9% 24-25.9% 22-23.9% 20-21.9% 18-19.9% 16-17.9% 14-15.9% 12-13.9% <12% % Obesity

14. Prevalence of Obesity in Scotland & England by Local Health Authority District Females Scotland 1998 England 1997/99 Greater London (see Insert) Reproduced by kind permission of Ordnance Survey © Crown Copyright NC/2005/32578  30% 28-29.9% 26-27.9% 24-25.9% 22-23.9% 20-21.9% 18-19.9% 16-17.9% 14-15.9% 12-13.9% <12% % Obesity Greater London

15. Prevalence of Obesity in Scotland & England by Local Health Authority District Females England 2000/2 Scotland 2003 Greater London Greater London (see Insert) Reproduced by kind permission of Ordnance Survey © Crown Copyright NC/2005/32578  30% 28-29.9% 26-27.9% 24-25.9% 22-23.9% 20-21.9% 18-19.9% 16-17.9% 14-15.9% 12-13.9% <12% % Obesity

16. Prevalence of Obesity in Scotland & England by Local Health Authority District Males England 1994-6 Scotland 1995 Greater London Greater London (see Insert) Reproduced by kind permission of Ordnance Survey © Crown Copyright NC/2005/32578  30% 28-29.9% 26-27.9% 24-25.9% 22-23.9% 20-21.9% 18-19.9% 16-17.9% 14-15.9% 12-13.9% <12% % Obesity

17. Prevalence of Obesity in Scotland & England by Local Health Authority District Males England 1997-99 Scotland 1998 Greater London Greater London (see Insert) Reproduced by kind permission of Ordnance Survey © Crown Copyright NC/2005/32578  30% 28-29.9% 26-27.9% 24-25.9% 22-23.9% 20-21.9% 18-19.9% 16-17.9% 14-15.9% 12-13.9% <12% % Obesity

18. Prevalence of Obesity in Scotland & England by Local Health Authority District Males England 2000-02 Scotland 2003 Greater London Greater London (see Insert) Reproduced by kind permission of Ordnance Survey © Crown Copyright NC/2005/32578  30% 28-29.9% 26-27.9% 24-25.9% 22-23.9% 20-21.9% 18-19.9% 16-17.9% 14-15.9% 12-13.9% <12% % Obesity

19. There is a wide, but not universal consensus that obesity should be counted as an epidemic, though it is not caused by a pathogenic agent. That assumption is only contested by a few of those working in or for the food industry, and by a few American ‘libertarians’ - demanding the right to police the language used by others.

20. The UK’s CMO endorsed the WHO description of an escalating global epidemic of overweight and obesity - as ‘ globesity ’. In 2002, Egger & Boyd Swinburn they characterised obesity as a ‘pandemic’.

21. Doak says: “ Developing countries are…facing a double burden of disease. The prevalences of overweight and obesity are rising among adults simultaneously with high rates of undernutrition among children.”

22. In August 2006 Popkin argued “ There are now more overweight people across the world than hungry ones…the number of overweight people had topped 1bn, compared with 800m undernourished.”

23. The main axis of debate about obesity concerns the attribution of responsibility for ‘ causation and ‘remediation’.

24. Causation: A small but influential group of geneticists and molecular biologists suggest that, fundamentally, the cause of obesity must be genetic, and so the treatment of individuals should be pharmacological and the treatment of populations should be selective breeding and/or genetic manipulation.

25. But human genes have barely changed over thousands of years, while the incidence of childhood obesity in the UK and many other countries doubled over 10 years, so genetic explanations are implausible and irrelevant. The anti-reductionist counterpoint has been encapsulated in Boyd-Swinburn’s phrase ‘the obesogenic environment’.

26. One debate therefore focuses on which aspects of our environment are most influential, where the main variables divide into those related to calories consumed as food and drink and those related to calories expended in physical and metabolic activity – gluttony versus sloth .

27. Food industry representatives have often argued that obesity is primarily a consequence of reduced levels of physical activity. Consumer campaigners and public health professionals often portray the food industry, and especially ‘junk food diets’ as responsible for obesity.

28. Remediation : the main axis of debates over how to reduce the incidence of obesity currently, and prevent it in the future, concerns the locus of responsibility for making the necessary changes – are their individual and personal or collective and systemic ?

29. The scope of this discussion does not include debates about therapies for those who are already obese – it focuses only on preventive measures.

30. Comparing across countries, there are major debates about: what role, if any, should be played by governments? A few governments (Singapore and Japan) have been tempted by draconian measures, while other eg the USA has adopted minimalist measures. The Europeans, however, are trying ‘constructive engagement’.

31. Those favouring an individualistic framing often argue that, if any measures are to be taken, they should be ones that strengthen individuals’ abilities to make ‘well-informed’ choices.

33. The Grocery Manufacturers of America’s insisted that: “ Individuals need to develop appropriate lifestyle plans that allow them to make small improvements in eating and physical activity patterns that over time add up and move them closer to meeting the recommendations of the Guidelines.” implying that radical changes are unnecessary and inappropriate.

34. Regina Lawrence in 2004 argued that: “ ..since 1985…the data suggest that [in the USA] a vigorous frame contest [had been]…under way between arguments emphasizing personal responsibility… and arguments emphasizing the social environment, including corporate and public policy. The evidence suggests that …risk has moved decisively toward the systemic pole…”

35. In April 2005 the US DHHS launched its main anti-obesity initiative so far this decade, specifically targeted at African American children and supported with just $1.2 million. The initiative emphasised individuals making more informed choices, including in particular increased levels of physical activity.

36. In Singapore all school pupils must have their BMI scores tested regularly, and that all students with BMIs higher than those specified in official guidelines are expected to engage in compulsory extra exercise for at least one hour a week, and they are formally and informally humiliated for being overweight or obese.

37. In March 2007 the Washington Post reported that the Singapore government had decided to end: “…its anti-obesity program in schools …after parents complained that overweight children were being singled out and teased… [It]… will scrap the 15-year-old ‘Trim and Fit’ campaign…and replace it with a holistic program that caters to all schoolchildren instead of just the overweight ones…The new holistic campaign will focus not only on raising fitness levels but also on mental and social health by promoting a healthy lifestyle....”

38. In April 2008, new Japanese legislation stipulated that: “…companies and local governments must...measure the waistlines of Japanese people between…40 and 74 as part of their annual checkups….Those exceeding government limits…will be given dieting guidance if after three months they do not lose weight. If necessary, those people will be steered toward further re-education after six more months.”

39. In the UK the government struggles with the tensions between individualistic and systemic framings. On 23 January 2008 the Health Secretary, Alan Johnson, launched the government’s latest shift in policy on the challenge of obesity. He said that: “It [obesity] is an issue of personal responsibility. We live in an obesogenic environment.”

40. In the UK, and much of not just the EU but all 46 countries of the WHO’s European Region, there is a consensus amongst policy-makers and many powerful stakeholder groups that some public policy initiatives are required - including mandatory nutritional labelling with front-of-pack indicators. The main debate is over its form.

42. In the UK there was also widespread agreement that school meals were in need of radical improvement – ‘the demise of the Turkey Twizzler’. The government also insisted that some restrictions were placed on junk food advertisements during children’s TV programmes.

43. European Charter on Counteracting Obesity . In Nov 2006, 46 countries signed a Charter saying: “ We declare our commitment to strengthen action on counteracting obesity…and to place this issue high on the political agenda of our governments. We also call on all partners and stakeholders to take stronger action against obesity... Sufficient evidence exists for immediate action.”

44. The Charter also said: “ A balance must be struck between the responsibility of individuals and that of government and society. Holding individuals alone accountable for their obesity should not be acceptable .”

45. The Charter also says: “ Special attention needs to be focused on vulnerable groups such as children and adolescents, whose inexperience or credulity should not be exploited by commercial activities….It is also a high priority to support lower socioeconomic population groups, who face more constraints and limitations on making healthy choices. Increasing the access to and affordability of healthy choices should therefore be a key objective.”

46. The Charter stipulated that: “ A process needs to… develop internationally comparable…national health surveillance systems. ..Monitoring progress on a long-term basis is essential, as the outcomes in terms of reduced obesity and the related disease burden will take time to manifest themselves. Three-year progress reports should be prepared at the WHO European level, with the first due in 2010.”

47. Conclusions The challenge posed by obesity is a ‘wicked one’ in the sense that there are no easy answers, and it is not a problem that can be addressed without encountering powerful and entrenched interests.

48. Conclusions The challenge posed by obesity is a ‘wicked one’ in the sense that there are no easy answers, and it is not a problem that can be addressed without encountering powerful and entrenched interests.

49. The UK government has adopted the slogan: “…small changes – big differences.” Governments are hoping that one or several will discover relatively modest and socially acceptable measures that will make a sufficiently big difference to either food intakes or expenditures of energy to solve the obesity problem without their having to confront contested issues of commercial and social acceptability. So far there are no indications that such a solution has been identified, or may be anticipated.