Our big fat fear
As our waistlines have grown, so has our collective prejudice against the overweight. How should we handle the obesity epidemic?
Walking through the park on the first sunny day of spring, I passed an ice-cream van surrounded by children. One boy, aged eight or so, was idling on his bike in my path, messily eating a strawberry split, the pink juice running down his plump cheeks.
As I swerved round him several thoughts ran through my head, all unedifying, in retrospect. He could do with a bit more cycling and a lot less junk. I wonder if he gets bullied because of his size? Probably not – loads of kids are fat these days, aren’t they? So I bet he’s fine. Until he gets diabetes, of course, then we’ll all be paying for it.
And so, judgement done, I went on my merry way. (Ironically, I think I was heading to the cheesemonger’s in search of a nice piece of Brie for an al fresco lunch.)
Now, I’m a liberal – I’d fondly believe I’m against all forms of discrimination. Yet here I was, blithely indulging in perhaps the last socially acceptable form of prejudice: fattism (yes, even the name is faintly risible). What’s worse, the object of my criticism was a child, who could hardly be said to be to blame for anything, let alone his weight.
Shocked or not, many of you, whatever your background, must have had similar thoughts at one time or another. Almost half of the people surveyed for a Mintel special report in 2009 blamed the rising tide of obesity on “laziness” and a fifth attributed it to greed. Even Tam Fry, the spokesman for the National Obesity Forum, has described the obese as “eating [themselves] silly”.
Indeed, hardly a month goes by without some hysteria in the tabloids about “fat Britain”. Whatever the story, the sentiment is the same – it’s all their own fault.
The government, hardly more understanding, seems to view fat people purely as a selfish drain on scarce national resources. “At a time when our country needs to rebuild our economy,” the former health secretary Andrew Lansley wrote in the introduction to the government’s 2011 Healthy Lives, Healthy People policy paper, “overweight and obesity impair the productivity of individuals and increase absenteeism.” Apparently it’s up to all of us “to be honest” about what we eat and drink. The subtext? If only fat people would lay off the junk, they’d save the economy £7bn a year. Simple as that.
The writer and professional campaigner Emma Burnell, who produces the Labour grass-roots Scarlet Standard blog and has struggled with her weight since she was a teenager, has written movingly about the painful realities of being morbidly obese in Britain, “the pointing, tutting . . . and judging” of strangers on the bus which, she tells me, happens “daily, hourly – every single day there’s something”, as well as the suspicion that her weight has held her back in her career. Sadly, she is probably not being paranoid: a survey of human resources professionals by the HR website Personnel Today found that, asked to choose between two identically qualified candidates for a job, one of whom was of average weight and one of whom was obese, 93 per cent would choose the former, solely because the person was slimmer.
Emma acknowledges that she alone is responsible for her size – “this is something I’ve done to myself” – but feels society treats her with less compassion than it would a smoker or an alcoholic. “I have to delete several comments a week from my blog relating to my weight. I’m constantly hearing people on the left wing making comments about Eric Pickles’s size. I mean, come on, there’s so much to criticise and you can only think of that?”
Even medical professionals, the very people who are supposed to encourage weight loss, aren’t immune to such prejudice. Research by the Johns Hopkins University School of Medicine in Baltimore, Maryland, found that the fatter the patient, the less respect they got from their doctor.
Although Emma says that her local primary care trust in south London has given her excellent service following her decision to join the waiting list for gastric bypass she agrees that she finds visiting her GP difficult. “I don’t like to go to the doctor’s because, for a start, I’m constantly being told I’m a drain on the NHS and I don’t want to be,” she says. “And secondly I know that, whatever’s wrong with me, they’ll just assume it’s to do with my weight.”
Such attitudes only make the problem worse: the biomedical scientists Peter Gluckman and Mark Hanson claim in their recent book Fat, Fate and Disease that the stress of stigmatisation can lead to “greater weight gain as rising stress hormone levels can induce both more eating and greater fat deposition”.
But then if you’re obese there’s quite a lot to be stressed about. A body mass index of 32 or over – the borderline between overweight and obese – doubles your risk of mortality straight off the bat. Get to that point, and not looking good on the beach is the least of your worries. Excess fat has major health repercussions, significantly raising the risk of diabetes, heart disease, stroke, asthma and some forms of cancer. Unsurprisingly, perhaps, obesity and depression are reciprocal risk factors; people who are obese are more likely to be depressed, and vice versa.
The plethora of related conditions has led the World Health Organisation to rank obesity alongside climate change and the global financial meltdown as a threat to human society as we know it. So, if excess weight is so dangerous, why do people find it so hard to ditch the chips?
And it is usually chips, isn’t it? You rarely hear that we should all be cutting down on the cassoulet, or the risotto, or the pains au chocolat, because obesity is, for the first time in history, largely a disease of the poor – in this country, at least.
When Anna Soubry, the minister for public health, made ill-judged comments in January about almost being able to tell a person’s background by their weight, there was public outcry but, unfortunately, she had a point. The 2010 Marmot review found that income and social deprivation have an important effect on the likelihood of being obese, and even the Guardian was forced to concede that there was a “notable correlation”.
So why are the least well-off members of our society “choosing” to be fat? One could argue, up to a point, that it’s the fat that’s making them poor. Adult obesity is linked to lower wages, both because of reduced productivity and because of the kind of workplace discrimination that Emma Burnell has experienced higher up the ladder. But diets differ, too. According to the Mintel report in 2009, manual, casual and low-grade workers, state pensioners and the unemployed are more likely not to pay much attention to what they eat, to snack between meals and to eat fast food more often than managerial or professional workers, more of whom avoid sugar and fatty foods – such as chips.
Partly this is a matter of education, but economics comes into it, too. Data from the US shows that when the price of energy-dense food falls, people buy more of it – and with food prices increasing by 17 per cent in the past five years, more consumers are turning to special offers to fill their cupboards.
You don’t often get buy-one-get-one-free promotions on fresh fruit and vegetables, but even if you did, the poorest people in our society are unlikely to come into contact with them. Most wealthier areas have more, and better, food available: supermarkets and restaurants, rather than convenience stores and fast-food vendors.
As Diane Abbott, the shadow minister for public health and MP for Hackney North and Stoke Newington, observes: “There are parts of the inner city which are like food deserts – streets in Hackney where there might be three or four bookmakers, three or four chicken and chip shops, but nowhere where you can go and get fresh fruit and vegetables.”
If you live in an urban area you can probably take public transport to the supermarket (but you’ll have to have the time to go there regularly, because you won’t be able to carry much home) or you can drive to one in a richer area – if you have a car. If not, you will be stuck more often than not with the kind of selection offered by my local “convenience store” in Finsbury Park, north London, which devotes twice as much space to crisps as to vegetables, and which at the moment is stocking a choice of sad-looking lettuces, frozen peas or tinned sweetcorn next to the Doritos and cheesy Wotsits.
It’s not a particularly small place, but if I had to shop there exclusively I wouldn’t be able to make a single one of the healthy “evening meal” recipes promoted on the Department of Health’s Change4Life website. With a little imagination, I could probably create something fairly balanced from the Best-One’s stock – a tuna and sweetcorn salad springs depressingly to mind – but then I should be able to; I write recipes for a living. Most people have neither the time nor the training.
To be honest, it’s almost impossible for me, coming from a home in which my parents cooked every single night, to imagine a situation where I had never been taught to make so much as an omelette. I suspect many people are similarly naive about the realities of life for the poorest in society. Take this comment beneath a piece on recession shopping habits published on the Guardian website: “I don’t understand this claim that lack of money forces people to buy processed food . . . we had a free-range chicken from a farm shop which was only £8, and it fed us for a roast dinner, for three dinners’ worth of chicken soup, a few days of sandwiches, and it went in with a pasta sauce too.”
Where to begin with such high-minded ignorance? It’s not easy to get to a farm shop without a car, even if you happen to live near one in the first place, and £8 is one-sixth of the £49 weekly food budget for the poorest of families. As for keeping the power-hungry oven on long enough to roast a chicken, or knowing how to make a chicken soup, both are beyond many people.
Despite their meagre selection most innercity shops are more expensive than the big supermarkets, so, all things considered, it’s easy to see why many people choose 99p instant noodles or a box from the local takeaway instead. My closest example (and Hackney is not alone in boasting more fast-food joints than shops) is the offer of a burger or fried chicken with chips and a fizzy drink for £2.50. Quicker, cheaper, and almost certainly a lot more tempting than a wilted tuna salad when you’re hungry.
The recession has made an already bad situation worse; consumption of fat, sugar and saturated fats has soared since 2010, parti - cularly among the poorest households. At the same time, fruit and vegetable intake has dropped among all but the richest, suggesting that when times are hard, healthy eating isn’t most people’s first priority. In a study for Barnardo’s published last month, many families echoed the sentiment that “fruit is expensive – it’s difficult to afford the five-a-day the government says you should eat”.
It’s a similar story with exercise: the most recent Active People survey from Sport England found that people in managerial or professional roles are one and a half times more likely to take regular exercise than those in the lowest social group. Those of us with expensive gym memberships can preach all we want about the virtues of walking around in the rain, but the fact is that most exercise costs money.
So, perhaps the government’s simple healthy choices are simply easier for some people to make than others – and the group with the least freedom of choice is children, the very individuals I was so quick to blame for eating ice creams in the park. Studies consistently show that many children are being fed food that is far too high in calories and fat; and even the least sympathetic commenters would have to agree that there is little your average two-year-old can do about a diet of sugary yoghurts and chicken nuggets.
That said, most parents want to do the best for their child, so again this is primarily a failure of education. Abbott talks of a generation of young women whose idea of motherhood “is what they glean from television and advertising – and advertising tells you, ‘Give your child follow-on milk . . .’ They can’t promote milk for newborns now, but they promote this follow-on, which is completely unnecessary [a claim echoed by the National Health Service], and they promote cheese spreads and crisps and McDonald’s, and of course some young women think, ‘Well, that’s being a good mother.’”
Indeed, a 2009 report by the Children’s Food Campaign found that significant numbers of popular products – innocuous-looking things such as rusks and bear-shaped biscuits, aimed specifically at babies and infants –were high in both sugar and saturated fats. Several of them exceeded the levels found in adult junk foods. Greater regulation and clearer labelling of foods marketed for children are obvious ways of countering this threat and they can’t come too soon for today’s kids. Research by the EarlyBird Diabetes Trust found that obesity is largely determined by the age of five, with girls gaining 90 per cent of their excess weight before they start school.
In fact, by this point, nearly a quarter of all are already overweight or obese, rising to a third by the age of 11. Abbott, who has been working on the Labour Party’s policy review of public health, tells me that, in a way, once a child has started secondary school, it’s already too late. “I’m not saying you shouldn’t support teenagers and adults with their weight issues but the key to a cost-effective intervention is young children.” And sadly, with a problem this large, cost-effectiveness has to be taken into account.
The uncomfortable truth is that many of us still cherish the idea that a fat baby is a healthy baby, an old wives’ tale Abbott is keen to dismiss. “There’s this notion that if a child is chubby they’ll grow out of it. Well, the stats show they don’t . . . and what’s charming chubbiness in a six-year-old isn’t so charming in a 16-year-old. I think attitudes need to be changed.”
Mark* from Lancashire would be the first to agree. He started to worry about his nine-year-old daughter’s weight after separating from her mother six years ago. At the time, his former partner had problems with alcohol. He had the impression, he tells me, that his daughter, Katie, was being dragged from pub to pub “and they were throwing a bag of crisps or a sausage roll [at her] to keep her quiet. She was no more than chubby at first. Puppy fat, maybe, as people would say.”
Her mother did not share his concern, but after he gained custody of his daughter her weight stabilised for a while, even though, Mark says, “She was never a skinny girl.” More recently, they have shared custody and he’s noticed Katie’s weight creeping up again to its current high of 9st 12lb – “about three stone overweight, in my estimation, but it’s really difficult to find out exactly what weight she should be”.
Katie’s first GP was “pretty dismissive”, but a new doctor recognised the problem and arranged for her to see a dietician, who Mark describes very favourably. Without the support of her mother, however, there was only a brief improvement.
As a father, Mark holds himself partly responsible for Katie’s size. “I could have pushed her harder, I’m sure. It’s very difficult, though, always to be the bad guy – ‘You can’t have this or that’ or ‘Do more exercise’, nag, nag.” He also feels, however, that his daughter’s school could encourage her to become more active. “One teacher she had for a year was just lazy and they didn’t have a single proper PE lesson,” he says. “I think sport needs to be pushed more in school but there seems to be a fear of upsetting kids if they come last. Everybody wins and nobody loses, so what’s the point of trying?”
Although Mark acknowledges that the celebrity chef Jamie Oliver has made a great effort to change attitudes to food in schools, “I don’t think he’s succeeded. There are healthy options on the menu but then there is still pizza.” And if you’re nine and you haven’t been taught much about nutrition, why wouldn’t you reach for the deep pan?
Education is critically important if we’re to resolve the obesity crisis – almost two-thirds of adults, and a third of children, are obese. The government has made a start by reintroducing cookery into the National Curriculum from September 2014, promising to teach all pupils to produce “healthy, wholesome dishes” for themselves from the age of eight.
This applies only to comprehensive schools, however. Michael Gove’s beloved state academies will not have to offer cookery, just as they don’t have to meet the same nutritional standards as local authority school food – standards that the Children’s Food Trust has called “the quickest, cheapest and most successful public health intervention to address children’s intake of fat, saturated fat, sugar and salt”.
Unlike their state counterparts, academies may also sell sweets, crisps and sugary drinks on the premises – presumably to help fund their task of “unleashing greatness”, as a recent Academies Commission report put it. (One teacher at a high-profile academy in south London tells me the children are fed slushies and muffins before coming back into class mid-afternoon, despite the claims about balanced meals on the school’s website. “Unsurprisingly, they go completely wild.”)
Healthy school meals produce the desired effect only if children eat them, and they are by no means the only thing competing for their custom – there are 23 junk-food outlets to every secondary school in England. Ninety per cent of parents claim they support “stay-on-site” policies at lunchtime, yet only 61 per cent of local authorities implement such policies at secondary level, despite evidence that eating away from the premises is likely to be significantly less healthy than the alternative.
Diane Abbott believes we should look at incorporating public health into our planning criteria, in part to help local authorities stop the proliferation of junk-food vendors around schools and other places where children congregate. “I haven’t got anything against chicken and chips,” she says, somewhat unconvincingly, “but I think it’s a problem when they’re deliberately opening around schools and encouraging children to eat something that’s deliberately unhealthy. You even get some sectors of the community where children eat chicken and chips on the way home from school, and then go home and eat dinner.”
Keeping children away from junk food, at least during school hours, will certainly help matters, but usually by the time they’re old enough to buy their own lunch it’s a matter of cure, rather than prevention. Far better to stop them getting fat in the first place.
This is especially true because, as a species, we are biologically programmed to maintain a fairly constant weight and consequently, once you’ve put on those pounds, it’s very difficult to shift them. Even if somehow, in the face of millions of years of evolution, you manage to succeed, your hormones and brain will be fighting to regain the missing fat reserves for the rest of your life, which is why it’s so hard to sustain significant weight loss long term. As Gluckman and Hanson put it, “Metabolic processes which were useful 10,000 years ago are one reason why we are in trouble now.”
With that in mind, it’s never too early to get children eating healthily. There’s growing evidence that to make the most difference, we should start before birth. The Southampton Women’s Survey found that respondents with the least education were far more likely to report an unbalanced diet during pregnancy, high in crisps, sugar, white bread and red meat and low in fruit and vegetables. Even if these women remained relatively thin, they gave birth to babies with elevated levels of body fat, a difference still evident at the age of four. (The survey also noted that the offspring of heavier mothers across all levels of income and education had a similar prop ensity towards childhood obesity – but of course, as we know, wealthier women are less likely to get fat in the first place.)
To help meet the self-evident need for work to promote healthy eating in the first years of life, Abbott believes health visitors should offer guidance on the subject. “I think they’re often reluctant to talk about diet because they don’t want to be judgemental,” she says, “but with training they could offer more support to young mothers.” Last year the Children’s Food Trust published nutritional guidelines for nurseries, childminders and pre-schools. Unlike the food guidelines for older children, however, these remain purely voluntary.
A balanced diet from day one is of vital importance, yet it is easy to forget that weight problems often have a mental element, too. Children born into deprived families are far more likely to have deficiencies in the maturation of non-cognitive skills such as self-control . . . the kind of self-control that, you know, might help you when confronted with, say, a packet of biscuits.
But biscuits, and fizzy drinks, and ice cream, are things with which all children are going to be confronted a great deal in the course of their lifetime. The fact is, we live in an obesogenic environment, stuffed with the kind of energy-dense food that Homo sapiens didn’t evolve to cope with, leading lifestyles that are increasingly sedentary. Why, as Gluckman and Hanson ask, did we think we could change our biology so quickly?
Many on the right argue that obesity is a personal problem and that the state has no duty to help. But our world has changed so quickly that parents are no longer equipped to counter the bombardment from the advertising and junk-food industries, and if the government wants to get the health costs under control, it needs to take action, rather than relying on “individual responsibility” among those who have very little choice.
Abbott argues that the coalition’s collaboration with the food industry, inviting firms to sign up to health pledges in a voluntary “responsibility deal” (to which, so far, only 11 per cent of UK businesses have committed), is “a nonsense . . . The food industry just wants to do a minimal amount from a corporate social responsibility point of view, but fundamentally it makes its money peddling unhealthy food to children and families – it doesn’t make money out of healthy, unprocessed food.”
Although she doesn’t rule out working with the industry, Abbott argues that it needs to know that, “if it comes to it”, the government will be prepared to legislate on matters such as advertising, calorie content and food labelling.
“I get it from even Labour MPs,” she says – “‘Oh, freedom of choice, freedom of choice.’ But as a society there are some things we don’t give children the freedom of choice to do – we don’t let them drink all the alcohol they want or smoke all the cigarettes they want; we have restrictions. I think when it comes to the food that’s fuelling the obesity epidemic, we have to have restrictions on advertising and access. It’s one thing for adults, but certainly as far as children are concerned, society as a whole should protect them, because society as a whole will pay the cost if they grow up obese.”
The Academy of Medical Royal Colleges, which describes obesity as “the greatest public health crisis facing the UK”, recently published a ten-point plan to break the cycle of “generation after generation falling victim to obesity-related illnesses and death”. Its recommendations include an experimental softdrinks tax and £300m investment in NHS weight-management programmes, together with measures also backed by Labour, such as nutritional standards for all schools and hospitals as well as council planning restrictions for junk-food vendors.
The Royal College of Physicians has demanded more training for health-service professionals and greater investment in obesity research, and Emma Burnell brings up the need for increased funding for mental health support. “The mental health aspect of obesity is often overlooked. Everyone thinks solving it is all about diet and exercise, but, to be honest, most people know about diet and exercise by now yet we still have an obesity epidemic. Why is that?”
Their focus may differ, but the support for a more interventionist approach to the obesity epidemic is near universal. What is clear, whoever you speak to, is that the current approach isn’t working and we are in danger of failing not just a generation, but every future generation. Suddenly fat doesn’t seem so funny after all.
*Some names have been changed to protect identities