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Boris Johnson has never been fond of telling people what to eat – back in 2006, he defended mothers protesting new healthy school meals, telling a Conservative Party conference to “let people eat what they like.” (The mothers had snuck pork pies to their kids at lunchtime.)
But since his near-death experience with Covid-19, the prime minister has abandoned this libertarian stance. “It was a wake-up call for me and I want it to be a wake-up call for the whole country,” he wrote in The Daily Express. “The facts are simple: extra weight puts extra pressure on our organs and makes it harder to treat heart disease, cancer and – as we have found – Coronavirus.” Now, the government has launched a new plan to tackle obesity, a plan that will supposedly help Britain weather the dangers of a deadly second wave. But will it work?
We know that being obese is a risk factor for Covid-19. A government review, published over the weekend, found that scientific evidence consistently suggests that people with Covid-19 who are overweight (a BMI of more than 25) or obese (a BMI of more than 30) are at an increased risk of severe complications and death.
In one systematic review, based on the findings of six studies including 667 patients, patients with severe Covid-19 had a higher BMI compared with patients with mild Covid-19. Another, based on 14 studies including 403,535 patients with Covid-19 from various countries, found patients who were overweight or obese were more likely to die, need advanced respiratory support and be critically ill from Covid-19. This pattern mirrors other viruses – H1N1, for instance, is also deadlier in overweight people.
These factors also play off each other – we know that Covid-19 is more dangerous for older people, for instance, just as we know that we put on weight as we age. Obesity also leads to other comorbidities, such as diabetes, heart disease and high blood pressure, that make the condition more dangerous. “So along with age, along with being a man, along with being in different ethnic groups, along with having underlying illnesses – all of those factors are combined to give you a risk of having a severe outcome from Covid-19,” says Paul Aveyard, professor of behavioural medicine at the University of Oxford.
But where studies have adjusted for confounding factors such as age, sex, measures of socio-economic status, ethnicity and comorbidities, the relationship between excess weight and Covid-19 risk has persisted. This is deeply worrying, because obesity is extremely common in the UK – it is estimated to affect around one in every four adults and around one in every five children aged ten to 11. “When interpreting the impact of a risk factor on population health, it’s important to note that a small increased risk of a very common risk factor is significantly more important to overall population health than a large increased risk of a rare risk factor,” says Tolullah Oni a public health physician scientist at the University of Cambridge. “In this context, the fact that the number of people affected by obesity is so high is concerning.”
Because of this relationship, the government has framed its new plan as a way of directly tackling a second wave of coronavirus – the measures include a ban on TV junk food adverts before nine in the evening, calorie counts on menus in chain restaurants and takeaways, an end to buy-one-get-one-free on unhealthy products, and calorie labelling on alcohol.
For the specific purpose of tackling a second wave, there are some measures hidden away in the government’s proposals that could prove useful. The NHS-offered weight management services, for instance, will be expanded so more people get the support they need to lose weight, including providing more self-care apps and online tools for people with obesity-related conditions. If weight itself is a risk factor, these diets and targeted support could make a difference over a short term period, explains Aveyard.
“People don’t go on weight loss attempts or diets for more than a few months at a time, and they will typically lose a few kilos with these attempts and they will lose more if they get support,” he says. “That’s what’s crucial about what the government’s announced. It’s rolling out support, which helps people stick to their plans.”
It may be, however, that the timescale for some of the government strategies is too short – we may not be slim in time for winter. “I welcome these measures,” says Martin Caraher, emeritus professor of food and health policy at City, University of London. “But in terms of prevention, this is probably a two to three year agenda, not a two to three month agenda.”
While unhealthy food advertising has been proven to cause obesity, particularly in children, some of these measures seem quite outdated, explains Caraher. “We know that companies have already moved online with promotions and games,” he says. “And why not remove fat, salt and sugar from products, or set levels as in the case of salt so the choice is not at the individual level.” Over the years, salty products have been subject to consistent Public Health England targets to lower their salt content.
There may also be other effective strategies that the government has not looked at. “The glaring omissions here are policies to create healthy environments across the country, particularly in low-income areas,” says Oni. “For example, through increasing local authority’s powers to restrict licenses for unhealthy food outlets, subsiding of healthy foods, and a commitment to healthy and sustainable urban development such as proposed by the Healthy Homes Act.” (The latter would require all new homes and neighbourhoods to be of decent quality, and outlaw those which undermine residents’ health and wellbeing).
One of the fundamental factors not tackled by the government’s drive is poverty. For instance, a 2008 study by the American Sociological Association found that low-income relative to the rest of society is associated with higher rates of chronic health conditions such as diabetes or heart disease. People with less money are more likely to eat unhealthily – whether this is buying cheaper, unhealthier food, or living in an area where this is the only food available. They may also have less room to exercise. “These strategies are largely focused on empowering people to make healthier choices,” says Oni. “The missed opportunity here is tackling the systemic and structural determinants, and the fact that “choices” are not in fact choices in the context of unhealthy environments.”
While we are all at risk of becoming obese, and all at risk of getting Covid, those who are poorest are at greatest risk. “We’re focusing on the symptoms, rather than the cause,” says Caraher. “Inequality is the driver. The symptoms of inequality are how people eat, what they eat, and what they can afford to eat. And the outcome is obesity.”
Will Bedingfield is a staff writer for WIRED. He tweets from @WillBedingfield
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