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An extended feature written for The Independent’s Section 2, mocked up in that layout using Adobe InDesign.
In the age of 24-hour gyms, nutrition experts and kale smoothies, it doesn’t seem possible that obesity rates are actually much worse than predicted. CHRIS WHARFE investigates why they’re still a problem in the 21st Century
Obesity rates in the UK are climbing faster and higher than ever before, according to the latest Public Health England statistics, published in January. They claim we’ve severely underestimated the rate by which the population’s stomach sizes will balloon. Previous predictions had it that by 2050, around half of us would be obese: now, we’re being told it’s more like 60% of men, 50% of women and 25% of children.
Those are some damning statistics – and at first, surprising ones. We’re told week in, week out what’s good for us. We have a better knowledge than ever before of what to eat, and in what quantities; we know how much exercise we should be doing – and all this information is, largely, grounded in (and backed up by) expert scientific studies. Yet still obesity rates continue to rise, in lieu of all this; it’s almost as if the nation is collectively remaining blissfully ignorant.
This might be for a number of reasons – poor education or distribution of information; poverty in the lower social classes; deeper psychological afflictions; simple genetics. The answer is not so black-and-white, but a composite of all these things and more, says Dr Katherine McCullough, clinical lecturer and researcher in the field of obesity at Imperial College London.
“There’s a whole host of things that happen. People frequently say it’s to do with [their] genetic makeup. There probably is a hereditary predisposition to it, but people in families eat together; attend the same social events; they have the same kind of environment around them – so it’s not a nice neat answer.”
While genetics may not be a clear-cut reason (or indeed, excuse) for obesity, the family environment can have an impact. The Health Survey for England (HSE) 2011 report showed around three in ten children aged 2 to 15 were classed as either overweight or obese – with a higher concentration in households where both natural parents were also classed as overweight or obese.
Dr McCullough points to the self-perpetuating problem of family and social circles, which can often skew people’s perceptions of what it means to be obese.
“What is interesting is young people – say, 16 or onwards – and their perception of obesity, which very much depends on their family makeup. So, somebody who may be medically classified as obese won’t think of themselves as being overweight, necessarily. And then when you ask them whether anyone else in their family is overweight or obese, they’ll say no, and you’ll ask them to bring in a photograph – and you can clearly see that this is a family issue.
“People’s perceptions of what overweight is and what obese means has changed significantly over the past 50 years because it has essentially become so common that it is now the norm.”
It’s easy to point the blame at parents – as Dr McCullough has noted, genetics are but one of a whole range of contributing factors, and it’s not unreasonable to imagine that weight loss would be achievable with the correct amount of exercise and reduced food intake. But the picture painted of childhood obesity in the 21st Century is certainly a grim one.
“This is the first generation where children are likely to die before their parents of weight-related illnesses. Children are living a more sedentary lifestyle with video games and social media and, unless encouraged, are unlikely to go jogging or do an exercise class,” says diet and nutrition adviser Elaine Hilides – and she warns that this lackadaisical lifestyle is a slippery slope. “If children are obese from a young age, they believe: ‘That’s just the way I am,’ and don’t believe that they can be different.”
But Dr McCullough says it isn’t necessarily the parents who are to blame for this rise in childhood obesity: “At an early stage in childhood obesity it will be largely due to parents and what they are eating at home – but don’t forget, kids go off to school as well. So there’s meals at school; at nursery; outside school – just look at food availability. We have fast food shops open left, right and centre.
“If you want to go out and get a packet of crisps you have to walk ten metres and there will be lots of nice high fat foods available. So it’s not just within the family: it’s within schools; it’s marketing; it’s retail; it’s advertisements; it’s government policies.”
Even if parents do their best to make sure their child eats healthily at school and limits fatty or unhealthy snacks, the pressures of maintaining a household in the 21st Century – in the midst of a financial crisis, no less – don’t make things any easier, as Dr McCullough argues: “In a time-pressured environment, if you’ve got both parents working, then it’s difficult to come home and think that ‘okay, I’m now going to spend two hours slaving over a hot stove cooking a nice healthy meal’.”
JUNK FOOD CRISIS
In this sense, it can often be much easier – and cheaper – to churn out a frozen, processed dinner, regardless of the effect on parents or children. This is particularly true in the lower social classes, where fresh fruit and vegetables are simply too expensive to purchase and store, with shorter shelf lives for fresh produce becoming ever more common. But prioritising time to focus on meals accordingly can be more rewarding – and even cheaper – in the long run, Elaine argues.
“It is true that processed foods appear to be cheaper. But when we eat processed food the body is expecting nutrition and energy and it isn’t getting them from these foods. So we will continue to eat to try and get the satisfaction that isn’t coming. People eat crisps and chocolate and drink fizzy drinks in an attempt to feel satisfied.
“So in reality people are spending and eating more than they realise. There is no junk food – there is junk, and there is food.”
It isn’t just that processed and unhealthy foodstuffs are becoming cheaper, of course – it’s that the general quality of food has decreased over the past few years in efforts by corporations to cut costs. Fat has long been vilified as detrimental to our health, resulting in the increase of low-fat products. But as Elaine points out, such products can be worse for you than you may think.
“When fat is removed, sugar is added for taste,” she says. “High Fructose Corn Syrup has also been a staple ingredient in fast food, which is 120 times sweeter than sugar and should be used sparingly – but is cheap for manufacturers to use.”
THE BMI LIE
It should be noted, however, that all statistics in this article are provided by the NHS (through HSE reports). The tool used to determine obesity levels by the NHS is the body mass index (BMI) calculator – which can be flawed at the best of times.
“We use the BMI calculator in hospitals, but I think it’s inaccurate and misleading,” says Hayley Selina, a nursing student at City University London. “It’s an invalid measure of healthy body weight. You could have a small build but carry a lot of muscle mass and you would still be considered medically obese. BMI doesn’t distinguish between excess fat and muscle or bone mass.”
Case in point, a female bodybuilder was last week told that she was medically overweight according to the BMI scale, and needed to go on a 1,000 calorie-per-day diet. Anita Albrecht, a 39-year-old personal trainer, was told she had a BMI of 29, one point short of being classified as medically obese – and yet, clearly, there is nothing wrong with her fitness or health.
The use of such an apparently inaccurate tool does raise questions about the validity of any reports on the scale of obesity in the UK, but it also raises the intriguing possibility of the ‘metabolically healthy obese’ concept. Such a concept has been cause for debate among many. Elaine says there’s “no such thing as healthy obesity”, but it’s hard to argue against the reality, as Dr McCullough points out.
“Being obese increases your predisposition to a whole host of diseases, including type 2 diabetes,” she says. “Interestingly, there are a subset of patients who are classified as obese, but don’t have diabetes – and we don’t know why. So they must have some kind of protective mechanism – whether it be in their genetic makeup, something in their environment or diet, or something that they’re doing right – that prevents them from developing diabetes.
“But we do not know why some people who are morbidly obese, and thus whom you would expect to have diabetes as a result, do not have it.”
One explanation, Dr McCullough says, is the concept of metabolically healthy obese. This can take two forms; the seemingly actually obese yet medically healthy person, and the small yet well-muscled person. A perfect example of the former is Katie Lowe, a journalist who managed to lose almost half her body weight over the span of two years.
“I’m still technically obese according to the BMI scale – admittedly sitting on the arbitrary line between that and merely ‘overweight’ – but I’m healthier than a lot of people I know,” Katie says. “I can lift my own body weight thanks to my muscles, and I’m fit, healthy and active. In fact, last time I had an assessment the results had to be ordered twice, because they were bang on where they ought to be – so I’d say I’m living proof of the metabolically healthy obese concept.”
In order for people to combat obesity at all, however, they have to be in a strong state of mind psychologically. Hayley says the NHS is doing all it can to help patients, but without resorting to complex operations, they’re in for the long haul – which can be a distressing and frustrating experience.
“In nursing school, we’re taught to use a holistic approach to patient care,” she says. “This means looking after not only the patient’s physical needs but also their psychological wellbeing. Not being psychologically stable can influence the way a patient responds to treatment.
“I’ve had experiences where patients have refused to take their medicine, or flat out refused medical intervention, because they feel frustrated, helpless and discouraged. Obesity isn’t cured overnight. It takes a lot of willpower and a positive mental attitude.”
Prevention will always be better than the cure, of course – but for those patients at the end of their tether, there’s always the option of gastric bypass surgery, medicine’s ‘miracle cure’ for obesity.
“It’s for patients who are on the morbidly obese spectrum, usually with an associated condition like diabetes or high blood pressure,” says Dr McCullough. “It’s a very invasive procedure. Essentially you go through the abdomen, remove part of the bowel and sew it back together again. You also reduce the size of the stomach with various surgical techniques.
“People lose a huge amount of weight; usually around forty to fifty per cent of their body weight. It cures their diabetes. But it’s not a particularly safe operation or one that’s amenable or appropriate for everybody.”
Indeed, the operation carries plenty of risks, including severe blood loss, blood clots, infection and loose skin, and must be followed up with a change in lifestyle habits.
“If a patient isn’t complying with a strict exercise program and watching their diet, simply giving them surgery is a waste of time, money and resources,” Hayley says. “Gastric bypass surgery isn’t just a quick fix. Patients who’ve had it have to stick to a lifelong plan to avoid just piling the weight back on.”
And gastric bypass surgery is, of course, an expensive operation. It can be done on the NHS, as long as the patient overcomes certain hurdles – prove weight loss through dieting for six months prior to the operation and see a psychologist – but Dr McCullough says it has not proven cost effective thus far.
“If you look at it long term, it actually saves you money compared to not doing anything at all and treating their diabetes, and treating all the problems related to obesity,” she says. “But people don’t look at long term; they look at what’s happening in the next few years – to the next election. I know that’s a very controversial thing but unfortunately that’s very much the case within the NHS and funding these services.”
So if the cure is too expensive, we must once again look to prevention. The government’s Change 4 Life scheme is doing little to really help (as Katie laments, “when even that is encouraging people to swap one soft drink for another diet version, it’s pretty obvious these things are run in partnership with food brands”) while we’re told conflicting information by newspapers. One week, marge is in; the next it’s butter. Today it’s fat, tomorrow it’s sugar.
Almost every food and ingredient under the sun has been damned at one point or another as a killer, so it’s obviously confusing for the average family attempting to feed themselves and their children nutritiously, often on a tight budget. A few afternoons spent browsing the depths of Google can yield plenty of useful information, which means the knowledge is out there – it seems it simply isn’t being distributed well enough.
And while the middle classes may well know precisely how much quinoa and kale they’re supposed to eat in order to maintain their super-healthy lifestyles, this information isn’t so readily available for children and adults across different socioeconomic environments.
As far as children are concerned, Elaine says schools should take a more direct approach and cover not just the effects of obesity, but the effects of food itself – and possible reasons for over-eating to counteract psychological causes: “Education about food and non-food products, and what they do to the body, should be taught in schools – along with education about why people look to food to make themselves feel better.”
“I think [education on obesity] could be much better,” says Dr McCullough. “It should start from a really early age, even before schools. Toddlers can start understanding what sugar is – you’re not going to pass a can of Coke to a two year-old; why then, when they’re five, six or seven, should it be acceptable? As parents you can educate your children as to what’s good and what’s bad, and get that balance really early on.”
Just like Britain’s waistlines, obesity is a problem that will continue to grow, without the proper education and distribution of information to combat it across all social classes. And that may have to happen sooner rather than later, lest there come a time when, as Dr McCullough predicts, obesity becomes the norm.
“You or I might see someone and, medically speaking, see that they are morbidly obese – but because they’re around that all the time, they really don’t see it as being anything abnormal,” she says. “They look at us and we probably are fairly abnormal to them – we’re becoming rarer and rarer, so we’re in the minority now, rather than the other way around.
“And if two thirds of the population are overweight or obese, then they’re right – it’s no longer abnormal.”