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In introducing their excellent recent analysis [7] of the obesity challenge in the UK and beyond, the McKinsey Global Insight authors noted:

...our analysis is by no means complete. Rather, we see our work on a potential program to address obesity as the equivalent of the maps used by 16th-century navigators. Some islands were missing and some continents misshapen in these maps, but they were still helpful to the sailors of that era. We are sure that we have missed some interventions and over- or underestimated the impact of others. But we hope that our work will be a useful guide and a starting point for efforts in the years to come, as we and others develop this analysis and gradually compile a more comprehensive evidence base on this topic. 

Similarly, the authors of the 2007 Foresight Report [2] engaged in extensive systems mapping work to develop a qualitative, causal loop model to:

• help us understand the complex systemic structure of obesity

• contribute to developing a tool that helps policy makers respond to obesity in the generation, definition and testing of possible policy options.

The obesity mapping project initiated here by The College of Contemporary Health [8] is grounded the same spirit and intent. It aims to create a comprehensive and coherent visual representation of the obesity governance space – including the causes, impacts, policy actors, proposed interventions, evidence, guidance, and barriers to change – that can help each stakeholder explore and understand the space as a systemic whole; that can be collaboratively and iteratively edited, refined, and evaluated by the policy community; and that provides a dynamic, open substrate for dialogue, learning and action across the policy community.

Obesity Mapping Project initiated by The College of Contemporary Health

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The Foresight report [2] refers to a “complex web of societal and biological factors that have, in recent decades, exposed our inherent human vulnerability to weight gain”, and presents an obesity system map (above) with energy balance at its centre and over 100 variables directly or indirectly influencing this energy balance; grouped in 7 cross-cutting themes (below):

• Biology: an individual's starting point - the influence of genetics and ill health;

• Activity environment: the influence of the environment on an individual’s activity behaviour, for example a decision to cycle to work may be influenced by road safety, air pollution or provision of a cycle shelter and showers; 

• Physical Activity: the type, frequency and intensity of activities an individual carries out, such as cycling vigorously to work every day; 

• Societal influences: the impact of society, for example the influence of the media, education, peer pressure or culture; 

• Individual psychology: for example a person’s individual psychological drive for particular foods and consumption patterns, or physical activity patterns or preferences; 

• Food environment: the influence of the food environment on an individual’s food choices, for example a decision to eat more fruit and vegetables may be influenced by the availability and quality of fruit and vegetables near home; and,

• Food consumption: the quality, quantity (portion sizes) and frequency (snacking patterns) of an individual’s diet.

​​The Government supports the Foresight view that while achieving and maintaining calorie balance is a consequence of individual decisions about diet and activity, our environment (and particularly the availability of calorie-rich food) now makes it much harder for individuals to maintain healthy lifestyles – and that it is for Government, local government and key partners to act to change the environment to support individuals in changing their behaviour.

Obesity takes time to develop and excess weight takes time to be lost. The risks of becoming obese may also start at an early stage. Growth patterns in the first few weeks and months of life affect the risk of later obesity and chronic disease. There is therefore a life-course component.

Tim Lang and Geof Rayner view the current obesity problem in the UK as the result of ‘societal, technical and ideological change' in the last half-century since the end of World War II and, while acknowledging that the present situation is partially a result of a culture in which highly calorific food is available at pocket money prices and  technological advances that have made us a more sedentary nation, note also that: 

‘the culture of clever and constant advertising flattering choice; the shift from meal-time eating to permanent grazing; the replacement of water by sugary soft drinks; [and] the rising influence of large commercial concerns framing what is available and what sells’ has powerfully contributed to the growing obesity problem.

• The physical and psychological drivers inherent in human biology mean that the vast majority of people are predisposed to gaining weight. We evolved in a world of relative food scarcity and hard physical work rather than the modern world, where energy-dense food is abundant and labour-saving technologies and sedentary life patterns abound. [5]​

• The predisposition (by phenotype) to lay down fat is an evolutionary genetic legacy; with the GAD2 gene (on chromosome 10, human genome) appearing to interact with, and speed up, brain neurotransmitters, which in turn activate part of the hypothalamus, stimulating people to eat more. [6]​

• However, moving from a genetic predisposition to obesity itself generally requires some change in diet, lifestyle, or other environmental factors. [7]

"The unhealthiest foods have also become, systematically, the: tastiest, cheapest, largest portion-ed, most accessible, most available, most marketed, and most fun foods." [6]

Snowdon [6] notes:

If one looks at day-to-day exercise and occupational physical activity, it becomes clear that lifestyles have become more sedentary. The transition from manual labour to office work saw jobs in agriculture decline from eleven to two per cent of employment in the twentieth century while manufacturing jobs declined from 28 to 14 per cent of employment (Lindsay, 2003) [4]. Britons are walking less (from 255 miles per year in 1976 to 179 miles in 2010) and cycling less (from 51 miles per year in 1976 to 42 miles in 2010).

Only 18 per cent of adults report doing any moderate or vigorous physical activity at work while 63 per cent never climb stairs at work and 40 per cent spend no time walking at work (British Heart Foundation, 2012b: 58-59) [3]. Outside of work, 63 per cent report spending less than ten minutes a day walking and 53 per cent do no sports or exercise whatsoever (ibid.: 52-4). Add to this the ubiquity of labour-saving devices and it is clear that Britons today have less need, and fewer opportunities, for physical activity both in the workplace and at home."

The Sedentary Behaviour and Obesity Expert Working Group [2] noted:

• Researchers have increasingly shown an interest in very low levels of movement and sitting, i.e., sedentary behaviour. While the obvious examples of such behaviours are TV viewing and playing computer games, there are many daily sitting behaviours, including car travel, socialising, reading, and listening to music, as well as long periods spent sitting at school or work. It is all of these sedentary behaviours that are of interest to health researchers and policy makers.

• However, the rise in the interest in sedentary behaviours is closely associated with the rapid increase in the availability and attractiveness of a wide range of screen-based behaviours, including school/work use of computers, leisure time computer use (games, online shopping, internet surfing etc), and TV viewing. While some of these behaviours will have replaced other sedentary pastimes (e.g., radio, reading) over the years, there is widespread belief that the ubiquitous nature of screens is a threat to health from the point of view of very low energy expenditure and hence a risk to the development of overweight and obesity.

Source:  S. Taheri [4]

Around one in two women and a third of men in England are damaging their health through a lack of physical activity. [8]

• over one in four women and one in five men do less than 30 minutes of physical activity a week, so are classified as ‘inactive’. [2]

• physical inactivity is the fourth largest cause of disease and disability in the UK. [7]

Snowdon [1] notes:

If one looks at day-to-day exercise and occupational physical activity, it becomes clear that lifestyles have become more sedentary. The transition from manual labour to office work saw jobs in agriculture decline from eleven to two per cent of employment in the twentieth century while manufacturing jobs declined from 28 to 14 per cent of employment (Lindsay, 2003) [4]. Britons are walking less (from 255 miles per year in 1976 to 179 miles in 2010) and cycling less (from 51 miles per year in 1976 to 42 miles in 2010).

Only 18 per cent of adults report doing any moderate or vigorous physical activity at work while 63 per cent never climb stairs at work and 40 per cent spend no time walking at work (British Heart Foundation, 2012b: 58-59) [3]. Outside of work, 63 per cent report spending less than ten minutes a day walking and 53 per cent do no sports or exercise whatsoever (ibid.: 52-4). Add to this the ubiquity of labour-saving devices and it is clear that Britons today have less need, and fewer opportunities, for physical activity both in the workplace and at home."

Self-reported percentage of adults meeting the physical activity recommendations, by sex, UK countries 1997 to 2011 

Source: British Heart Foundation / University of Oxford [1]

• Drinking just one regular soda a day is the equivalent of consuming over 221,000 sugar cubes over an average lifetime.

• Evidence shows that SSBs are major contributors to childhood obesity [19], [20], as well as to long-term weight-gain, type 2 diabetes, and cardiovascular disease [21], [22].
  

UK purchases of soft drink (concentrated and unconcentrated), 1992–2013 

Source: DEFRA

• This was mirrored by an upward trend in ‘low calorie soft drinks’ with household purchases 36 per cent higher in the same period up from 579 to 786 grams per person per week.

• WHO recommends a reduced intake of free sugars throughout the lifecourse (strong recommendation).

• In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake (strong recommendation).

• WHO suggests a further reduction of the intake of free sugars to below 5% of
  total energy intake (conditional recommendation).

Average energy intake from food and drink since 1940

Source: DEFRA

Energy derived from household food and drink 2001-2013

Source: DEFRA

"In fact, it appears that lean people overshoot in terms of weight gain because the state of hyperphagia (in response to weight loss) appears to persist well beyond complete recovery of fat mass and interestingly until fat free mass is fully recovered (which may take months during which time fat gain continues)." [1]

Sources: Scott Kahan, U.S. Federal Trade Commission, Yale Rudd Center, Kaiser Family Foundation

Sources: Scott Kahan, Kaiser Family Foundation

Source: Scott Kahan

​

Source: Scott Kahan [2]

Sources: Scott Kahan, Chicago Tribune (2006)

• Although in theory minimal processing of foods can improve nutritional content, in practice most processing is done so to increase palatability, shelf-life, and transportability (and these processes tend to reduce nutritional quality). [2]

Robert H. Lustig, MD, UCSF Professor of Pediatrics in the Division of Endocrinology, explores the damage caused by sugary foods. He argues that fructose (too much) and fiber (not enough) appear to be cornerstones of the obesity epidemic through their effects on insulin. Series: UCSF Mini Medical School for the Public [7/2009]

Sources: Scott Kahan, Am J Clin Nutr (2004), New York Times (2009)

 From Moodie et al. [6]:

• Transnational corporations are major drivers of non-communicable disease epidemics and profit from increased consumption of tobacco, alcohol, and ultra-processed food and drink (so-called unhealthy commodities).​

• Alcohol and ultra-processed food and drink industries use similar strategies to the tobacco industry to undermine effective public health policies and programmes.

• Unhealthy commodity industries should have no role in the formation of national or international policy for non-communicable disease policy.​

• Despite the common reliance on industry self-regulation and public–private partnerships to improve public health, there is no evidence to support their effectiveness or safety.​

• In view of the present and predicted scale of non-communicable disease epidemics, the only evidence-based mechanisms that can prevent harm caused by unhealthy commodity industries are public regulation and market intervention

From Dorfman et al:

"Tobacco companies launched CSR campaigns to rehabilitate themselves with the public when their image had been tarnished [20]. Because the most comprehensive initiatives were introduced well after intense public outcry, however, their CSR efforts struggled to achieve their aims [42]. As soda denormalization is nascent, soda companies may enjoy benefits from CSR that Big Tobacco labored to accomplish. In addition to effectively preempting regulation and maintaining its favorable position with the public, the soda industry's CSR tactics may also entice today's young people to become brand-loyal lifetime consumers, an outcome that current social norms dictate Big Tobacco cannot explicitly seek.

Without sustained denormalization of soda, it will be harder for public health advocates to see why partnering with industry may further the companies' goals more than their own. While tobacco denormalization was facilitated by litigation, which used the discovery process to procure internal documents revealing the industry's duplicitous intent, it is possible to respond to the soda industry without a “smoking gun.”

For example, one instance of tobacco industry denormalization that did not rely on internal documents was the revelation that PM spent more on publicizing its charitable efforts than it spent on the charities itself, which exposed the cynical nature of Big Tobacco's CSR [114]. The Refresh Project's $20 million price tag, and the statements from company representatives, give public health advocates a similar opportunity to argue that this is marketing, not philanthropy [115].

Such criticism appeared in a Lancet editorial, which stated that the U.K.'s Change4Life should have avoided “ill-judged partnerships with companies that fuel obesity” [116]. Research on the health harms of sugary beverages can help advocates name these products as one of the “biggest culprits” [117] behind the obesity crisis.

Emerging science on the addictiveness [118] and toxicity [119] of sugar, especially when combined with the known addictive properties of caffeine found in many sugary beverages, should further heighten awareness of the product's public health threat similar to the understanding about the addictiveness of tobacco products.

Public health advocates must continue to monitor the CSR activities of soda companies, and remind the public and policymakers that, similar to Big Tobacco, soda industry CSR aims to position the companies, and their products, as socially acceptable rather than contributing to a social ill."

The table below (via HOOP) [1] provides a summary of each of the public health issues, the prevalence of the issue in adults and children and young people as well as the direct NHS and indirect social and economic costs, (where data is available): 

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• Despite the higher direct and indirect costs, the allocation of public health funds by local authorities to help overweight and obese people to lose weight is significantly lower than the allocation for other public health issues. 

• This is short sighted and  this lack of action is the primary reason we are not seeing progress on tackling obesity. 

• Why central government funding for weight management services is not available whilst £2bn worth of central government funding has been made available for substance misuse (in addition to already high local authority investment). 

• Evidence seems to suggest that both central and local governments are either not aware of the disparity or they are simply not taking the issue of obesity seriously when compared to other public health issues. 

• Given evidence that weight management services are cost effective local and central governments should be prioritising investments that provide a positive return.

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• Some prevention and intervention strategies are provided in primary care, but secondary care and specialist services remain underdeveloped or unavailable to meet the need.

Sources: Scott Kahan, Kaiser Family Foundation

 Background on the oligopoly in the global food system: [2]

• In the United States, the ten largest food companies control over half of all food sales [4] and worldwide this proportion is about 15% and rising. 

• More than half of global soft drinks are produced by large multinational companies, mainly Coca-Cola and PepsiCo. [5] Three-fourths of world food sales involve processed foods, for which the largest manufacturers hold over a third of the global market.

• Big Food is a driving force behind the global rise in consumption of sugar-sweetened beverages (SSBs) and processed foods enriched in salt, sugar, and fat. [5]

Illustration of obesity and waist circumference From left to right, as labeled in the original image, the "healthy" man has a 33 inch (84 cm) waist, the "overweight" man a 45 inch (114 cm) waist, and the "obese" man a 60 inch (152cm) waist. (image source) (image reference) Source: Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2000. Infographic: FDA/Renée Gordon / Wikipedia

Body Mass Index (BMI) is also used as an indicator of healthy weight for height (although people who are very muscular can have a high BMI, without excess fat). For most adults:

• a BMI of 25 to 29.9 is considered overweight​;

• a BMI of 30 to 39.9 is considered obese​; and,

• a BMI of 40 or above is considered severely obese.

Older patients, in particular, may have a normal BMI while having a waist measurement which places them into the high risk category. 

The Royal College of Physicians [4] notes that:

1. Obesity is strongly heritable (60% of weight variance is attributed to heredity) yet currently known gene mutations and polymorphisms account for <5% of weight variability.


2. Diagnosis by BMI requires measuring height and weight accurately; risk stratification in overweight and modest obesity requires measuring waist circumference and possibly the use of a clinical staging system (Edmonton Obesity Staging System (EOSS)).


3. Prevention and long-term weight loss maintenance require sustained changes in diet and physical activity habits.


4. Obesity is a major risk factor in diabetes (5 x), cancer (3 x the risk of colon cancer), and heart disease (2.5 x).


5. Modest weight loss (~10 kg) helps to improve diabetes, improves quality of life and reduces morbidity.


6. An energy deficit of only 100 calories per day predicts a 0.5 kg weight loss in a month.


7. Cost-effective treatments in appropriate patients include weight loss programmes (commercial: e.g. WeightWatchers; GP delivered: eg Counterweight); pharmacotherapy (egorlistat); and bariatric surgery.

Obesity

• The proportion of adults with a normal Body Mass Index (BMI) decreased between 1993 and 2012 from 41.0% to 32.1% among men and from 49.5% to 40.6% among women.​

• There was a marked increase in the proportion of adults that were obese between 1993 and 2012 from 13.2% to 24.4% among men and from 16.4% to 25.1% among women.​

• The proportion of adults that were overweight including obese increased between 1993 and 2012 from 57.6% to 66.6% among men and from 48.6% to 57.2% among women.​

• The proportion of adults with a raised waist circumference increased from 20% to 34% among men and from 26% to 45% among women between 1993 and 2012.​

• In Reception class in 2012/13, the proportion of obese children (9.3%) was lower than in 2011/12 (9.5%) and also lower than in 2006/07 (9.9%) (when data was first published).​

• In Year 6 in 2012/13, the proportion of obese children (18.9%) was lower than in 2011/12 (19.2%) but higher than in 2006/07 (17.5%).

Physical activity In 2012

• 67% of men and 55% of women aged 16 and over met the new recommendations for aerobic activity. 26% of women and 19% of men were classed as inactive.​

• 46% of men and 37% of women reported walking of at least moderate intensity for 10 minutes or more on at least one day in the last four weeks.​

• 52% of men and 45% of women had taken part in sports/exercise at least once during the past four weeks.

Diet

• While overall purchases of fruit and vegetables reduced between 2009 and 2012, consumers spent 8.3% more on fresh and processed vegetables and 11.7% more on fresh and processed fruit.​

• Total expenditure on household food and non-alcoholic drink rose by 4.3% in 2012 from the previous year and was 8.9% higher than in 2009. There have been significant upward trends in household expenditure on total fats and oils, butter, sugar and preserves, fruit and fruit juice, soft drinks and beverages.

• For men, waist circumference of less than 94 cm is low, 94–102 cm is high and more than 102 cm is very high.
• For women, waist circumference of less than 80 cm is low, 80–88 cm is high and more than 88 cm is very high.

Source: Public Health England – Obesity

Nonetheless, the absolute level of obesity remains very high and England (along with the rest of the UK) ranks as one of the most obese nations in the world; there are no signs yet of a sustained decline, and (as obesity tends to increase with age) the UK's ageing population remains a concern.

Source: Public Health England  [9]

Compared with a non-obese man, an obese man is:

• five times more likely to develop type 2 diabetes

• three times more likely to develop cancer of the colon 

• more than two and a half times more likely to develop high blood pressure – a major risk factor for stroke and heart disease.

An obese woman, compared with a non-obese woman, is:

• almost thirteen times more likely to develop type 2 diabetes

• more than four times more likely to develop high blood pressure 

• more than three times more likely to have a heart attack.

Risks of other diseases, including angina, gall bladder disease, liver disease, ovarian cancer, osteoarthritis and stroke, are also increased. 

If current trends persist, one in three people will be obese by 2034 and one in ten will develop type II diabetes (Figure 9, below); whereas, reducing obesity back to 1993 levels, would avoid five million cases of disease (Figure 10, below).

Source: Public Health England  [9]

• Around 58% of type 2 diabetes, 21% of heart disease and between 8% and 42% of certain cancers (endometrial, breast, and colon) are attributable to excess body fat.

• Obesity reduces life expectancy by an average 9 years and is responsible for 9,000 premature deaths a year in England.

• In addition, people who are obese can experience stigmatisation and bullying, which can lead to depression and low self-esteem. [1]

Health impact: People with diabetes are at a greater risk of a range of chronic health conditions including cardiovascular disease, blindness, amputation, kidney disease and depression than people without diabetes. Diabetes leads to a two-fold excess risk for cardiovascular disease, and diabetic retinopathy is the leading cause of preventable sight loss among people of working age in England and Wales. Diabetes is a major cause of premature mortality with around 23,300 additional deaths in 2010-11 in England attributed to the disease.

Economic impact: It is estimated that in 2010-11 the cost of direct patient care (such as treatment, intervention and complications) for those living with type 2 diabetes in the UK was £8.8 billion and the indirect costs (such productivity loss due to increased death and illness and the need for informal care) were approximately £13 billion. Prescribing for diabetes accounted for 9.3% of the total cost of prescribing in England in 2012-13.

Type 2 diabetes

• The underlying disorder for type 2 diabetes is usually insulin insensitivity combined with a failure of pancreatic insulin secretion to compensate for increased glucose levels. The insulin insensitivity is usually evidenced by excess body weight or obesity, and exacerbated by over-eating and inactivity.

• It is commonly associated with raised blood pressure and a disturbance of blood lipid levels. The insulin deficiency is progressive over time, leading to a need for lifestyle change often combined with blood glucose lowering therapy.

• Factors which influence someone's risk of type 2 diabetes include: weight, waist circumference, age, physical activity and whether or not they have a family history of type 2 diabetes.

• Particular conditions can increase the risk of type 2 diabetes. These include: cardiovascular disease, hypertension, obesity, stroke, polycystic ovary syndrome, a history of gestational diabetes and mental health problems. In addition, people with learning disabilities and those attending accident and emergency, emergency medical admissions units, vascular and renal surgery units and ophthalmology departments may be at high risk.

• In addition to these individual risk factors, people from certain communities and population groups are particularly at risk. This includes people of South Asian, African-Caribbean, black African and Chinese descent and those from lower socioeconomic groups.

Metabolic Syndrome

• Metabolic syndrome is a combination of disorders including high blood glucose, high blood pressure and high cholesterol and triglyderide levels, that is more common in obese individuals and is associated with significant risks of coronary heart disease and Type 2 diabetes. There is also a greater risk of dyslipidemia (for example, high total cholesterol or high levels of triglycerides), which also contributes to the risk of circulatory disease by speeding up atherosclerosis (fatty changes to the linings of the arteries).

• The International Agency for Research on Cancer (IARC) has found that around 7,000 male and 13,000 female cancer cases in the UK each year could be attributed to obesity –and that over four in 10 cancers in the UK could be prevented through lifestyle changes that encourage healthy eating and exercise. [5]

• Research has suggested that body-mass index (BMI) is an important predictor of cancer risk, 2 and a Norwegian cohort study reported associations with several cancer sites, including the thyroid 3 and ovaries; 4 and the UK Million Women Study showed associations between BMI and ten of 17 sites investigated.5 

• Two large reviews brought these and many smaller studies together.6, 7 In a meta-analysis of 221 datasets, strong associations were recorded between BMI and cancers of the oesophagus, thyroid, colon, kidneys, endometrium, and gallbladder, and weaker associations were shown for several other sites. 7 

• Increased BMI was negatively associated with lung cancer.

• There is a two-way relationship between obesity and disability in adults. 

•  Obesity is associated with the four most prevalent disabling conditions in the UK: arthritis, back pain, mental health disorders and learning disabilities. 

• One third of obese adults in England have a limiting long term illness or disability compared to a quarter of adults in the general population. 

• The prevalence of obesity-related disabilities among adults is increasing.

• Adults with disabilities have higher rates of obesity than adults without disabilities. 

• For those adults who are disabled and obese, social and health inequalities relating to both conditions may be compounded. This can lead to socioeconomic disadvantage and discrimination.

• The combination of rising obesity and disability has significant implications for health and social care services in England.Obesity may lead to disability as a consequence of increased body weight, associated co-morbidities, environmental factors, or a combination of these. 

• Obesity places mechanical stress on joints, increasing the risk of back pain and osteoarthritis which may in turn limit mobility.  Some obese people may face difficulties in performing tasks such as walking, climbing steps, driving or dressing. This in turn can lead to physical inactivity, pain and discomfort, functional limitations and mental distress. 

• Older people who are obese are at particular risk of joint pain and arthritis and may be less motivated to engage in physical activity if they are concerned about falls and bone fractures. 

• Among people with severe obesity, limitations in mobility-related activities have been reported to be between five and nine times greater than for healthy weight subjects. 

• A recent UK cohort study of adults with severe obesity found that the prevalence of self-reported disability was strongly associated with BMI, age, the presence of type 2 diabetes, metabolic syndrome and clinical depression. 

• Obesity is an important risk factor for the condition: over 66% of overweight people, and over 90% of obese individuals are at risk of NAFLD.

• As levels of obesity have risen, so has the prevalence of NAFLD. There is a lack of high quality data related to the prevalence of NAFLD in the UK. This is due to a number of factors including variations in diagnostic criteria, the invasive nature of diagnosis, and the lack of symptoms in people with mild forms of the condition. 

• Approaches to tackling the condition focus on weight reduction through a combination of diet and physical activity, but there is no specific evidence-based treatment for NAFLD. 

• Scientific understanding of the condition is limited, and there is a lack of high quality data on it. The impact of rising obesity levels on the prevalence and severity of NAFLD is not known, nor are the natural history or optimal management of the condition. There is a lack of scientific consensus on just how significant a threat to health NAFLD presents. In order to explore these issues in more detail we held an initial expert workshop in October 2013, and are continuing to develop this work in PHE and with external partners. 

• Improvements in outcomes from NAFLD will require better data collection through primary and secondary care, death certification, and transplant registers, as well as research into the causes and treatment of the condition.

• The mental health of women is more closely affected by overweight and obesity than that of men.

• There is strong evidence to suggest an association between obesity and poor mental health in teenagers and adults. This evidence is weaker for younger children. 

• The perception of being obese appears to be more predictive of mental disorders than actual obesity in both adults and children (although the relationships between actual body weight, self-perception of weight and weight stigmatisation are complex and vary across cultures, age and ethnic groups). 

• Weight stigma increases vulnerability to depression, low self-esteem, poor body image, maladaptive eating behaviours and exercise avoidance. 

• There is an urgent need for evaluations of weight management interventions, both in terms of weight loss and psychological benefits.​

• Intervention strategies should consider both the physical and mental health of patients. It has been recommended that care providers should monitor the weight of depressive patients and, similarly, in overweight or obese patients, mood should be monitored. This awareness could lead to prevention, early detection, and co-treatment for people at risk, ultimately reducing the burden of both conditions. 

More Details – PHE Obesity >>

• Obesity is related to social disadvantage among adults [6], [8] and children [7], [8].

• It is also linked to ethnicity: it is most prevalent among African-Caribbean and Irishmen and least prevalent among Chinese women [7], [8].

Life expectancy at birth, UK (1980-1982 to 2011-2013)

Source: ONS

Simon Stevens, Chief Executive of NHS England warned in September 2014 of the need to get serious about obesity or bankrupt the NHS (with the cost of treating the health consequences of obesity escalating as the prevalence of obesity spreads in the population):

Obesity is the new smoking, and it represents a slow-motion car crash in terms of avoidable illness and rising health care costs... If as a nation we keep piling on the pounds around the waistline, we’ll be piling on the pounds in terms of future taxes needed just to keep the NHS afloat. [13]

The McKinsey Global Institute analysis [11] found that obesity generated an economic loss in the UK of more than $70 billion a year in 2012, or 3.0 percent of GDP (see below); the second biggest impact – within the analysis as defined (covering the loss of productive life, direct health-care costs, and investment to mitigate the cost) – of 14 human generated burdens:

Source: McKinsey Global Institute

A 2010 review by the National Obesity Observatory of previous economic analyses of the burden of obesity in the UK noted: ^[2]

• Estimates of the direct NHS costs of treating overweight and obesity, and related morbidity in England have ranged  from £479.3m in 1998 [4] to £4.2bn in 2007. [1] 

• Estimates of the indirect costs (those costs arising from the impact of obesity on the wider economy such as loss of productivity) from these studies ranged between £2.6bn [4] and £15.8 billion.[1] Modelled projections suggest that indirect costs could be as much as £27bn by 2015. In 2006/07, obesity and obesity-related illness was estimated to have cost £148 million in inpatient stays in England. [10]

 Source: Foresight Report, 2007

• Premature deaths attributable to obesity lead to the annual loss of around 45,000 years of working life. Sickness absence attributable to obesity is estimated at between 15.5 million and 16 million days per year.Obese people are much less likely to be in employment than those of healthy weight, with associated welfare costs estimated at between £1 billion and £6 billion. The total cost to the economy of being overweight or obese has been estimated as some £16 billion in 2007, rising to £50 billion per year by 2050 if left unchecked.​

• It is estimated that 23% of spending on all drugs is attributable to overweight and obesity. The minimum annual cost of any drug prescriptions at BMI 20 rose from £50.71 for men and £62.59 for women by £5.27 and £4.20, respectively, for each unit increase in BMI to a BMI of 25.3 Increases for each BMI unit were greater to BMI 30, and greater still, £8.27 (men) and £4.95 (women), to BMI 40.

 Source: Foresight Report, 2007

A Snapshot of Obesity-Related Costs

Source: Harvard School of Public Health 

Obesity Policymaker Survey 2014

Source: EASO, C3 Collaborating for Health

• The total direct financial cost of obesity for the Australian community was estimated to be $8.3 billion in 2008. Of these costs, the Australian Government bears over one-third (34.3% or $2.8 billion per annum), and state governments 5.1%.

• This estimate includes productivity costs of $3.6 billion (44%), including short- and long-term employment impacts, as well as direct financial costs to the Australian health system of $2 billion (24%) and carer costs of $1.9 billion (23%).

• The net cost of lost wellbeing (the dollar value of the burden of disease, netting out financial costs borne by individuals) was valued at $49.9 billion. 

• Direct medical costs (including counselling, outpatient and hospital visits, a range of bariatric surgical procedures, new treatment, nursing home care, rehabilitation and hospice) account for $190 billion of the annual costs. ​[5]

• Non-medical costs (including health education and behavioural change) add $50 billion per year.​

• Absenteeism and sub-par productivity in the workplace costs an additional $65.1 billion a year.

​​

Earlier Analysis of the Economic Impact of Obesity on the US

• In 2010, the nonpartisan Congressional Budget Office reported that nearly 20 percent of the increase in U.S. health care spending (from 1987-2007) was caused by obesity. 

• Annual health costs related to obesity in the U.S. is nearly $200 billion, and nearly 21 percent of medical costs in the U.S. can be attributed to obesity. 

• Researchers estimate that if obesity trends continue, obesity related medical costs, alone, could rise by $43 to $66 billion each year in the United States by 2030.

• Per capita medical spending is $2,741 higher for people with obesity than for normal weight individuals.

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Obesity's Impact on the US Workforce

• Full-time workers in the U.S. who are overweight or obese and have other chronic health conditions miss an estimated 450 million additional days of work each year compared with healthy workers-- resulting in an estimated cost of more than $153 billion in lost productivity annually, according to a 2011 Gallup Poll.

• Medical expenses for obese employees are 42%  than for a person with a healthy weight, according to the Centers for Disease Control.

 Clive Coleman, BBC's legal correspondent

"Today's ruling was of great interest to employers across Europe. The judgement makes no direct link between Body Mass Index and obesity, but is a powerful statement that an obese worker whose weight hinders their performance at work is entitled to disability protection.

That will mean employers must, on a case by case basis, make reasonable adjustments such as providing larger chairs or special car parking, and protect such employees from verbal harassment.

But there are wider implications. Providers of goods and services such as shops, cinemas and restaurants will also have to make reasonable adjustments for their customers, which might include things like special seating arrangements.

The key concept here is that adjustments must be "reasonable" - so it may be deemed reasonable for a Premier League football club to make two seats available for someone disabled through obesity, but not for a small, non-league club.

Obesity, particularly what is sometimes known as morbid or severe and complex obesity, can be a particularly sensitive subject.

Employers and service providers will have to take care not to make assumptions about the needs of an obese worker or customer."

• The National Child Measurement Programme (NCMP) measures the height and weight of around one million school children in England every year, providing a detailed picture of the prevalence of child obesity.​

• In addition to showing that 19.1% of children in Year 6 (aged 10-11) were obese and a further 14.4% were overweight, the figures for 2013/14 show that 9.5% of children in Reception (aged 4-5), were obese and another 13.1% were overweight (meaning that a third of 10-11 year olds and over a fifth of 4-5 year olds were overweight or obese. [1], [2]

• Results from the 2012 Health Survey for England (HSE)—which includes a smaller sample of children than the NCMP but covers a wider age range—show that around 28% of children aged 2 to 15 were classed as either overweight or obese. [1] 

Source: MGI Overcoming Obesity 

The main findings of the McKinsey Global Institute discussion paper include:

• Existing evidence indicates that no single intervention is likely to have a significant overall impact. A systemic, sustained portfolio of initiatives, delivered at scale, is needed to reverse the health burden. Almost all the identified interventions (exhibit) are cost effective for society—savings on healthcare costs and higher productivity could outweigh the direct investment required by the intervention when assessed over the full lifetime of the target population. In the United Kingdom, for instance, such a program could reverse rising obesity, saving the National Health Service about $1.2 billion a year.​

​​Cost-effective interventions to reduce obesity in the UK

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• Education and personal responsibility are critical elements of any program aiming to reduce obesity, but they are not sufficient on their own. Other required interventions rely less on conscious choices by individuals and more on changes to the environment and societal norms. They include reducing default portion sizes, changing marketing practices, and restructuring urban and education environments to facilitate physical activities.​

• No individual sector in society can address obesity on its own—not governments, retailers, consumer-goods companies, restaurants, employers, media organizations, educators, healthcare providers, or individuals. Capturing the full potential impact requires engagement from as many sectors as possible. Successful precedents suggest that a combination of top-down corporate and government interventions, together with bottom-up community-led ones, will be required to change public-health outcomes. Moreover, some kind of coordination will probably be required to capture potentially high-impact industry interventions, since any first mover faces market-share risks.​

• Implementing an obesity-abatement program on the required scale will not be easy. We see four imperatives:

(1) as many interventions as possible should be deployed at scale and delivered effectively by the full range of sectors in society;

(2) understanding how to align incentives and build cooperation will be critical to success;

(3) there should not be an undue focus on prioritizing interventions, as this can hamper constructive action; and

(4) while investment in research should continue, society should also engage in trial and error, particularly where risks are low.

• For example, policies on health and transport may conflict, if people are being encouraged to be physically active but are living in environments dominated by busy roads. 

Encouraging daily physical activity and modifying dietary intake raises complex questions for public policy across a number of areas; including:

• agriculture – because policy affects what is produced;​

• manufacturing – for ingredients, portions and products;​

• retail – for planning, prices, availability and location;​

• education – for health knowledge and skills;​

• culture – for the shaping of consciousness around food and physical activity;​

• trade – for product pricing and terms of trade;​

• economics – for differential taxation and subsidy of foods.

From the NICE Guidelines: [8] 

"Those responsible for setting competences and continuing professional development programmes for health professionals (including local education and training boards; local education and training councils and professional bodies) should:

• Ensure professional development training on weight management is available for health and social care professionals.

• Train GPs and other health and social care professionals to identify when to raise weight management with someone and to do so confidently, but with empathy. They should understand why many adults have difficulty managing their weight and the experiences they may face in relation to it. This includes considering the effect of their attitudes to, and any concerns about, their own weight.

• Train GPs and other health and social care professionals to accurately measure and record height and weight, determine BMI and accurately measure waist circumference.

• Train GPs and other health and social care professionals to understand the practical skills and behaviours that can help someone lose or maintain their weight and how to provide ongoing support and encouragement. This includes encouraging people to self-manage and self-monitor their weight and any associated behaviours over the long term.

• Train GPs and other health and social care professionals to discuss the likely benefits of a lifestyle weight management programme with service users, taking into account someone's personal circumstances. For example, they should take into account any associated medical conditions or personal factors, such as someone's commitment to change.

• Train GPs and other health and social care professionals in how to help people make an informed decision about the best weight management option for them. They should also be able to refer people to the most appropriate weight management service. This includes identifying people with more complex needs and referring them to appropriate services (such as mental health, psychological or alcohol services).

• Train GPs and other health and social care professionals to identify when someone may benefit from re-referral to a lifestyle weight management programme."

Source: HEE [1] via IOM [2] and Kings Fund [3]

• The Department of Health should encourage training and accreditation schemes that exist on this subject, as these will help GPs in making every contact with patients count. 

• The training includes increasing awareness amongst GPs of the importance of waist measurement during medical appointments in order to identify indicators of visceral adiposity or ectopic fat deposits, which can adversely affect health outcomes.

GPs should have appropriate training to provide useful advice to patients.

The Royal College of Physicians [1] notes that:

1. In the UK 1 in 4 adults are obese (2012).


2. In the UK 1 in 5 children aged 10–11 are obese (2011).


3. Obesity is strongly heritable (60% of weight variance is attributed to heredity) yet currently known gene mutations and polymorphisms account for <5% of weight variability.


4. Diagnosis by BMI requires measuring height and weight accurately; risk stratification in overweight and modest obesity requires measuring waist circumference and possibly the use of a clinical staging system (Edmonton Obesity Staging System (EOSS)).


5. Prevention and long-term weight loss maintenance require sustained changes in diet and physical activity habits.


6. Obesity is a major risk factor in diabetes (5 x), cancer (3 x the risk of colon cancer), and heart disease (2.5 x).


7. Obesity is a major cause of health inequality and impaired quality of life and costs the NHS £5.0bn per year (2012).


8. Modest weight loss (~10 kg) helps to improve diabetes, improves quality of life and reduces morbidity.


9. An energy deficit of only 100 calories per day predicts a 0.5 kg weight loss in a month.


10. Cost-effective treatments in appropriate patients include weight loss programmes (commercial: e.g. WeightWatchers; GP delivered: eg Counterweight); pharmacotherapy (egorlistat); and bariatric surgery.

From the BMJ Press Release: [2] 

"Few UK family doctors seem to be treating overweight/obesity appropriately, with some not treating it all, suggests an analysis of patient records published in the online journal BMJ Open.

The researchers scrutinised the anonymised health records of more than 90,000 obese and overweight adults, whose data had been entered into the Clinical Practice Research Datalink (CPRD) between 2005 and 2012.

The CPRD is the largest primary care database in the world, and contains the health records of over 5% of the UK population, submitted by 680 general practices.

The researchers looked at all the weight management options provided, including lifestyle advice, specialist referrals, and prescription of obesity drugs.

The average age of the patients was 56. Some 60% were overweight and 40% were obese, including 5% who were morbidly obese with a body mass index (BMI) of 40kg/m2 or more.

Between 2005 and 2012, no weight management intervention was recorded for most (90%) of the overweight patients. Many practices didn't record any interventions at all for obese patients during this time.

A weight management intervention was more likely to be recorded in the health records of obese patients, but it was still not documented in more than 80% of those with simple obesity.

Patients with severe obesity were more than three times as likely to be offered weight management, but this was still not recorded in the case notes of over half (59%) of them.

Lifestyle change, including dietary advice and exercise, was the most common weight management plan offered in all but the most severely obese patients, for whom drug treatment was the most commonly recorded intervention.

And there was little documented evidence that progress on weight loss had been tracked after an intervention had been introduced.

Monitoring progress on weight loss in the first year after an intervention was most frequently recorded in the case notes of patients who had been referred to specialist services (34%). But it was only recorded for one in five of those given lifestyle advice and one in four of those prescribed an obesity drug.

There was no evidence that outcomes were being monitored for any intervention after five years.

Factors associated with weight loss intervention included older age, type 2 diabetes, and depression, with morbid obesity the strongest predictor of weight management provision. Women, former smokers, and those from disadvantaged backgrounds were also more likely to be treated for overweight/obesity.

The researchers point out that the findings might simply be the result of poor documentation, and that brief advice may have been offered, but not recorded in the patient's notes.

On the other hand, the findings "might also indicate a lack of patient access to appropriate body weight management interventions in primary care due to a lack of clinician awareness or confidence in treating obesity," they write.

The reasons for this might include too little time to tackle the issue in consultations, doubts about the success of weight loss attempts, greater use of drugs to treat obesity related risk factors and disease, and possibly 'normalisation' of excessive body weight.

Nevertheless, they conclude:

"The results of this study suggest that primary care interventions given to patients with the aim of reducing weight are underutilised, and that follow up to determine their success is poor."

And they emphasise:

"The growing burden of obesity on primary healthcare services and lack of long term follow up on the effectiveness of these treatments supports the use of structured recording of interventions for weight management."

In a 2010 review of the training of health professionals for prevention and treatment of overweight and obesity, the Royal College of Physicians concluded [4] that:

‘health professionals either lack appreciation of the health and medical consequences of obesity or lack confidence and the ability to help […and…] too often health professionals ignore the obvious signs or symptoms of obesity or simply instruct the individual to go on a diet and lose significant weight.’ 

Similarly, Professor Anthony Leeds of the University of Surrey has highlighted [3] the fact that specific training on obesity management is missing from most GP training programmes, and most GPs are better equipped to deal with the consequences of obesity, such as heart disease, type-2 diabetes, and osteoarthritis, than they are to help patients deal with the underlying weight gain which has caused the problem.​

Eating healthily is about eating the right amount of food for your energy needs. In England, most adults are either overweight or obese. This means many of us are eating more than we need, and should eat and drink fewer calories in order to lose weight.

Based on the eatwell plate, try to eat:

• Plenty of fruit and vegetables: Did you know that we should be eating at least five portions of a variety of fruit and veg every day?​

• Plenty of potatoes, bread, rice, pasta and other starchy foods: Choose wholegrain varieties whenever you can, or eat potatoes with their skins on for more fibre.​

• Some milk and dairy foods: Go for lower-fat milk and dairy foods. These are healthier options to help you get enough protein and calcium.​

• Some meat, fish, eggs, beans and other non-dairy sources of protein: These are important sources of protein, vitamins and minerals, and form part of a healthy balanced diet.​

• Just a small amount of foods and drinks that are high in fat or sugar: Cut down on fat and sugar by eating fewer sweets, cakes and biscuits, and drinking fewer sugary soft drinks.

Is the eatwell plate for me?

The eatwell plate applies to most people – whether they're a healthy weight or overweight, whether they eat meat or are vegetarian, and no matter what their ethnic origin.

However, it doesn't apply to children under the age of two because they have different nutritional needs. Between the ages of two and five, children should gradually move to eating the same foods as the rest of the family, in the proportions shown on the eatwell plate.

Anyone with special dietary requirements or medical needs might want to check with a registered dietitian whether the eatwell plate applies to them.​​

Source: DEFRA

Key facts

• A healthy diet helps protect against malnutrition in all its forms, as well as noncommunicable diseases (NCDs), including obesity, diabetes, heart disease, stroke and cancer.
• Unhealthy diet and lack of physical activity are leading global risks to health.
• Healthy dietary practices start early in life – breastfeeding may have longer-term benefits, like reducing the risk of overweight and obesity in childhood and adolescence.
• Energy intake (calories) should balance energy expenditure. Evidence indicates that total fat should not exceed 30% of total energy intake to avoid unhealthy weight gain [2] , [3], [4], with a shift in fat consumption away from saturated fats to unsaturated fats [4], and towards the elimination of industrial trans fats [5].
• Limiting intake of free sugars to less than 10% of total energy [3], [6] is part of a healthy diet. A further reduction to less than 5% of total energy [7] is suggested for additional health benefits.
• Keeping salt intake to less than 5 g per day helps prevent hypertension and reduces the risk of heart disease and stroke in adult population. [8]
• WHO Member States have agreed to reduce the global population’s intake of salt by 30% and halt the rise in diabetes and obesity by 2025.

Overview

Consuming a healthy diet throughout the life-course helps prevent malnutrition in all its forms as well as a range of noncommunicable diseases (NCDs) and conditions. But increasing production of processed food, rapid urbanization and changing lifestyles have led to a shift in dietary patterns. People are consuming more foods high in energy, saturated fats, trans fats, free sugars or salt/sodium, and many do not eat enough fruit, vegetables and dietary fibre such as whole grains.

The exact make-up of a healthy, balanced diet will vary depending on the individual needs (e.g. age, gender, lifestyle, degree of physical activity).

For adults

A healthy diet contains:

• fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains (e.g. unprocessed maize, millet, oats, wheat, brown rice);
• at least 400 g (5 portions) of fruit and vegetables a day [3]. Potatoes, sweet potatoes, cassava and other starchy roots are not classified as fruits or vegetables;
• less than 10% of total energy from free sugars [3], [6] equivalent to 50g (or around 12 level teaspoons), but possibly less than 5% of total energy for additional health benefits. [7] Most free sugars are added to foods by the manufacturer, cook or consumer, and can also be found in sugars naturally present in honey, syrups, fruit juices and fruit concentrates;
• less than 30% of total energy from fat. [2], [3], [4] Unsaturated fats (e.g. found in fish, avocado, nuts, sunflower, canola and olive oils) are preferable to saturated fats (e.g. found in fatty meat, butter, palm and coconut oil, cream, cheese, ghee and lard). [4] Industrial trans fats (found in processed food, fast food, snack food, fried food, frozen pizza, pies, cookies, margarines and spreads) are not part of a healthy diet;
• less than 5 g of salt (equivalent to approximately one teaspoon) per day [8] and use iodized salt.

Infants and young children

The first 2 years of a child’s life are vital as optimal nutrition during this period reduces the risk of dying and of developing NCDs. It also fosters better development and healthy growth and development overall.

Advice on a healthy diet for infants and children is similar to that for adults but these elements are also important.

• Infants should be breastfed exclusively for the first 6 months of life.
• Infants should be continuously breastfed until 2 years and beyond.
• From 6 months of age, breast milk should be complemented with a variety of adequate, safe and nutrient dense complementary foods. Salt and sugars should not be added to complementary foods.

Practical advice on how to have a healthy diet

Fruit and vegetables

Eating at least 5 portions, or 400 g, of fruit and vegetables per day reduces the risk of NCDs [3], and helps ensure an adequate daily intake of dietary fibre.

In order to improve fruit and vegetable consumption you can:

• always include vegetables in your meals;
• eat fruit and raw vegetables as snacks;
• eat fresh vegetables in season;
• vary choices of fruits and vegetables.

Fats

Reducing the amount of total fat intake to less than 30% of total energy helps prevent unhealthy weight gain in adult population. [2], [3], [4]

Also, the risk of developing NCDs is lowered by reducing saturated fats to less than 10% of total energy, [3], [4] and trans fats to less than 1% of total energy, and replacing them with unsaturated fats contained in vegetable oils. [3], [4]

Fats intake can be reduced by:

• changing how you cook – remove the fatty part of meat; instead of butter, use vegetable oil (not animal); and boil, steam or bake rather than fry;
• avoid processed foods containing trans fats;
• limit the consumption of foods containing high amounts of saturated fats (e.g. cheese, ice creams, fatty meat).

Salt, sodium and potassium

Most people consume too much sodium through salt (corresponding to an average of 9–12 g of salt per day) and not enough potassium. High salt consumption and insufficient potassium intake (less than 3.5 g) contribute to high blood pressure, which in turn increases the risk of heart disease and stroke. [9]

Millions of deaths could be prevented each year if people’s salt consumption were reduced to the recommended level of less than 5 g per day.

People are often unaware of the amount of salt they consume. In many countries, most salt comes from processed foods (e.g. ready meals, processed meats like bacon, ham and salami, cheese and salty snacks) or from food consumed frequently in large amounts (e.g. bread). Salt is also added to food during cooking (e.g. bouillon, stock cubes) or at the table (e.g. table salt, soy sauce and fish sauce).

You can reduce salt consumption by:

• not adding salt, soy sauce or fish sauce during the preparation of food;
• not having salt on the table;
• limiting the consumption of salty snacks;
• choosing products with lower sodium content.

Some food manufacturers are reformulating recipes to reduce the salt content of their products, and it is good to check food labels to see how much sodium is in a product.

Potassium, which can mitigate the negative effects of elevated sodium consumption on blood pressure, can be increased with consumption of fruits and vegetables.

Sugars

Evidence indicates that intake of free sugars by adults and children should not exceed 10% of total energy [3], [6], and that a reduction of under 5% of total energy provides additional health benefits. [7] Free sugars are all sugars added to food or drinks by the manufacturer, cook or consumer, as well as sugars naturally present in honey, syrups, fruit juices and concentrates. [3]

Consuming free sugars increases the risk of dental caries (tooth decay). Excess calories from foods and drinks high in free sugars also contribute to unhealthy weight gain, which can lead to overweight and obesity.

Sugars intake can be reduced by:

• limiting the consumption of foods and drinks containing high amounts of sugars (i.e. sugar-sweetened beverages, sugary snacks and candies); eating fruit and raw vegetables as snacks instead of sugary snacks.

How to promote healthy diets

Diet can depend on an individual’s food choices, but also the availability and affordability of healthy foods, and sociocultural factors. Therefore, promoting a healthy food environment requires involvement across multiple sectors and stakeholders, including government, public and the private sector.

Governments have a central role in creating a healthy food environment that enables people to adopt and maintain healthy dietary practices.

Effective actions by policy-makers include:

• Coordinate trade, food and agricultural policies with the protection and promotion of public health:
  • increase incentives for producers and retailers to grow, use and sell fruits and vegetables;
  • reduce incentives for the food industry to use saturated fats and free sugars;
  • set and enforce targets to reformulate food products to cut the contents of salt, fats (i.e. saturated fats and trans fats) and free sugars;
  • implement the WHO recommendations on the marketing of foods and non-alcoholic beverages to children;
  • establish standards to promote healthy, safe and affordable food in public institutions;
  • encourage private companies to provide healthy food in their workplaces;
  • set incentives and rules so consumers have healthy, safe and affordable food choices;
  • encourage transnational, national and local food services and catering outlets to improve the nutritional quality of their food, create real choices, and review portion size and price;
  • consider taxes and subsidies to encourage food manufacturers to produce healthier food and make healthy products available and affordable.
• Encourage consumers demand for healthy foods and meals:
  • promote consumer awareness;
  • develop school policies and programmes that encourage children to adopt a healthy diet;
  • educate children, adolescents and adults about nutrition and healthy dietary practices;
  • encourage culinary skills, including in schools;
  • allow informed choices through proper food labelling that ensures accurate, standardized and comprehensible information on food content in line with the Codex Alimentarius Commission guidelines;
  • provide dietary counselling in primary health care.
• Promote healthy nutrition in infants and young children:
  • implement the International Code of Marketing of Breast-milk Substitutes
  • promote and support breastfeeding in health services and the community, including through the Baby-Friendly Hospital Initiative.

• The evidence shows that high-dose nutrient supplements can be protective or can cause cancer.

• The studies that demonstrate such effects do not relate to widespread use among the general population, in whom the balance of risks and benefits cannot confidently be predicted. 

• A general recommendation to consume supplements for cancer prevention might have unexpected adverse effects.

• By focusing primarily on healthy eating and food choices, existing guidance overlooks the undermining effect that poor hydration choices can have – and equally the benefits of good hydration choices such as water.

• The Eatwell plate, for example, could be usefully re-designed replacing soft drinks with water and incorporating reduced carbohydrates and a redefinition of fats.

The European Food Safety Agency (EFSA) recommends a total water intake of 2.0 litres a day for adult women and 2.5 litres a day for adult men under normal conditions. A greater intake is needed for those taking part in intense exercise, those who are pregnant or sick, or when the weather is particularly hot or humid.

While some fluid in the diet will come from food, the majority of this will come from drinks throughout the day. There are two related issues to consider:

(1) The importance of adequate fluid intake to maintain good health. Studies have proven that poor hydration can affect  brain function. The benefits of an adequate fluid intake – particularly water – include maintaining a proper fluid balance within the body, maintaining normal bowel and kidney function, controlling hunger and maintaining an optimum cognitive ability. It is also an essential element of exercise.

• Yet it is not clear that the people of the UK are remaining properly hydrated. The initial findings of the UK Fluid IntakeStudy, published in 2012, found that 30 per cent of adults had inadequate intakes of fluid – as did more than 50 per cent of children. The study also found low levels of water consumption in relation to hot beverages and sugar sweetened beverages.

• These figures are backed by separate studies commissioned by the Department of Health and Food Standards Agency. This body of research has shown that children aged four to ten years typically consume 276ml  of water per day and 620ml from other beverages (of which216ml was milk). Children and young people aged 11 to 18 years were found to consume 453ml of water per day and 680ml of other beverages, of which 150ml was milk.

(2) The contribution of fluid intake to calorie consumption. The initial findings of the UK Fluid Intake Study found that on average, sugar sweetened beverages provided 175 kcal per day of the calorie intake of children. This demonstrates the contribution that sugar sweetened beverages are making to rising levels of obesity.

• A study published by the British Journal of Nutrition in 2012 showed that, in 2008/09, beverages accounted for 21%,14% and 18% of daily energy intake for children aged 1.5–18 months, 4–18 years, and adults (19–64 years) respectively. 

• The study noted that, since the 1990s, there had been an increased consumption of fruit juices (as well as reduced-fat milk) among children, while adults saw similar trends but additionally saw an increased consumption of alcohol. The study highlighted that using water as a substitute for caloric beverages may reduce overall energy intake. 

• From a policy perspective, this leads to an imperative to acknowledge the contribution of sugar sweetened beverages to the diet and take steps to reduce this level. Many people will pay attention to what they eat, while overlooking the fact that sugar sweetened beverages can make a significant contribution to the amount of calories they consumer. In particular, there is a tendency to overlook the contribution that fruit juices and smoothies can make to sugar intake. While such drinks can provide one portion of the daily fruit and vegetable intake, the amount of sugar contained is  similar to many carbonated beverages, the acidity can have a negative impact on dental health, and many of the juices lack the fibre content of fruit and vegetables, lessening the benefits to digestive health. 

• Policy should focus on reducing the amount of sugar in beverages, reducing the amount of sugar sweetened beverages that are consumed, and promoting water or low calorie alternatives as the best way of remaining hydrated. 

• Change4Life acknowledges this need, recommending that “all the family swapping to water, milk (ideally semi-skimmed, one per cent or skimmed), or sugar free drinks  can really make a difference.” However, there is a need to make this more prominent in public health messaging.

From Linda Bauld [1]:

Although evidence on the health effects of smoking began accumulating over 200 years ago, it was not until the 1950s that any real attention was paid to this evidence. In 1950 five case control studies were published illustrating the link between lung cancer and smoking, including Doll and Bradford Hill‟s study. It took a further decade before the role of government in addressing smoking was acknowledged and a policy framework was proposed. In the UK, this framework was set out in the 1962 Royal College of Physician‟s report on Smoking and Health. This report set out recommendations for policy in six areas:

• the provision of public education on harm from smoking;​

• restrictions on sales of tobacco to children;​

• restrictions on advertising; restrictions on smoking in public places;​

• increasing tobacco taxation; providing information on cigarette packs about tar and nicotine content; and,​

• investigating the value of „anti-smoking clinics‟.

However, it would be almost half a decade later until all these measures were in place in the UK. Progress was achieved slowly. In 1965, television advertising of tobacco products was banned and in 1971 the first health warnings appeared on cigarette packs, followed by tar and nicotine yields in 1973. Also in the 1970s tobacco taxes were raised above inflation.

However, during the 1980s and early to mid 1990s relatively little policy progress took place. Instead, advocacy efforts escalated, led by Action on Smoking and Health (ASH) the tobacco control strategy established by the RCP in 1971. International tobacco control efforts also increased during this period and World No Tobacco Day was launched by the WHO in 1988. In 1993, Doll and Peto published results from the British Doctor‟s study that showed the extent of premature death due to smoking, with one in two smokers dying from smoking-related diseases13. This and other evidence persuaded the incoming New Labour government in 1997 to begin developing a package of policies that were outlined in the 1998 White Paper, Smoking Kills18. The policies in combination represented a comprehensive approach to tobacco control and included:

• An advertising ban (introduced in stages from 2002 to 2005)
• Tax increases (above the rate of inflation to 2001)
• Action on smuggling (increased from 2000)
• Mass media campaigns
• Enforcement of underage sales
• Better access to stop smoking medications
• The establishment of NHS stop smoking services

The policies set out in Smoking Kills did not include smokefree legislation but this was eventually introduced in England in 2007 following Scotland, Wales and Northern Ireland. Thus by 2007 all of the policies originally recommended in the RCP report were in place. Further progress, including the introduction of visual health warnings on packs (2008), raising the age of sale from 16 to 18 (2007) and the commitment to a point of sale display and vending machine ban (2009, not yet implemented) was made more recently.

What factors explain this progress, particularly in the past 10-15 years?

Key ingredients include:

• A sound scientific evidence base
• Authoritative reports from key organisations setting out action needed 
• A central point to lead advocacy and campaigning
• Coalition building Public support for policies and interventions
• Political support for policies and interventions

The evidence for tobacco control began with studies on the impact of smoking but now includes a considerable body of research setting the rationale for, and impact of particular policies and interventions. This evidence has been invaluable in persuading planners and policy-makers to invest in tobacco control measures.

Key organisations such as the RCP and the British Medical Association (BMA) have used this evidence to produce authoritative reports that have made the case for policies and interventions, underpinned by international developments such as the implementation of the World Health Organisation Framework Convention on Tobacco Control (FCTC) from 2005.

The existence of ASH as a central point for advocacy and campaigning has also been crucial, and ASH has been able to act as a focus for coalition building. The Smokefree Action Coalition, for example (with its roots in earlier coalitions, this partnership was formed to advocate for smokefree legislation) is centred around ASH but includes a wide range of charities and other organisations that are advocates for tobacco control.

Their actions combined with the evidence (often communicated through mass media campaigns) have helped to shape public opinion in favour of measures to address smoking. These measures have built up over time, assisting in denormalising tobacco use which has further contributed to public support.

New Labour‟s support for tobacco control undoubtedly contributed to the rapid progress observed in reducing smoking between 1998 and 2008 in particular - a steady decrease of 0.5% each year. It remains to be seen to what extent the change in government at Westminister in 2010 will affect tobacco control, and smoking prevalence, in the longer term. 

​​Cost-effective interventions to reduce obesity in the UK

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The Cochrane Review [4] concluded:

We found strong evidence to support beneficial effects of child obesity prevention programmes on BMI, particularly for programmes targeted to children aged six to 12 years. However, given the unexplained heterogeneity and the likelihood of small study bias, these findings must be interpreted cautiously. A broad range of programme components were used in these studies and whilst it is not possible to distinguish which of these components contributed most to the beneficial effects observed, our synthesis indicates the following to be promising policies and strategies:

· school curriculum that includes healthy eating, physical activity and body image

· increased sessions for physical activity and the development of fundamental movement skills throughout the school week

· improvements in nutritional quality of the food supply in schools

· environments and cultural practices that support children eating healthier foods and being active throughout each day

· support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development, capacity building activities)

· parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in screen based activities

However, study and evaluation designs need to be strengthened, and reporting extended to capture process and implementation factors, outcomes in relation to measures of equity, longer term outcomes, potential harms and costs.

Childhood obesity prevention research must now move towards identifying how effective intervention components can be embedded within health, education and care systems and achieve long term sustainable impacts.

​​Cost-effective interventions to reduce obesity in the UK

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​​Cost-effective interventions to reduce obesity in the UK

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 ​​Cost-effective interventions to reduce obesity in the UK

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​​Cost-effective interventions to reduce obesity in the UK

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​​Cost-effective interventions to reduce obesity in the UK

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​​Cost-effective interventions to reduce obesity in the UK

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​​Cost-effective interventions to reduce obesity in the UK

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"Using the example of school food we were told of the anomaly that existed within many local authority boroughs where licencing practices mean councils actually end up undermining their own efforts in the schools by allowing the expansion of outlets which sell food that is high in salt, sugar and saturated fats which in effect pull children away from healthy eating.

Many times in the inquiry we heard about the valiant secondary school doing its utmost to put on high quality, affordable lunches for their pupils but being undercut by the local chip and chicken shop with its ‘pocket money’ prices. Older children understandably want the freedom of going off site at lunchtime but it is extraordinary that the local authority which is trying to encourage a child to have a healthy lifestyle in school allows an environment which nudges them to do precisely the reverse.

We were told that many local authorities do not exercise the appropriate controls which can be placed on mobile food units which results in the paradox that burger vans, once licenced, are in effect free to pitch up wherever they like so long as they do not infringe traffic regulations.

Some local authorities have woken up to this and are taking decisive action to create a more level playing field. Councils such as Waltham Forest and Tower Hamlets  and cities like Liverpool have introduced strategies to reduce obesity which include addressing obvious inconsistencies such as this."

​​Cost-effective interventions to reduce obesity in the UK

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From Measuring Up: [1] 

"In the NHS we have begun to realise that the environment in which we treat our patients can sometimes be as critical as the way in which we treat them. It is perplexing therefore to walk into a hospital canteen, a place where we should be sending strong signals about good nutrition, to find that the food provision is unhealthy and fails to meet the same requirements that we expect, for example, in schools. It is even more astonishing that in many hospital receptions patients pass by high-street fast food franchises or vending machines selling confectionery, sugary drinks and crisps. If the NHS is to send out a message that it takes the obesity crisis seriously, then it needs at the very least to avoid providing the same obesogenic environment as the high street and make sure that patients and staff alike are offered healthy and nutritious meal choices.

The sustainable food alliance Sustain has long campaigned on this issue and point out that while schools and prisons have food standards, to improve the health of children and prisoners, hospitals do not. [2] In the same manner that smoking was banned in hospitals and healthcare settings, we believe that staff and patients should be given healthy catering options.

There are many ways to present nutritionally balanced meals which are also attractive and affordable. Indeed, we were pleased during the writing of this report that our recommendation has already been partially adopted by the Department of Health in England with the announcement of new ‘principles’ for hospital food which will be evaluated by teams of assessors, half of whom must be patients.

However, these ‘principles’ are vague and voluntary and may by themselves have little impact. We think that mandatory standards may prove necessary. We hope that the health departments in the other home nations take on the challenge, and that mandatory standards for food are introduced in hospitals across the UK."

Adults have been recommended to take part in 150 minutes of moderate intensity activity every week – but evidence suggests that in England only one in 20 people meet this recommended level of activity.

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• For the hypothetical tax we model, the poorest households lose around seven times more, as a proportion of income, than the richest households do, on the assumption that there is no behavioural change.

• The regressivity of a ‘fat tax’ is likely to hold no matter how the tax is implemented – whether on fat content, on calories or just attached at a particular rate to certain foods.

Trends in fruit and vegetable purchases measured as portions 

Source: DEFRA

• On average, all households purchased 4.0 portions of fruit and vegetables per person per day in 2013.​

• Lower income households (deciles 1 and 2) have consistently purchased smaller quantities of fruit and vegetables, although both have increased in the last two years.​

• Income decile 1 households purchased 3.2 portions of fruit and vegetables per person per day in 2012.

​​Cost-effective interventions to reduce obesity in the UK

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Factors that contributed the success of the voluntary salt-reduction programme, included:

(1) The programme provided a level playing field.

(2) The reformulation process was slow and unobtrusive; so taste receptors could adjust and there was no rejection of the reformulation by the public.

(3) The voluntary policy was supported with a clear and transparent monitoring programme and strong enforcement (thanks, in part,  to the role played by  the Food Standards Agency).

(4) Continuous media exposure of the issue.

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Source: Feng J He, Sonia Pombo-Rodrigues, Graham A MacGregor, BMJ

Examples of some of the approaches used by the food industry to reduce calories under the government’s Public Health Responsibility Deal Calorie Reduction Pledge.

Responsibility Deal

The government’s approach to working with industry is not to mandate action but to create voluntary agreements through the Responsibility Deal. The Public Health Responsibility Deal brings together the government, industry, the voluntary sector, non-governmental organisations and local government to voluntarily agree the actions they can take to help people make healthier choices. Organisations signing up to the Responsibility Deal commit to voluntarily improving public health through their responsibilities as employers, as well as through their commercial actions and their community activities and to reporting annually on the action they have taken in response to pledges they sign up to.

Collective pledges on alcohol, food, health at work and physical activity set out the specific actions that partners agree to take in support of the core commitments. The following collective pledges (with the most recent first) support the core commitment to encourage and enable people to adopt a healthier diet.

Pledges

• “Recognising that the Call to Action on Obesity in England set out the importance of action on obesity, and issued a challenge to the population to reduce its total calorie consumption by 5 billion calories (kcal) a day, we will support and enable our customers to eat and drink fewer calories through actions such as product/ menu reformulation, reviewing portion sizes, education and information, and actions to shift the marketing mix towards lower calorie options. We will monitor and report on our actions on an annual basis.”

• “We will provide calorie information for food and non-alcoholic drink for our customers in out of home settings from 1 September 2011 in accordance with the principles for calorie labelling agreed by the Responsibility Deal.”

• “We commit to the salt targets for the end of 2012 agreed by the Responsibility Deal, which collectively will deliver a further 15 per cent reduction on 2010 targets. For some products this will require acceptable technical solutions which we are working to achieve. These targets will give a total salt reduction of nearly 1g per person per day compared to 2007 levels in food. We recognise that achieving the public health goal of consuming no more than 6g of salt per person per day will necessitate action across the whole industry, Government, NGOs and individuals.”

• “We have already removed, or will remove, artificial trans-fats from our products by the end of 2011.”

The Department is currently developing a pledge on salt for catering, and fruit and vegetable consumption.

Annual feedback provided to the Department of Health shows Responsibility Deal partners are taking action on calories.

Big names such as Britvic, Burton’s Biscuits, Coca-Cola, Mars, Mondelēz, Nestlé, Premier Foods and Unilever, all of the major retailers as well as high street chains JD Wetherspoon and Subway included.

These are some of the actions already taken on reducing calories:

• Tesco: Reduced the number of calories sold in its own brand soft drinks by over 1 billion in 2012.

• Sainsbury’s: Reduced the sugar content of its own brand high juice squashes by between 4 and 10%, removing over 600 million calories from customers’ baskets per year; as well as removing 23 tonnes of saturated fat from the pastry in its biggest selling mince pies. 

• Coca-Cola: Sprite now contains 30% fewer calories.

• JD Wetherspoon: Reduced the calories in 12 dishes. 

• Nestlé: Over half (54%) of Nestlé confectionery now contain less than 110 calories per serving. 

• Mars: On way to reducing the calories in all its chocolate products to no more than 250 calories per portion (by end 2013); with further reductions in some leading products, including Twix (from 284 to 248 calories). Has also launched the Maltesers Teasers chocolate bar (186 calories per bar). 

• Burton’s Biscuits: Changes to the ingredients across all its brands will result in an estimated national reduction of 700,000 kcals per day for its customer in 2013. 

• Subway: In 2012, Subway spent around 65% of its promotional budget on healthier eating; and launched a new range of low fat flatbreads. 

• Morrisons: Launched a new healthier range, NuMe, which includes lower calorie options on an extended range of products.  

• Aramark and Beefeater are now offering meals of less than 500 calories 

• Britvic is to remove its full sugar Fuit Shoot from the market

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• In our hospitals there are few ‘joined up’ services for people who are overweight or obese; there is a need to develop and integrate weight management services with those healthcare services that manage the complications and conditions which arise from obesity such as coronary heart disease (CHD), diabetes, arthritis, sleep disorders and gynaecological disorders.

• Multidisciplinary teams have a proven track record in cancer care to promote quality by providing integrated services for patients, and we recommend that this model is translated to obesity. 

1 All members of the multidisciplinary team (MDT) should be trained and experienced in motivational interviewing and incorporate these techniques into their clinical practice.

2 Since type 2 diabetes is common among the overweight and obese population, and management of obesity may directly affect diabetes prevention and management, integration with diabetes services is recommended.

3 Adoption of the Edmonton Obesity Staging System (EOSS) will allow better 'phenotyping' of the individual patient and facilitate audit and outcomes review and research.

4 The primary care team has an important role in signposting to relevant services which are known to be effective. Many patients may contemplate commercial programmes, or increasingly such services maybe providers of care within the NHS, and request advice from the primary care team. It is vital to ensure that patients attend services most suited to them.

5 The specialist MDT needs expertise in multiple obesity-related disorders. The MDT should include specialist consultant physicians, consultant surgeons, dietitians, nurses, psychologists and psychiatrists and exercise/physical activity professionals.

6 A particular issue amongst patients with extreme obesity is the increased prevalence of psychiatricdisorders, including eating disorders, anxiety and depression. Thus, close collaboration with primary care and mental health services is required to assist patients with significant psychological trauma or psychiatric illness.

7 A growing number of patients within primary care will have had bariatric surgery (sometimes performed outside the UK), and links with the (hospital-based) medico-surgical MDT are essential.8 Adequate administrative support to ensure that patients move smoothly through the MDT assessment is essential.

​​Cost-effective interventions to reduce obesity in the UK

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1. Employers should encourage healthy eating among staff by:

• implementing the National Institute for Health and Clinical Excellence (NICE) recommendations for obesity in the workplace (NICE CG43) [2]

• ensuring that healthy food is available in the workplace at affordable or subsidised prices

• encouraging nutritional labelling to allow employees to make informed food choices

• setting strict nutritional criteria as part of procurement contracts for food made available in food outlets and vending machines.

2. Employers should encourage physical activity by:

• signposting to and encouraging the use of walking and cycling routes and stairs, including the provision of safe cycle storage areas

• recommending the use of active travel methods to and from work, and provision of changing room facilities

• working with local authorities to enhance access to health services by public transport

• considering the use of staff incentives such as discounted membership of fitness clubs.

3. Employers should encourage healthy behaviour change by:

• developing a strategy for staff health and wellbeing

• encouraging staff to take regular breaks to move around as well as sufficient time to eat well

• using innovative ways to encourage lifestyle change amongst staff, e.g. intranet messages on health, and signposting local activity/weight management opportunities

• using staff training as an opportunity to ensure that leaders are aware of the importance of encouraging proactive approaches to staff health

• enabling equitable staff access to a range of weight management and activity options, by commissioning weight management services which have proven effectiveness.

4. Occupational health departments have a responsibility to diagnose overweight and obesity in new employees, and wherever employees make health contacts (eg winter influenza vaccination) to communicate the health benefits of weight loss, and signpost obese employees either to ‘in-house’ or community-based services. Occupational health services could contribute to the monitoring of those engaged in weight management programmes by providing weighing facilities and information on healthy eating and activity opportunities within and outside the workplace. 

Cost-effective interventions to reduce obesity in the UK

8 Risks and Behaviors drive 15 Chronic Conditions that account for 80% of total costs for all chronic illnesses worldwide.

Break a workforce into three categories. There's the healthy part of the population, those who are at risk, and the third part, which we call 'in the system' [people being treated for chronic conditions]. You want to design strategies not only about wellness, but overall plan creation and communications strategies that are a dimensional integration between your population's health, the demographics of that population and the three segments—the healthy, the 'at risk' and those who are in the system.

"In many ways, today’s workplaces promote—or at least enable—poor eating habits and physical inactivity, says Arla Day, PhD, Canada Research Chair, Industrial and Organizational Psychology, at Saint Mary’s University in Halifax.

'A lot of workplaces offer no access to healthy eating options,” she says. In addition, many jobs involve sitting at a desk in front of a computer all day.'

And if you are sedentary for eight hours, that’s both strike one and two against you,” she adds, noting that some experts think that sitting is the “new smoking” in terms of impact on health. Strike three is experiencing high workplace stress and being treated poorly at work. Stress can be particularly detrimental in maintaining or managing your weight. Not only are the biological effects of chronic stress directly related to the development of obesity, but unhealthy coping mechanisms, such as overeating and physical inactivity, may also contribute to weight gain.

'When people are under stress, their eating can become disordered—skipping meals, binge eating—which can lead to obesity, and which then can lead to more stress, so that it can continue as a downward cycle,' says Dr. Day." [2]

Manansala notes [1] that the guidelines:

• aimed to reduce the overweight population by 10% over the 5 years and by 25% over the next 7 years​.

• called for local governments and employers to conduct mandatory annual examinations, including measurement of waistlines for people  between the ages of 40 and 74 (44% of the population).​ [3]

• required individuals who exceeded the maximum waist line of 33.5 in (85 cm) for men and 35.4 in (90 cm) for women, and who doctors determined were in the most severe category, to attend counseling sessions over the next three months to lose weight and make lifestyle changes.​ [2]

• required employers to ensure a minimum of 65% participation with the exam and 25% reduction in obesity within 7 years (or face penalties of up to 10% of the current payments – which would go to fund elderly care.

• As things stand, the Quality Outcomes Framework simply requires GPs to register obese patients and effectively penalises GP for taking action to improve their patients’ outcomes and help remove them from the obesity register. GPs should be encouraged to engage with patients on obesity and weight management issues.

• The QOF should contain an indicator that would award points to incentivise and encourage GPs for providing advice on weight management and recommending appropriate guidance and support from the wide range of resources available to tackle obesity, including the range of structured community based weight management programmes which are available. 

• QOF indicators are intended to identify areas where responsibility lies mainly with GPs in primary care, where there is evidence of health benefits from improved primary care, and where the disease is a priority in a number of the devolved nations.

• One QOF indicator relates to obesity:

“if a practice can produce a register of patients aged 16 or over and with a BMI greater than 30 in the preceding 15 months” then eight points are added to the QOF score.

• However,  this indicator requires no action – aside from the production of a register – to be taken for any points to be received.

• GPs should be provided with better incentives to tackle obesity before it leads to major health complications.

The Cochrane Review [1] concluded:

• Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used.​

• When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only. Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial.​

• Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.

​​Cost-effective interventions to reduce obesity in the UK

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​​Cost-effective interventions to reduce obesity in the UK

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​​Cost-effective interventions to reduce obesity in the UK

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"Within complex systems it is normal for there to exist radically different perspectives about how the system works or ought to work. The existence of these different perspectives adds significantly to the complexity of the system‟s operation, in part because messages and data will be interpreted differently by people with different perspectives and also because different agents and agencies are likely to be pursuing competing goals." [1]

"The shift away from "solutions‟ toward "improvements‟ is also consistent with a recognition that it is impossible to have sufficient understanding or control of the context to predict the outcome of interventions in complex systems. It is therefore more realistic to aim for small improvements and to support this with a learning approach involving as many of the key agents and agencies in the system as possible. This approach also recognises that sustainable change in complex systems occurs slowly and requires continued attention to improving rather than a strategy or policy designed to „solve‟ the problem once and for all.

Another aspect of adopting a systems approach to issues is that it requires those involved to reflect on their own perspective and the implicit assumptions involved The challenge of exploring different framing of the issue is similar to, but not identical to, that of appreciating the perspectives of other agents or agencies within the system." [1]

"When progress on an issue requires people to change their beliefs, behaviours or values then, according to Heifetz and co-workers, the issue is an "adaptive issue" and requires a different leadership style – known as Adaptive Leadership. [2]

One of the key insights from Heifetz‟s work is that people resist change because they perceive the losses more clearly than the benefits. The losses may be of familiarity, of dearly held values or beliefs, of some aspect of self-esteem or simply loss of resources or power.

Heifetz and his colleagues stress that one of the key tasks in facilitating change is to acknowledge these losses. What they do not emphasise is the degree to which this requires those fostering the change to appreciate the perspectives of those involved so that the nature and depth of loss can be acknowledged." [1]

The Current Structure of the Maps

The current work-in-progress is presented as a cluster of three interlinked maps: (1) The main obesity policy discussion map, (2) the map of the obesity policy stakeholders, and (3) the map of the Foresight systems model:

Although the scale of the mapping can seem overwhelming at first—particularly if you are new to DebateGraph—DebateGraph gives us a way to explore and deepen our understanding of the policy space through small manageable steps. 

This process isn't effortless—it involves learning how to use DebateGraph and taking the time explore the maps—but it delivers high rewards:

(1) Exploring the map is a highly efficient way of deepening your understanding: the mapping team has spent hundreds of hours mapping and inter-linking a vast body of evidence and reports to develop insights that you can grasp in a few hours of exploration.

(2) The complexity of the obesity challenge is not infinite; just of a sufficient degree that it's difficult for us to hold and process it as a whole in our minds: DebateGraph helps us overcome this cognitive limitation by allowing us to externalise and work through this structure from our own starting point at our own pace.

(3) Moreover, this externalised structure isn't just the parts that are in our heads, it interweaves the disparate parts that are in many heads and allows us to see them as a coherent whole.

(4) The maps are living structures that continue to evolve and reshape as more people share their knowledge and insights and as more evidence emerges, and, once you have a feel for the structure of the map, it becomes almost effortless to keep with this process and to recognise the contextual significance of new information. 

DebateGraph is also fun to play with, but it's not a toy: it has been designed by policy makers for policy makers to enhance our understanding systemic and network governance – and it has been used by the UK Prime Minister's Office, the White House Office of Science and Technology Policy, and the European Commission.

Exploring the maps

The Views menu (above) lets you toggle between different visualizations of the map or parts of the map – with each type of view having specific strengths and uses. You can also vary the behavior of each View type using the Options menu.

Contributing to the Map

There are various ways in which you can contribute to the development of the current map:

(1) Add a Comment to an idea, by clicking on the Comment button under the map. The process is just the same as commenting on a blog. Your comment will also appear in the Map activity stream and in the email digests to the Map community.

(2) Add a Citation to an idea, using either the Cite button (beneath the map) or the Cite radio button underneath the Details text. Citations are one of the easiest and most useful contributions you can make to a map; as they tell the map community about articles elsewhere on the web that you think are relevant to a particular idea and/or that contain ideas that you think should be added to the map.

(3) Add a new idea to the map by navigating to the relevant part of the map and then clicking on the Add idea button (beneath the map in the Hub view). Prior to adding a new idea, it's generally worth exploring the map and using the Search this map facility on the Finder tab to check whether the idea is included elsewhere on the map already. When adding a new idea, it's always fine to use the default Issue idea type (although you are also welcome to change the idea type using the color selector beneath the idea text entry box – and the idea selector will always guide you as to the types of idea that are available in any given location).

(4) Rate an idea, either by clicking on the Rating scale shown at the bottom of the Details text or by clicking on the arrow that points from the idea to its parent (which opens a small version of the rating scale on the map). Rating ideas in this way helps the community to see which ideas are perceived to be the most important (and why).

(5) You can also Edit an existing idea – for example, to correct a typo, to clarify or improve the text, to change the idea type, or to add more details to the Details text – either by clicking on the small Edit link (bottom left on the map in the Hub view) or by clicking on the Edit details link (at the bottom of the Details text). Each idea has a full Edit history; so you can always revert to an earlier version of the idea at any time.

Adding your insights to the map