The obesity pandemic
This report examines the complex systems that lead to unhealthy environments and recommends actions to address the underlying and basic drivers of The Global Syndemic. The Commissioners also believed it essential to include the stories of people who create these systems and people who are affected by them. For the boxes on people’s experience used throughout this report, we focus on the experiences of the obesity component of The Global Syndemic.
Obesity affects people. Yet too often, the media images of people with obesity we see are of headless bodies, dehumanising them as individuals living in societies in which most of us are vulnerable to obesogenic environments.
One of the most pervasive challenges facing people with obesity is the bias and stigmatisation that accompanies the disease. The perceptions of obesity vary widely, depending on the country context. For example, in LMICs where undernutrition is a major threat to health, fatter babies and children are valued. Likewise, in countries with a high prevalence of HIV/AIDS, obesity can be an indicator that the person is disease-free. However, in most western cultures, obesity is seen as a personal failing rather than a predictable consequence of normal people interacting with obesogenic environments. People with obesity are often blamed for their disease by being prejudged as stupid, ugly, unhappy, less competent, sloppy, lazy, and lacking in self-discipline, motivation, and personal control.13 Medical providers and family are the most frequent sources of stigma, and the bias among physicians leads to a scarcity of preventive services, especially for women.13
Bias against people with obesity affects acceptance to institutes of higher education, hiring, and job advancement.14 Bias might also account for the lack of recognition of obesity as a serious medical problem that deserves care (panel 3). Holding people responsible for their obesity distracts attention from the obesogenic systems that produce obesity. These systems and their drivers are deservedly the focus of the Commission’s report.
Many people with obesity experience bias from the medical community. I learned this difficult lesson when I was just 8 or 9 years old. The school nurse weighed each student publicly and said to me, “You’re fat,” followed by, “You need to lose weight.” I wanted to crawl under my desk and hide from my peers. Being singled out for my weight, especially by a person of authority, was humiliating.
The bias continued into adulthood. Virtually every physician I saw told me to lose weight, but never offered any real help or support in meeting that goal. Nurses would remark “We don’t have big gowns” in unkind tones that both blamed me for needing one and failed to comprehend the discomfort I felt at leaving my body exposed. A physical therapist once equated me to another mammal when she said, “Let’s talk about the elephant in the room — your weight.”
Worse yet, a physician unable to look past my weight missed an important diagnosis. Severe hip pain was hampering my ability to walk and exercise.
X-rays and MRIs showed no obvious problems, so I saw an orthopaedist. I started to describe my symptoms when he interrupted saying, “Let me cut to the chase. You need to lose weight.” I told him that I had lost about 70 pounds, and he quickly said, “You need to lose more weight. Have you considered weight loss surgery?” He continued to lecture me about weight and, without examining me, concluded that my weight caused the pain. I left in tears feeling demeaned, ashamed, and abandoned. He later related his diagnosis to my primary care physician: “Obesity pain. I see it all the time.”
I delayed further treatment until the pain became intolerable. The second orthopaedist I saw realised that my once mild scoliosis had progressed; I now had a 60-degree curve in my spine, which led to my hip pain. Thankfully, this physician focused on the problem, not my weight. With a correct diagnosis, I obtained appropriate treatment.
People with obesity want and deserve the same care and compassion that those with other diseases receive. Health-care providers who overcome their biases can have a dramatic positive impact in lessening obesity’s burdens, especially in the weight-management context. Because I have now received intensive science-based treatment from an obesity specialist – one who supports rather than judges me for my condition — I am managing my weight effectively.
Contributed by Patty Nece, attorney and board member for Obesity Action Coalition, and Lancet Commissioner, Washington, DC, USA.
The Commission also recognised that understanding the way people experience obesogenic environments is essential to modify the environments and foster meaningful change in people’s lives.
Panel 4 provides a story from a deprived area of London, UK. This narrative illustrates that people might not necessarily want to feed their children fast food. Competing demands in people’s lives often make processed fast foods from restaurants and takeaways the easiest, most convenient, and rational choice given one’s reality, even though it is not the healthiest option. The Commission acknowledged the importance of involving people living with obesity in finding solutions that recognise the reality of their lives. It is also a way to mobilise and empower people who experience the problem but also want to change. Furthermore, an understanding of the perspectives and perceptions of the people who create obesogenic systems is needed. They do not intentionally set out to create unhealthy environments, so we need to clarify the incentives that drive their actions that have that effect. We also need to understand the experiences of people who are trying to change these unhealthy systems to identify the barriers they face, factors that facilitate action, and the lessons learned from their successes and failures. Throughout this report, The Commission gives voice to people who are confronted with these challenges.
It’s the hours. If me and my husband worked fewer hours the kids would be eating more healthily. And I volunteer teaching children to cook healthily because others work even longer. A friend goes to the food bank. Her daughter is 14 and is size 20. She’s petrified, on a zero-hour contract [a contract but with no guaranteed hours of work], and pays rent and bills before food. She has to leave kids’ food in the fridge. Mums on benefits have more time for cooking with kids. Mine only put on weight when I started working full-time!
At the supermarket you shop big, saving every penny, and buy things that won’t go off. It’s all about affordability. It’s not cheap to cook from scratch. As kids are growing up, fast food’s everywhere. We see it every day — liquor for adults, fast-foods for meals, sweets for kids, and betting shops — it’s not good. Fast foods taste nice, as a treat, but most should close down or sell healthy foods. In these lower-class urban areas, it’s not so nice, more crime and drugs makes it hard to have a clear mind to think “I want healthy food” and for people to care about themselves. They know their audience and dump these foods here and there’s no choice. Shops in affluent areas are not life-threatening and the nannies prepare the dinners. But when you’re worrying every day and sometimes stuck indoors kids will get snacks. The kids come first, so some days I have nothing.
I cook healthy meals and joined Change4Life [a UK behaviour change programme] but everyone’s busy. You need first hand advice, at the school or community. When you get the letter with child measurements, other parents think you’re obese and neglecting your child. Others panic and might malnutrition the child. Schools should focus on all children. Obesity is scary, a health risk. If real food was cheaper, people would be healthier. It’s all about making money. It’s the economy, the government. Everything linked together. One big chain and we’re in the middle. But how can I blame someone else for what I do?
Government gives the impression of helping but it’s like what they’ve done for smoking. It’s going to take years. They allow the food companies to produce unhealthy foods, it should be an offence. If I was prime minster there’d be community shopping with butchers, grocers, proper bakers, clubs with families eating together, different cultural foods for children and to bring community together. Yes, I’d be involved in policy making, people and community taking ownership through schools and children centres. But there’s no time — that’s why I’m talking to you! I should go into politics!
Contributed by Dr Sharon Noonan-Gunning, prepared from interviews with an ethnically diverse group of mothers in deprived parts of London, UK.
The obesity context
The obesity pandemic requires a wider perspective because it is a symptom of deeper, underlying systemic problems that require systemic actions. The Commission expanded the concept of the obesity problem into four dimensions: increasing obesity, policy inertia, lack of urgency, and action on obesity that is not joined up with action in other areas (eg, separate food agendas for health and environmental sustainability).
First, there has been an unabated rise in obesity prevalence in all countries in the past four decades, and no country has succeeded in reversing its obesity epidemic.1
Second, the patchy implementation of WHO’s best buy policies, which have been endorsed by governments at successive World Health Assemblies over 15 years, is attributable to many actors.2, 3, 15 Industries with vested interests, such as transnational food and beverage manufacturers, are powerful and highly resourced lobbying forces that have opposed governments’ attempts to regulate commercial activities or modify them through fiscal policies, such as imposing a tax on sugary drinks or changing agricultural subsidies. Politicians are either intimidated by industry opposition or they might hold beliefs that education and market-based solutions that are grounded in neoliberal economic and governance models are sufficient to reverse the obesity epidemic. Civil society organisations are generally supportive of WHO’s best buy policies. Public opinion polls suggest support for these policies,16 which has not translated into sufficient public demand for action to overcome the industry opposition and government reluctance. This insufficient public demand for action to address obesity contrasts markedly with the successful activist approach taken by campaigners to address HIV/AIDS, which is another highly stigmatised global health problem.17
Third, obesity, by itself, has proven to be an insufficiently urgent problem for the implementation of specific policies, such as restricting the marketing of unhealthy foods and beverages to children and young people, let alone for the tackling of underlying systemic drivers, such as the commercial determinants of health.18
This inertia exists despite the enormous health and economic costs and abundant media stories about obesity and diabetes in the last several decades.
Finally, obesity is often considered in isolation of, rather than in concert with, other major global challenges. In particular, the Commission asserts that obesity, undernutrition, and climate change have multiple common causes and mitigating actions.
Malnutrition in all its forms
Since its original publication on obesity in 2000,19 WHO has progressively incorporated recommendations for action on obesity into many reports, action plans, targets, and monitoring plans to address NCDs, for which obesity is a major risk factor. Several recommendations, such as the restriction of children’s exposure to advertising for unhealthy foods and non-alcoholic beverages and fiscal policies, were accepted in resolutions of the World Health Assembly in 2010, and received attention at each of the UN High-Level Meetings on NCDs from 2011 to 2018.20 Targets of no increase in obesity and diabetes prevalence in adults above 2010 levels and no increase for overweight prevalence among children less than 5 years of age were set, although no targets were set for older children and adolescents.21, 22
WHO has also published several reports on and targets for undernutrition. Although some progress has been made on reducing stunting and under-5 mortality, the reductions for these and other indicators of undernutrition will not reach the targets set by WHO.23, 24 One of the main outcomes from the WHO and Food and Agriculture Organization (FAO) Second International Congress on Nutrition in 2014 was to combine all nutritional problems as malnutrition in all its forms.25 This concept and wording has flowed into the SDGs and a parallel global effort around the UN-declared Decade of Action on Nutrition (2016–25), which seeks specific commitments from countries to deal with their major nutrition issues.26 The UN’s 2015 SDGs included a goal for 2030 to end all forms of malnutrition (Goal 2.2),27 and nutrition and health can contribute to and benefit from all goals in the SDG 2030 agenda (appendix p 2). Despite this high-level rhetoric, many LMICs have not yet reoriented their nutrition funding, development aid, professional capacity, institutions, and mindsets to encompass the challenges of obesity and the consequences of malnutrition in all its forms.
The Global Burden of Disease has recently assessed the burden of malnutrition in all its forms (panel 2; Ashfin A, Institute for Health Metrics and Evaluation, Seattle, WA, USA, personal communication). Globally and in the lower income countries, malnutrition in all its forms contributes as much disease burden as the next 2–3 leading categories combined (figure 1).
For countries with a low Socio-demographic Index, undernutrition incurs a much higher burden both in absolute terms and relative to the other leading contributors. The 2018 Global Nutrition Report found that, of 141 countries, 83 countries (59%) had double burdens of malnutrition (ie, high prevalence of two of three nutrition conditions: childhood stunting, anaemia in women, and overweight in women) and that 41 countries had triple burdens.28 Therefore, within these countries, the political economy and food systems are the underlying causes of the high prevalence of both undernutrition and obesity, suggesting that common, underlying solutions could also exist. These solutions require a shift from the perception that undernutrition and obesity are simply a consequence of too few or too many calories, to understanding their co-occurrence and common drivers, and then to taking concerted action to address these drivers. The recognition that undernutrition and obesity are both due to poor diet quality and a low variety of healthy foods is a more helpful perspective to resolve nutrition problems collectively.
The four major global outcomes
The conceptual and communications challenge of combining the major global problems of obesity, undernutrition, and climate change requires a coherent narrative to understand their common causes and solutions without compounding the existing complexities inherent in each of the problems themselves. The common narrative of The Global Syndemic, as outlined in the next section, seeks to bring the three pandemics together into a compelling story that creates an urgency for action that will overcome the existing policy inertia that has hampered progress on obesity, undernutrition, and climate change.
The backdrop for The Global Syndemic is the broader picture of global outcomes. The four major global outcomes of concern for people and the planet are the net results of the complex adaptive systems created by humans that interact with each other and the natural ecosystems (figure 2A). Human systems have been established to achieve certain outcomes, such as economic prosperity. Due to the way that these systems have been designed, the inevitable overconsumption and inequitable distribution of resources has caused negative externalities and poor outcomes for the other three outcomes of social equity, human health and wellbeing, and ecological health and wellbeing. These global outcomes will be considered in more depth later in this report in relation to the different country contexts and their priorities for action.