Urgently needed: a framework convention for obesity control

In this issue of The Lancet, we publish a Series of four papers that critically examine what we know about the global obesity pandemic. The fi rst paper summarises its drivers, the second its economic and health burden, the third the physiology behind weight control and maintenance, and the fourth concludes what science tells us about the kind of actions that are needed to change our obesogenic environment and reverse the current tsunami of risk factors for chronic diseases in future generations. Almost no week goes by without a new headline about obesity. The latest Centers for Disease Control and Prevention fi gures for the US population in 2010 released in July are alarming: 12 states have obesity rates higher than 30% and no state had a rate lower than 20%. Since these fi gures rely on self-reported height and weight, they are likely to be underestimated. In the fi rst paper of the Series, Boyd Swinburn and colleagues report estimates of 1·46 billion adults and 170 million children overweight or obese worldwide in 2008. If we continue without successful interventions, the projections for 2030 in the second paper of the Series estimate 65 million more obese adults in the USA and 11 million more in the UK alone with an additional 6–8·5 million people with diabetes, 5·7–7·3 million with heart disease and stroke, and 492 000–669 000 with cancer. The projected costs to treat these additional preventable diseases are an increase of $48–66 billion per year in the USA and £1·9–2 billion per year in the UK. Health systems everywhere are already struggling to contain costs. Without prevention and control of the risk factors for obesity now, health systems will be overwhelmed to breaking point. Yet governments’ reactions so far are wholly inadequate and rely heavily on self-regulation by the food and beverage industry, and the so-called nudge approach. After all, they argue, it is up to the individual to make the right choices. Unlike tobacco, food and drink need to be consumed and the state’s interference could be perceived as too intrusive. The UK Government, in particular, has made it clear that only voluntary agreements with food and beverage companies are on the agenda, and many of the public health committees are made up of large numbers of these very industry representatives. So do these voluntary agreements work? All indications so far are that they do not. In a year-long investigation, a UK House of Lords Science and Technology Select Committee examined the evidence base for the eff ectiveness of nudges in the context of alcohol, food, and physical activity. In the report Behaviour Change, released on July 19, the conclusions are clear. While businesses and industry, with their very diff erent aim of making as much money as possible and with an enormous and expensive apparatus of clever advertising, are very eff ective at nudging people to buy and consume their products, non-regulatory measures to increase consumption of healthy food in isolation are unlikely to be eff ective. The committee goes further and speculates that regulations might in fact create a more level playing fi eld and increase choices for the individual. A study published on August 1 in Archives of Pediatrics & Adolescent Medicine examining the eff ect of a voluntary agreement by the food and beverage industry on advertising during children’s programmes also shows that such agreements are far from successful. There was a reduction in the proportion of advertisements for fatty, sugary, or salty products but almost all were still such adverts (86% compared with 94% before the agreement). And, more alarmingly, the overall number of adverts for fast food had increased by a third. Our Series has many messages about the complex issue of obesity and how it is best tackled. One important premise is that the increasing weight of people worldwide is the result of a normal response by normal people to an abnormal environment. There are fi ve messages that need to form the basis of a concerted response. One, the obesity epidemic will not be reversed without government leadership. Two, business as usual would be costly in terms of population health, health care expenses, and loss of productivity. Three, assumptions about speed and sustainability of weight loss are wrong. Four, we need to accurately monitor and evaluate both basic population weight data and intervention outcomes. Five, a systems approach is needed with multiple sectors involved. Sadly, the forthcoming high-level UN meeting on non-communicable diseases is marred by the reluctance of some to set targets. One immensely important next step in the fi ght against non-communicable diseases could be the agreement on a framework convention on obesity control. Who will take the lead? ■ The Lancet For more on the UK House of Lords Science and Technology Select Committee report see http://www.publications. parliament.uk/pa/ld201012/ ldselect/ldsctech/179/179.pdf