The World Health Organisation claims over a billion people worldwide are overweight, and at least 300 million obese (WHO 2003). The UK population has grown steadily fatter: twenty-three percent of the UK population is now obese, a threefold increase since 1980 (Lister 2005). Obesity is both a major cause of chronic ill health and “considered a disease in its own right” (WHO 2003).
If current trends continue, by 2025, 40% of people in England will be obese. Obesity in Brazil currently 10%, in 2025 could be 15%.
Scoping the Foresight Project on Tackling Obesities: Future Choices
1 Why a Foresight project?
Foresight is uniquely placed to build a broad vision of obesity futures, able to bring together disciplines as diverse as nutrition and the built environment or food technology and sports science, whilst also encompassing medicine, pharmacology, economics and the social and behavioural sciences. Foresight's ability to envision future trends, inject new thinking and to identify those health impacts fundamental to policy making will provide fresh insight to this challenging area, identifying the interventions most likely to make a difference to obesity.
Over the last 25 years, the number of people classed as either overweight or obese in
In 1998 the National Audit Office estimated that obesity cost the NHS £480 million. By 2002, the Health Select Committee considered the costs to the NHS to be between £990 - £1,125 million. Indirect costs to the economy are thought to be £2 billion a year, rising to £3.6 billion by 2010.
The health and economic costs to the nation alone are compelling reasons for the need to seriously address obesity. However, obesity is set within a complex cultural, social and behavioural framework, with a dynamic landscape of contributing factors. Such complexity suggests that solutions will not come from a single source but will involve multiple scientific disciplines and evidence sources.
2 Work to date
Foresight has already conducted scoping activity for a project on obesity by consulting widely with stakeholders, which include those from the public and private sector, together with NGOs and researchers from a diverse range of disciplines. Foresight has also conducted a series of in depth interviews with key stakeholders and obesity experts and has run two multidisciplinary workshops. This paper presents key conclusions from the work undertaken to date and illustrates where Foresight could add value to this complex field.
3 Key findings
Complex and not as well understood as represented
Obesity is often represented as a well understood condition, at the heart of which is a simple energy equation; too much in, not enough out. Foresight's scoping work has already established that the causes of obesity are neither simple nor well understood. It was significant that every discipline consulted suggested a different driver to be of primary importance.
For nutritionists it is too much energy dense food whereas exercise physiologists assert that calorie intake has not changed significantly over time, reduced levels of exercise are the dominant factor. Meanwhile economists explain obesity in terms of falling food basket prices and economic development, social scientists point to the negative correlation between obesity and socio-economic status, architects highlight changes in the built environment while physiologists pinpoint the falling number of hours slept, saying that causes an increase in the level of appetite driving hormones.
One area of agreement on cause is that whilst genetic variants are known to be associated with extreme forms of obesity, changes in genes cannot be responsible for such a rapid rise in obesity at a population level. Modulation of gene expression over the entire lifecourse is a more likely cause with the impact of environment at critical stages of human development such as fetal life and early childhood, having a lifetime programming effect, determining not only body weight but also the risk of chronic disease in later life.
Obesity is a complex and dynamic mix of the social, behavioural and biological, with significant granularity not only at a population level between different age, gender, ethnic and socio-economic groups but even within households, with for instance, obese and normal weight children frequently being raised together. Such a wide range of opinion and of presentation of obesity, has led to polarised views on cause, making it difficult for policy makers to pick myth from reality. It also points to the likelihood of multiple and complex points of intervention.
A very active area for research with little collaboration
Obesity is already a dominant research theme across many different disciplines. However a major concern is the silo nature of this research, which means that few, if any, have an overview or understanding of the whole system. This became apparent during Foresight's obesity scoping workshops, which brought together a very wide range of individuals. Many confessed to rarely speaking to researchers from other fields.
The 'silo mentality' is exacerbated by the current science career and research structure which is not currently configured to reward the large scale co-operation required for multi or transdisciplinary research with funding, RAE points or publications. There is also no doubt that the integration of data across a broad range of disciplines is technically difficult, meaning that it is rarely attempted. An additional problem here is the sheer breadth of determinants, making it a challenge to identify those which are key and understand how they interact.
The link between obesity and broader social determinants
Obesity is widely seen not merely as a marker for an increased risk of health problems, but also one of broader social and economic impacts, such as poverty, fractured families and lack of education. Many pointed to the social stigma of obesity and the risks of intervention creating an outcast obese underclass, perceived as lazy and worthless.
Agreement on the issue of responsibility
All consulted have highlighted the issue of responsibility; whether it should lie solely with the individual and, especially in the light of the above, if individuals are not sufficiently empowered to make change, who has the power to help them and how.
Key brakes to understanding
Foresight has also identified several key brakes to understanding, some of which Foresight may not be able to change directly, but which it can have a key role in highlighting for those able to influence them.
One is the need to understand the motivations behind lifestyle choice, especially given their importance in determining effective interventions. Why people make the choices they do is in fact well researched by the food, diet and exercise industries but it appears that this information is not shared widely enough with the science and health community.
A further concern is the current reliance on linear projections of obesity, with no alternative scenarios currently under consideration. Another is the tools for human studies, including the need for long term studies of population groups, together with the means for accurate assessment of food intake which are currently unwieldy, expensive and only suitable for small scale studies. Finally the need for a forum for inter-disciplinary debate is clear.
Despite the gaps and uncertainties identified by many in the evidence base, there is a need to act on the best available evidence whilst instigating an action research mechanism to ensure that activity is responsive to the appearance of new data.
4 WHERE FORESIGHT CAN ADD VALUE
The key challenge is to develop a shared understanding of what is likely to work and how to create change.
Foresight has the credibility, knowledge and impartiality needed to widen the breadth of understanding of obesity, joining up many silo activities and, enabling a better understanding of the wider causes and impacts of obesity.
Foresight is also uniquely placed to be able to demonstrate 'the big picture' on obesity, in a way which would be impossible for virtually any other organisation or research group.
This broad vision is necessary in order to build on existing work and enable more effective co-ordination of activity together with a joined up strategic approach on an issue which currently causes the premature death of 30,000 Britons a year.
In addition Foresight could add value in terms of pointing to the need for co-ordination of data gathering on a large scale (beyond the scope and capability of normal scientific collaboration), suggesting to the most appropriate bodies, that a framework be developed for combining surveillance activities (as carried out within the NHS) with academic evidence. This increasing need will converge with future advances in sensor technology and automated surveillance throughout the environment creating fascinating possibilities for a new approach to the study of human behaviour and activity. Such interventions would need to be rigorously evaluated to maximise value from datasets.
A particular advantage of an overview which covers many technologies is that Foresight can act as a 'broker', between disciplines as well as introducing new technologies with potential obesity applications, to researchers who would otherwise never have been exposed to them. Foresight can also provide the forum in which debate can be created.
Collaboration between industry knowledge and databases and science brokered by Foresight may lead to more innovative experimental approaches to studies of human populations, including long term longitudinal studies.
A better understanding of behaviour will lead to interventions that are more likely to succeed.
5 CONCLUSION
There is undoubtedly a great deal of activity in this area but it is apparent from the scoping activity that it has reached a point where a step change is required in both approach and thinking if a sustainable response to obesity is to be delivered.
By taking a look at the whole system - how the various elements mesh together and interact and what they might look like in the future, Foresight could deliver this step change as well as create an exemplar which will help understand how to effect change in other intractable public health issues.
Trends and drivers of obesity: A literature review for the Foresight project on obesity
reposted from: Foresightmy: highlights / emphasis / key points / comments
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