Two thirds of adults and one third of children leaving primary school in the UK are overweight or obese. People who are obese are more at risk of hospitalisation, severe symptoms, admission to intensive care and death from COVID-19. Not to mention the increased risk of cardiovascular disease, type 2 diabetes, cancer and a reduced life expectancy. As an intensive care doctor, I have witnessed first hand over the past few months the reality of the devastation that these statistics have caused to patients and their families. In July 2020, following the first wave of the coronavirus pandemic, the government published a new ‘Tackling Obesity’ policy, aimed at reducing levels of obesity in adults and children in the UK. One of the main initiatives in this policy is to enforce calorie labelling on food in restaurants, cafes and fast-food chains. (1)
A review was undertaken in 2014, looking at whether calorie labelling on food menus influences food choice. Three different groups were investigated. Firstly restaurants and fast food establishments, secondly cafeterias and thirdly ‘lab’ based research environments.
Twelve studies were included in the first group, of which ten showed no change in customer’s food choice with calorie labelling. The other two studies, one in Starbucks and one in a sandwich shop, showed small but significant decreases in total calories purchased following labelling.
In cafeterias, five of the six studies demonstrated a somewhat positive impact on food orders, resulting in a decrease in total calories, fat, or serving size ordered.
In research settings, two of three studies showed no change in overall calories consumed.
What was identified in the majority of these studies was that calorie labelling on menus might have an impact on certain subgroups of customers. There was more likely to be an impact in women, in those from higher-income backgrounds, and in those who were aware or noticed the calorie labelling. Unfortunately, these are not the groups that need to be targeted in policies reducing obesity.
The review concluded that whilst there are some positive results reported from studies examining the effects of calorie labelling, overall the best designed studies show that calorie labels do not have the desired effect in reducing total calories ordered at the population level. They advised that – moving forward – researchers should consider novel, more effective ways of presenting nutrition information, whilst keeping a focus on particular subgroups that may be differentially affected by nutrition policies. (2)
A similar 2011 study by Swartz examined seven papers and concluded that calorie labelling was not an effective way to reduce calories purchased or consumed. (3) A further review in 2016 concluded that ‘overall, the evidence regarding menu labelling is mixed, showing that labels may reduce the energy content of food purchased in some contexts, but have little effect in other contexts’. (4)
So what other options do we have?
A recently published Swedish study in which a primary care prevention programme focusing on physical activity and promoting a healthy lifestyle was trialled on 5761 participants and compared to a control group investigating cardiovascular events and mortality over a 22 year follow up period. The programme reduced cardiovascular events, cardiovascular deaths and all-cause deaths after two decades. (5)
The interventions in this study included a multi-faceted approach to health promotion. Each patient was given individualised advice on diet and exercise. Physicians, nurses and all staff were advised to follow the guidelines; however, they were free to make individual assessments regarding counselling, treatment and follow-up. Prior to the start of the program and during the first 6-7 years, education was offered to the health care personnel on approximately 40 different occasions.
Advice given to patients included:
- control of overweight by decreasing energy intake and increasing physical activity with advice on exercise suitable for the individual
- reduction of total fat intake to 30% or less of total dietary energy intake
- reduction of the intake of saturated fatty acids to less than 10% of total dietary energy intake
- encouragement of the use of unsaturated fat
- reduction of dietary cholesterol to less than 300mg/day
- increased consumption of complex carbohydrates
- increased intake of fruit, vegetable and cereal fibre with some emphasis on legumes
- moderation in salt
- Exercise ‘physical activity on prescription’
- regular dynamic oxygen-demanding physical activity like walking, swimming, jogging, cycling and dancing
- low-intensity fitness training at a submaximal level
- regular activity at least 2-3 times a week for about 30 minutes at each session
- encouragement of daily physical activity in general
An open lecture series on lifestyle and health as well as how to change a habit was started and operated for 17 years. The method ‘physical activity on prescription’ was already used in primary care, and the work was intensified and used extensively. After ten years, 27 different physical activity groups run in cooperation with local sports clubs could be offered to participants each semester. Group activities for smoking cessation, cooking and stress management were also available periodically. (6)
A complete reform of health promotion in primary healthcare has long been needed in the UK. Whilst some of the proposals in the July 2020 ‘Tackling Obesity’ policy are positive – expanding training on weight management for primary care staff and weight management services – I believe that many of the proposals are missing the mark. Wasting resources on initiatives like calorie labelling on food is taking away from strategies that will have a meaningful impact. This is particularly important as our evidence shows that these interventions are less likely to have an impact on those from lower-income backgrounds, yet these are the people most affected by obesity. Children in the most deprived areas of the country are more than twice as likely to be obese than their peers in the richest parts.
Despite news reports about GPs being able to provide patients with bikes, there is no mention of this in the document. In fact, there is no mention of exercise at all. Instead, the focus is on food labelling and food placement in shops. (1)
We need to learn from countries like Sweden and implement comprehensive educational initiatives which empower people to understand and make their own informed decisions about food. We need to introduce nutrition education into schools, or at least into medical schools. We need GPs and practice nurses to be educated in how to prescribe appropriate exercise programmes for their patients, and we need funding and availability of classes and groups for this to be overseen in a safe and supportive environment. Yes this would be expensive, and I understand that it can’t happen overnight, but the money and lives that would be saved from the reduction in obesity-related morbidity and mortality would pay it back multiple times in the long run.