policy interventions to tackle the obesogenic...

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Policy Interventions to Tackle the Obesogenic EnvironmentFocusing on adults of working age in Scotland

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Policy Interventions to Tackle the Obesogenic Environment

Policy Interventions to Tackle the Obesogenic Environment Focusing on adults of working age in Scotland

John Mooney, Sally Haw and John Frank

Scottish Collaboration for Public Health Research and Policy

MRC Human Genetics Unit building

Western General Hospital

Crewe Road

Edinburgh EH4 2XU Scotland U.K.

Available on the internet at www.SCPHRP.ac.uk

ISBN: 978-0-9565655-7-0

Copyright ©Scottish Collaboration for Public Health Research and Policy 2011

This work was funded by the Medical Research Council and the Chief Scientist Office of the Scottish Government. Views expressed in this publication are those of the authors and do not necessarily reflect those of the Medical Research Council or the Chief Scientist Office of the Scottish Government.

John Mooney BSc, MPH, MFPH

Sally Haw BSc, HnMFPH

John Frank MD, CCFP, MSc, FRCP (C), FCAHS, FFPH

A report for the Early to Mid-Working Life Working Group of the Scottish Collaboration for Public Health Research and Policy (SCPHRP)

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Acknowledgements

• MembersoftheWorkingLifesub-groupoftheScottishCollaborationforPublicHealthResearchandPolicy.

• DonnaCiliska,ScientificDirectorandSharonPeck-Reid,ResearchAssistant,NationalCollaboratingCentrefor(PublicHealth)MethodsandToolsatMcMasterUniversity,Canada.

• SamBainandCarolineRees,AdministratorsfortheScottishCollaborationforPublicHealthResearchandPolicy.

• HealthPromotionDepartmentatNHSHighlandforhostingpilotrunofFeasibilityScoringMethodsinNovember2010(chapter8).

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Table of contents

Executive Summary

Introduction

Physicalenvironment

Economicenvironment

Legislativeenvironment

Socioculturalenvironment

Overallapproachtoavailableevidence

Developmentofpolicyoptions

Chapter 1: Introduction and overview

1.1 Background

1.2 Conclusionsoffirstmeeting:Workstreams

1.3 Searchstrategyandinitialguidance

1.4 Structureandpurposeofthisreport

Chapter 2: Obesity in adults

2.1 Definingobesity

2.2 Obesityasapublichealthpriority

2.3 TheepidemiologyofobesityinScotland

2.4 Keydriversofobesity

2.5 Theobesogenicenvironment

2.6 Appraisingevidenceforobesityprevention

2.7 Towardsacoherentobesitystrategy

Chapter 3: The physical environment

3.1 Ecologicalmodelforphysicalenvironment

3.2 Nutritioninterventions(macro-level)

3.3 Nutritioninterventions(micro-level)

3.4 Physicalactivityinterventions(macro-level)

3.5 Physicalactivityinterventions(micro-level)

Chapter 4: Interventions to the economic environment

4.1 Introduction

4.2 Nutritioninterventions(macro-level)

4.3 NutritionInterventions(micro-level)



Chapter 5: Interventions in the legislative environment

5.1 Introduction

5.2 Nutritionintervention(macro-level)

5.3 Nutritionintervention(micro-level)



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Chapter 6: Interventions in the sociocultural environment

6.1 Introduction

6.2 NutritionInterventions(macro-level)

6.3 Nutritioninterventions(micro-level)



Chapter 7: Current policy landscape in Scotland

7.1 Backgroundandoverview

7.2 BeyondForesightintheUKandScotland

7.3 TheroutemapforobesitypreventioninScotland

Chapter 8: Prioritising the way forward

8.1 Theportfoliomatrixandevidenceinformedpolicy

8.2 Portfolioimplementation

8.3 Obesityasa‘complexadaptivesystem’

8.4 Combiningpublichealthandeconomicperspectives

8.5 Historicalpublichealthparallels

8.6 Integrationwithotherpoliticalandhealthpriorities

8.7 Recommendationsfornextsteps

8.8 Limitationsofthisreview

8.9 Overallconclusion

References

Weblinkedreferencesarepresentedwithinthemaintextashyperlinkedfootnotesandallliteraturecitationsarelistedinthereferencesection.

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I. Introduction

ObesityhasbeenconfirmedasoneofScotland’smostseriouspublichealthproblemsandlevelshavebeenrisingsteadilyoverthelast10years,withmarkedincreasesinmenaged35–64yearsandinwomenaged35–44years.Whenincreasingpopulationobesityisviewedsimplyasadistortedenergybalance(towardsexcess),thesolutions,namelytoreduceenergyintakeandincreaseexpenditure,wouldappeartobeselfevident.Driverstowardsincrementalweightgainhowever,arenowcloselyassociatedwithalmosteveryaspectofmodernlivingandthescaleandcomplexityofthechallengesinvolvedshouldnotbeunderestimated.Thisreportpresentsabroadoverviewofthepublishedliteratureonobesitypreventioninadults,inaformatthatshouldhelpfacilitatediscussionaboutwhatarelikelytobethemosteffectivepolicyoptionsacrossthefourdomainsofthepolicyenvironmentinitsbroadestsense,thesebeing:physical,economic,legislativeandsociocultural.InaccordancewithSwinburnandEggers’ANGELO(analysisgridforenvironmentslinkedtoobesity)framework,theevidenceineachofthesedomainsisconsideredatthemacro-level(i.e.national/regional)andmicro-levels(local/community/institution/household).Theothersignificantdistinctiontobedrawninanydiscussionaroundpotentialsolutionstotheobesityepidemicistherelativeimportancegiventoenergyintakeversusenergyoutputormorespecifically,dietversusphysicalactivity.Sinceanyseriousattempttoaddresstheproblematasocietallevelneedstopayattentiontoboththeseaspects,bothnutritionandactivityinterventionshavebeenreviewedforeachofthefourANGELOdomains.Agrowingconsensusthattherecentrapidpopulationrisesinobesitycanlargelybeexplainedbyincreasedenergyintake,alsohighlightstheimportanceofgivingequivalentorgreaterattentiontonutritionalfactorswhendecidingonhowbesttotackletheepidemic.

II. Physical environment

ThegreateravailabilityoffastfoodoutletsinsociallydeprivedandinAfrican-AmericanneighbourhoodsintheUS(wheremuchoftherelevantresearchhasbeenconducted),hasbeenassociatedwithanincreasedlikelihoodofobesityinthesepopulations.Thisfindingdoesnotapplytothesameextentinrelativelydeprivedareas/predominantlyethnicminoritylocalitiesofUKtownsandcities.Additionally,physicalproximitytoaffordablefoodchoicesdoesnotappeartobeastrongdeterminantofahealthydietinUKsettingswherethishasbeenexamined.AnimprovinginternationalandUKresearchliteratureinthisareahoweverclearlydoesdemonstratearoleforlocalenvironmentaldeterminants,mainlyaroundaccesstoamenitiesandtheextentofneighbourhooddisorder.Alsoatthelocallevel,theclearestassociationsforexcessenergyintakeincommercialcateringoutletsincludingrestaurants,hasbeenforlargerportionsizesandenergydensefoods.

Workplaceenvironmentalinterventions,includingnutritionavailabilityandinformation,havebeenrobustlydemonstratedtoresultinsignificantmeanreductionsinbodymassindex(BMI)andbodyweightfortargetedgroupsofworkersacrossawiderangeofemploymentsectors.Perhapsunsurprisingly,andinkeepingwithecologicalmodels,multi-componentandmoreintensivelystructuredinterventionsareassociatedwiththebestoutcomes,althoughseparatingoutthecontributionsofvariousprogrammecomponentscanbeproblematic.Lowintensityenvironmentalinterventionsbythemselves(suchasnutritionsigns),havelimitedbenefitswithinworkplacesettings.

Consistentassociationshavenowbeendemonstratedinanumberofcountriesbetweenfeaturesoftheexternalbuiltenvironmentandthelikelihoodofundertakingregularphysicalactivity,aswellastherelativeprevalenceofobesityandoverweight.SincethemajorityofthisworkisbasedonUSandAustralianstudies,therearelegitimateconcernsaboutthetransferabilityofthesefindingstoaUK/Scottishcontext.Theevidencebaseonbuiltenvironmentfactorsisalsocharacterisedbyincreasinglysophisticatedmethodsofenquiryincludingnaturalexperiments,longitudinalmeasuresandstratificationbydominantpreferencesandbehaviours,allofwhichpointtowardsadegreeofpromiseforbuilt-environmentinterventions,infacilitatingpositivebehaviourchange.

Executive Summary

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ThereislimitedUKevidencethatenvironmentalsurroundingscaninfluenceactivetravel,butthisisnotparticularlysurprisinggiventhatbaselinelevelsofactivetravelintheUKarelowandlargelyconfinedtoself-selectedpopulationsub-groups.Internationalcomparisonshowever,withcountriesthathaveequallyhighlevelsofcarownershipandsimilarclimates(e.g.GermanyandHolland),givessomegroundsforoptimismthatactivetravelcouldbepromotedbybuiltenvironmentmodifications.Inthiscontext,earlyresultsfromtheevaluationsofsix“cyclingdemonstrationtowns”inEngland,whichhaveseensubstantialincreasesincyclingasameansoftravel,arealsogreatlyencouraging.Additionally,thefindingthatmuchoftheexistingpublishedevidencerelatestothecapacityofbuiltenvironmentinterventionstoimprovesafety,shouldnotbediscouragingtopolicymakers,inviewoftheclearimportanceofimprovedsafetyinencouragingwiderparticipationinactivetravel.

Simplemotivationalsignscanbeaneffectivemeansofpromotingphysicalactivityinpublicsettingssuchasshopsandpublictransporthubs,althoughlongtermsustainabilityofthedesiredbehaviourchangehasyettobedemonstrated.Structuralinterventionssuchasengineered‘stair-skip’featuresinbuildingscanalsoincreasestairuseandtheinitialemployee/publicresistancetotheseinterventionsappearstodeclineovertime.Thepotentialimpactofsuchverymarginalincreasesinenergyuseonpopulationweighthowever,areofcourseonlylikelytobesmallandthesekindofmeasuresarebestusedasjustonepartofamorecomprehensivemulti-componentstrategy(e.g.attheworkplaceorcommunitylevel).

III. Economic environment

Evidencefromawidevarietyofstudieshasshownthattherearestrongassociationsbetweenpopulationlevelweightgainandtheconsumptionofenergydensefoodanddrink.Softdrinksinparticularhavearelativelyhigh‘priceelasticity’,inthattheirpurchasebyconsumers,particularlythoseatriskfromobesityandthemoreeconomicallydisadvantaged,ishighlypricesensitivecomparedtoothertypesoffood.Adiscretionarytaxonsoftdrinkswouldalsobeameansforgovernmenttoaddressa‘marketfailure’(insofarastherisksarecurrentlypoorlyunderstoodbyconsumers)andalsopotentiallyreapsignificantpublichealthbenefits.

Attheindividuallevel,althoughfinancialincentiveschemeshavebeensuccessfullyemployedinotherareas,particularlyinsmokingcessation,theiradoptionisrelativelyrecentinobesitypreventionandweightmaintenance.Aswithotherincentivebasedinterventions,longtermbehaviourchangeremainselusive.RecentlypublishedworkcarriedoutinNewZealandsupermarketswasabletodemonstrateincreasedfruitandvegetablepurchasinginresponsetomodestpricediscounts,althoughtherewerenooverallchangesin‘keyindicatornutrients’likesaturatedfat.

IV. Legislative environment

Growingrecognitionbygovernmentsofthetruescaleoftheobesitythreathasledsomecommentatorstodrawparallelsbetweenobesityandcommunicablediseaseinthattheremaynowbeacaseforstatutoryinterventiontoprotectpublichealth.Legislativeinterventionscouldinvolveanythingfromstraightforwardrestrictionsonsupply,throughtofiscalmeasuresaswellasobligationstoprovidemorecomprehensiveinformationaboutrisks.Traffic-lightlabellingschemes,suchasthatdevelopedbytheFoodStandardsAgencyandadvocatedbytheFacultyofPublicHealth,arethemosteffectivemeansofconveyingnutritionalinformationtoconsumers.Moderndevelopedeconomieswithsaturatedfoodmarketsarecurrentlyfacedwith‘increasedover-consumption’astheonlymeansbywhichfoodmanufacturerscangrowtheirbusiness.Dominantagriculturalpolicies,gearedtowardsoverproductionfortimesofscarcity,arealsonolongerappropriateinaworldofplenty,andneedtoberecognisedasafundamentaldriveroftheobesityproblem.Onthephysicalactivityfront,transportpoliciesandurbanplanningarrangementsrepresentlikelykeycomponentsofanylegislativeapproachtoincreasebothactivetravelandleisureparticipation.

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V. Sociocultural environment

Massmediaisperhapsthemostuniversalreflectorandparticipantshaperofsocioculturalattitudesinmodernsociety.Theeffectivenessofmediacampaignsthemselveshowevertoencouragehealthybehavioursismodestatbest,althoughtheystillhavethepotentialtobringaboutmarginalpopulationhealthgainatthenationalorregionallevel.Largescalepublicparticipationeventsareaneffectivemeansofbeginningtochangepopulationattitudesandbehaviours,aswellasinfluencingindividualperceptionsofability.Individuallyfocusedactivityincentives(suchasprimarycarebasedexercisereferral),haveaverymixedevidencebaseandtheireffectivenessandwideruseislikelytodependonthedevelopmentofimprovedtargetingalongsidebetterevaluation.Personaltravelplanning,ontheotherhand(athouseholdlevel),hasbeenassociatedwithconsistentreductionsincardependenttravel,althoughtherearesignificantconcernsaboutthequalityoftheevidence.Theimpactofanyfurtherinvestmentinsuchschemesneedstoberobustlyevaluated.WorkplacebasedtravelplanshavealsobeenshowntobeacosteffectiveandfeasiblemeansofincreasingmoreactiveformsofcommutinginaUKsetting.

Thevastmajorityofmediacommunicationonnutritionisaimedatchildren,althoughtelevisionviewingingeneralislinkedtoobesityinanumberofways.UKbroadcastregulatorrestrictionsonjunkfoodadvertisingintroducedin2006,havecertainlybeeneffectiveinreducingexposureduringchildren’stelevisionhours,buttherehasundoubtedlybeensomemigrationofthesetypesofadvertstofamilyviewingtimes.Multi-componentnutritioninterventionshavealsohadsomesuccessinchangingworkplaceandinstitutionalfoodcultures.TheambitioushighprofilemediapublicisedbehaviourchangecampaigninEngland,Change4Life,isaimedprincipallyatfamiliesandhasevaluatedwelltodateonawarenessraisingoutcomes.Ongoingevaluationisintendedtolookforevidenceofanybenefitindirectoutcomessuchaspopulationhealthyweightmaintenance.

VI. Overall approach to available evidence

Sinceobesitypreventionandcontrolissucharapidlyevolvingfieldofenquiry,manyinterventionproposalsarecurrentlybasedonlyonstudiesofassociation,althoughincreasinglysophisticatedquasi-experimentalworkisnowbeingusedtorefinetheevidencebasearoundwhatmightworkthroughdeliberatedesignedinterventions.Bynecessitytherefore,thisrapidreviewofthepublishedliterature,drawsuponawidevarietyofstudyformats,dependingontheextentofcurrentprogressineachparticulararea.Severalcommentatorshavealsohighlightedtheneedforresearchersnottoberestrictedbyconventionalmodelsofdiseaseprevention,wherecausationneedstobefirmlyestablishedbeforepotentialinterventionsaretriedandtested.Theonecertaintyisthatobesityremainsahighlycomplexmultifacetedproblem,closelyentwinedwithmanyaspectsofmodernliving.Unravellingthecomponentsthataremostamenabletointerventionwillrequireasolutionorientatedapproachandareadinesstoconsiderunconventionalmulti-componentstrategies,withalltheadditionalchallengesthatthisrepresentsforrobustmonitoringandevaluation.

VII. Development of policy options

Thefollowingdocumentpresentsarelativelyselectivesummaryoftheevidenceavailableineachoftheaboveareasanddrawsonawiderangeofpublishedsourcesincludingsystematicreviewswherethesewereavailable.ItisintendedtofacilitatediscussionsamonglocaldecisionmakersandstakeholdersaboutwhatmightbethemostpracticableandrealisticenvironmentalandpolicyinterventionsthatwouldhavethegreatestchanceofsuccessinScotland.Chapter7presentsanoverviewofthecurrentpolicylandscapeinScotland,whilechapter8presentsthereviewfindingsinasummarytableformatanddescribesastructureddiscussionmethodforrefiningpotentialproposalstowardsimplementation.

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Chapter 1 – Introduction and overview11.1 Background

TheScottishCollaborationforPublicHealthResearchandPolicy(SCPHRP)wassetuptospecificallyidentifythebestevidenceavailableforpolicyinterventionstoaddressScotland’smajorpublichealthpriorities.SCPHRP’scoremandateisto:

• Identifykeyareasofopportunityfordevelopingnovelpublichealthinterventionsthatequitably addressmajorhealthproblemsinScotland,andmovethoseforward

• Fostercollaborationbetweengovernment,researchersandthepublichealthcommunityinScotlandtodevelopanationalprogrammeofinterventiondevelopment,large-scaleimplementationandrobustevaluation

• Buildcapacitywithinthepublichealthcommunityforcollaborativeresearchofthehighestquality,withmaximumimpactonScottishpolicies,programmesandpractice.

Specifically,theCollaborationseesitsownroleverymuchas‘brokers’betweenpublichealthdecisionmakersandresearchers,whootherwisedonotregularlyinteractinScotland(orelsewhere.)TheCollaboration’soverridingobjectiveistobuildrelationshipsacrossthisdividesothatnewpublichealthprogramsandpoliciesareproperlythoughtoutandpilottested,beforefullimplementation,andthenrobustlyevaluatedfortheireffectivenessandcostsasapartoffullrollout.SCPHRPhasfiveyearsofMedicalResearchCouncil(MRC)/theChiefScientistOffice(CSO)fundingtodemonstratethatsucha‘collaborative’approachcanachievethesegoals.

1.2 Conclusions of first meeting: Workstreams

TheinauguralworkshopsoftheCollaborationinearly2009identifiedfourmajorworkstreamsthatwouldconstitutealife-courseapproachtotacklingpublichealthproblemsinScotlandaccordingtokeylifestages:

• Earlylife-Preconceptionthroughthepre-andperi-natalperiods,totheprimaryschoolyears,whenstrongpredictorsoflifelonghealthtakeroot,butareexceptionallyamenabletochange

• Teenageandearlyadulthood-Whenculturallyinfluencedexternalcausesofillhealthpredominate,andarecurrentlytippingthebalancetowardsgreaterhealthinequalitiesinScotland(i.e.violence,suicideandrelatedmentalhealthproblems;smoking,drugandalcoholabuse;andriskysexualbehaviours)

• Earlytomid-workinglife-Whencareersuccess,workrelated-disabilityandfamilyfunctioning,andconsequentlymentalhealthandsocialissues,figurestronglyaskeyoutcomesforhealthyandproductiveadults,butarangeofchronicdiseaseriskfactorsalsotendtobecomefirmlyestablished,includingthecurrentpandemicofoverweight,withallofitsattendanthealthconsequences

• Laterlife-Especiallytheperiodbetweenages45and65,whensymptomaticchronicdiseasesandassociateddisabilitybegintoappear,typicallyinunequalwaysacrosssocioeconomicstrata,leadingtoquitedifferentialexperiencesofsenescence.

Chapter1

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Eachdedicatedworkgroupthendecidedonwhattheprioritytargetsforinterventionshouldbe.FortheEarlytoMid-WorkingLifegrouptherewasextensivediscussionaroundwhethertofocusatthewholepopulationlevelorwhethera‘settingsbased’approachthroughworkplaceinterventionswouldbemorepracticable,giventhetimeandresourceconstraintsinvolved.Thegroupdecidedtoincludebothlevelsofintervention,thetopicsprioritisedbeing:

• Interventionstotackleobesogenicaspectsoftheadultenvironment

• Interventionstoreducesickness/injuryabsenceandimprovehealthintheworkforce.

Thecurrentoverviewdealswiththefirstofthese,namely:‘obesogenicaspectsoftheenvironment’andidentifyingpotentialpoliciesorinterventionswhichmightbeeffectiveintacklingtheminaScottishcontext.

1.3 Search strategy and initial guidance

Thebroadall-encompassingquestionfortheinitialsearchwas:‘Arethereanyprovenorevaluatedpolicyinterventions,ormodificationstothebuiltenvironment,whichcanpromotephysicalactivityoractivetravel(e.g.walkingandcycling);reduceconsumptionofunhealthy(energydense)dietswhicharehighinfatandsugarorpromoteconsumptionofhealthier/lessenergydensefoodssuchasincreasedfruitandvegetables?’

AninitialscopingsearchwasconductedusingthefollowingMeSHtermsinPubMed:

Terms ((‘EnvironmentDesign’[Mesh]OR(‘NutritionalSciences’[Mesh]OR‘NutritionPolicy’[Mesh])AND‘Obesity/preventionandcontrol’[Mesh])OR‘Overweight/preventionandcontrol’[Mesh])

Limits Humans,Editorial,PracticeGuideline,Review,English,Adult(19–44years),MiddleAged(45–64years).Thisinitialsearchidentified144articlesintotal,116ofwhichwerereviews.

Thecomplexityandbroadnatureofinfluencesonobesityfromthesurroundingenvironmentcallsforamuchwiderperspectivethanwouldnormallybecoveredbytraditionalmedico-healthpublicationdatabases.Forthefullsearchamorecomprehensivelistoffullyexplodedterms(seeAppendixE1)wasperformedineachofthefollowingdatabases(whichwereidentifiedfromreviewsconductedbytheWHOInternationalObesityTaskForce[1]andtheNationalInstituteforClinicalExcellenceintheUK(physicalactivityfocus).

Databases

MEDLINE Sociologicalabstracts

EMBASE Planex*

CINAHL ICONDA*

PSYCHINFO Environline*

CampbellCollaboration

*Morerecentlydevelopeddatabases(unlikelytohavemanyarticlesofinterestbefore2000).

Inclusion

• Englishonly

• Human

• Adultworkinglife19to64yearsinclusive#

• Preventioninterventionscanbe:community,societal,infrastructural(e.g.builtenvironment)orlegislative(nationalorlocalgovernmentpolicy)

• Studytypes:reviews;(cluster)randomisedtrials;quasi-experimentalstudies;observationalandcross-sectionalstudies(includinglongitudinalcohortandfollow-upstudies)

• Timewindow:1990onwardsuntilSeptember2010(end)# Note:ForPubMedsearchestheagecategorieswererestrictedtoadult(19–44years)andmiddleaged

(45–64years).

1 Appendix E1 – available electronically through web-link: http://www.scphrp.ac.uk

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Exclusions

• Individualbased(e.g.clinical/therapeutic)interventionsforobeseoroverweightpatients

• Rehabilitationprogramsormeasuresafterinjuryormedicalprocedures

• Nutritionmeasures/interventionsforindividualsorgroupswitheatingdisordersorotherseriousunderlyingillness.

Thissearchstrategyidentifiedatotalof78reviewlevelarticlesand49primarystudies.ReferencelistsandforwardcitationtrackingthroughWebofScienceidentifiedafurther34interventionspecificreports.Theremainingreferencesourceswereeditorials,policyframeworksandelectronicallyaccessedgreyliterature.Allreviewswhichmateriallycontributedtothisreportwillbesummarisedinaseparateappendix(E2)tobepublishedelectronicallyontheSCPHRPwebsite.

Notallidentifiedstudiesweresufficientlynovelorrelevantafterscrutinytobeincluded.

Thescanalsodrawsuponmanygovernmentdocuments,web-publishedmaterialandothergreyliteraturepromptedbycitationtrackingandconsultingoriginalsourcedocumentsanddata.

Othersources

• ConsultationwithestablishedUKexperts(PhillipInsall,NickCavill)

• Thirdsectororganisations(principallySUSTRANS)

• Localdedicatedresearchteams(SPARCOL)

• CollaborationwithapublichealthpolicyresearcheratNHSLothianHealthBoard

• Fourexpertinvitedreviewersforcommentsonthefirstcompletedraft.

1.4 Structure and purpose of this report

ThebreadthandcomplexityofallenvironmentalinfluencesandsocietaldriverswhichmightimpactonobesityandwhichweresetoutcomprehensivelyintheUKGovernment’sForesightReportonthesubject[2]providesomeinsightintopotentialtargetsforpreventativeinterventionsbutdonotreadilyleadtoawell-definedresearchquestion,orevenseriesofquestions.Thenatureoftheassociatedproblemsthatunderlyobesityarealsonotespeciallysuitableforclassicalrandomisedstudydesigns,whichconstitutethehigheststandardofscientificevidencefordecidingwhichinterventionsmightbethemosteffective.Thecurrentreporttherefore,isintendedprincipallytopresentasummaryofthebestevidenceavailablewithinaframeworkthatwehopewillbeofmostusetopolicymakers.Thankfully,thereareanumberofveryusefulecologicalmodelsthathelptoclarifyandhighlightpotentialenvironmentalandpolicyinterventions,someofwhichhavealreadybeenimplementedinotherpartsoftheworld(andwhicharediscussedinthecourseofthedocument).Intermsofmakinguseofavailableevidence,thescanfollowsapragmaticapproachandaimstopresentpotentialinterventionsinthecontextoftheirlikelypopulationimpactaswellasthestrengthofevidenceasitcurrentlystandsintheliterature(seesection2.7andtable2.4).

Chapter1

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2 Chapter 2 – Obesity in adults

2.1 Defining obesity

Obesitycanbedefinedastheaccumulationofexcessfattotheextentthatitcanseriouslyimpairnormalbodilyhealthandfunctioning.Whileitisrecognisedthatsomepeoplearemoregeneticallysusceptiblethanothers,thedirectcauseofobesityinanindividualisanexcessofenergyintakeoverexpenditure.Themostwidelyacceptedclinicaldefinitionofobesityinadultsisbasedonbodymassindex(BMI)whichisdefinedasaperson’sweightinkilogramsdividedbythesquareoftheirheightinmetres(kg/m2).Thestandardcategoriesforobesityclassificationforadultsareshownintable2.1.

Inthecaseofchildren,theUKnationalBMIpercentileclassificationhasbeenthemostusedforreportingobesity.ChildrenaredefinedasoverweightorobeseiftheirBMIfallsabovethe85thand95thpercentilerespectivelyoftheUK1990referencechartforageandsex.

2.2 Obesity as a public health priority

Thedirectandindirectconsequencesoftreatingobesityareconsiderable.Obesityreduceslifeexpectancybyanaverageof9yearsandisstronglyrelatedtoanumberofseriousdiseases,mostnotablyheartdisease,typeIIdiabetesandcertaincancers.ThelikelihoodofdevelopingdiabetestypeIIforinstanceisalmost13timeshigherforwomenwhoareobeseand5timeshigherforobesemen(table2.2).TheriskofmajorcardiovasculareventsinacohortofBritishmenagedbetween40and59withnopriorhistoryincreasedby6%foreach1kg/m2increaseinBMI[4].

Chapter2

BMI range (kg/m2)

<18.5

18.5–24.9

25.0–29.9

30–34.9

35–39.9

40+

Classification

Underweight

Healthy weight

Overweight

Mildly obese (obesity I)

Moderately obese (obesity II)

Morbidly obese (obesity III)

Table 2.1 Classification of overweight and obesity in adults [3]

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Inadditiontoincreasingtherisksofillhealth,obesitysignificantlyincreasestheriskofmortalityatanygivenage.Formidlifeadults(50to71yearsold),whohaveneversmoked,theallcausemortalityriskincreasesby20%to40%inoverweightpersonsandby200%to300%inthosewhoareobese[5].Thereisalsoalinkbetweenmortalityriskandthedurationofoverweight,withthosewhohavebeenoverweightforlongestbeingatthehighestrisk.Severelyobeseindividualsarelikelytodieonaverage11yearsearlier(13yearsforaseverelyobesemanbetween20and30yearsofage),thanthoseofahealthyweight.Thisriskiscomparableto,andinsomecasesworsethan,thereductioninlifeexpectancyfromsmoking.Extrapolationsinthegovernment’srecentForesightreport[2],suggestthatby2025fortheUKpopulationasawhole,somethingintheregionof40%ofadultscouldbeobese.

2.3 The epidemiology of obesity in Scotland

TheScottishPublicHealthObservatoryreportin2007[6]confirmedthestatusofobesityasoneofScotland’smostseriouspublichealthproblems(asisalsothecasefortherestoftheUK).Thereportsetsouthowobesitylevelsinbothadultsandchildrenhaverisensteadilyoverthelast10yearswithmarkedincreasesinmenaged35–64yearsandinwomenaged35–44years.Amongitskeyfindingsare:

• Theprevalenceofobesity(BMI>30kg/m2)inScotlandhasincreasedoverthepasttwodecades,reaching22%inmenand24%inwomenin2003,withmarkedincreasesin(workingage)menaged35–64yearsandinwomenaged35–44years

• Theprevalenceofobesityclearlyincreaseswithagethroughoutmostofthelife-courseinbothmenandwomen(figure2.1).

Disease

Type II diabetes

Hypertension

Myocardial infarction

Cancer of the colon

Angina

Gall bladder disease

Ovarian cancer

Osteoarthritis

Stroke

Relative risk for women

12.7

4.2

3.2

2.7

1.8

1.8

1.7

1.4

1.3

Relative risk for men

5.2

2.6

1.5

3.0

1.8

1.8

–

1.9

1.3

Table 2.2 Classification of overweight and obesity in adults [3]

(Source:NationalAuditOffice20012)

2 Tackling Obesity in England. National Audit Office 2001. http://www.nao.org.uk/publications/0001/tackling_obesity_in_england.aspx

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Chapter2

3 Scottish Public Health Observatory, ISD Scotland (http://www.scotpho.org.uk/home/home.asp)

Figure 2.1 PrevalenceofobesityandoverweightinScotlandbyageband,2008

• Whileoverallobesityprevalenceisnotrelatedtodeprivationatthepopulationlevel,thereisevidenceofaninverseassociationinwomenwithhigherlevelsofobesityinlowersocialgroups

• Obesityinchildrenisnowcommon.InScotland,nearlyoneinfive(18%)boysandapproximatelyoneinseven(14%)girlsaged2–15yearsareclassifiedasclinicallyobese

• ItisestimatedthatobesityinScotlandispresentlylinkedtonearly500,000casesofhighbloodpressure,30,000casesoftypeIIdiabetes,andsimilarnumbersofcasesofosteoarthritisandgout

• ObesepeopleinScotlandare18%morelikelytobehospitalisedthanthoseofnormalweight.

LevelsofobesityinScotlandandEnglandarebroadlysimilarformen,althoughScotlandhashigherlevelsofobesityamongwomen.InternationalcomparisonsshowthatScotlandhasrelativelyhighlevelsofobesitycomparedwithotherOECDcountries(figure2.2).Thiscombinedpictureprovideslittlereassurancethattraditionalapproachestoobesity,whichwerelargelybasedaroundappealstoindividuallifestylechange,havehadanymeasurableimpact.ItisprobablytooearlyhowevertocommentonmorerecentpolicyinitiativessuchasUKChange4Life(seechapter7)regardinganyimpactonthetrendonobesityandoverweight.

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Men

0102030405060708090

16-24 25-34 35-44 45-54 55-64 65-74 75+

Age group

Perc

ent

Obese (BMI 30 or more) Overweight (BMI 25 to <30)

Women

01020304050607080

16-24 25-34 35-44 45-54 55-64 65-74 75+

Age group

Perc

ent

Obese (BMI 30 or more) Overweight (BMI 25 to <30)

Figure 2.1 Prevalence of obesity and overweight in Scotland by age band, 20082

• While overall obesity prevalence is not related to deprivation at the population level, there

is evidence of an inverse association in women with higher levels of obesity in lower social

groups.

• Obesity in children is now common. In Scotland, nearly one in five (18%) boys and

approximately one in seven (14%) girls aged 2–15 years are classified as clinically obese.

• It is estimated that obesity in Scotland is presently linked to nearly 500,000 cases of high

blood pressure, 30,000 cases of type II diabetes, and similar numbers of cases of

osteoarthritis and gout.

• Obese people in Scotland are 18% more likely to be hospitalised than those of normal

weight.

2 Data source: Scottish Public Health Observatory, ISD Scotland (http://www.scotpho.org.uk/home/home.asp)

Formatted: Bulleted + Level: 1 +Aligned at: 0.63 cm + Tab after: 1.27cm + Indent at: 1.27 cm

(Source:ScottishPublichealthObservatory,2010.3)

18


Figure 2.2 ObesityinOECDCountries:%adultpopulation(>=15years)withaBMI>=30kg/m2

(Source:OECDhealthdata,2006)

Giventheadverseconsequencesforindividualandpopulationhealth,thecurrentestimateddirectlinkedcostsofobesitytotheNHSintheUKareestimatedtobearound£4.2billion[2](thelastavailableestimatefortotalNHStreatmentcostsinScotlandwasin2001at£171million).

Additionally,internationalevidencesuggeststhattheriskofdeathamongobesepeopleistwotothreetimeshigherthanpeopleofnormalweightdueto‘all-causemortality’acrossallageranges[7].TheForesightReportonlikelyfuturechallengesofobesitygaveanestimateofaround£16billionforthecoststotheeconomyasawhole,risingto£50billionperyearby2050ifleftunchecked.TheUK’sentireGrossDomesticProductatSeptember2009is£316billion4.Suchafinancialburdentothewidereconomy,tosaynothingoftheeffectsonthequalityandlengthoflifeexperiencedbycurrentandsubsequentgenerations,isclearlyunsustainable.

4 Office for National Statistics; September 09 http://www.statistics.gov.uk/instantfigures.asp#bopt

17

Levels of obesity in Scotland and England are broadly similar for men, although Scotland has higher

levels of obesity among women. International comparisons show that Scotland has relatively high

levels of obesity compared with other OECD countries (figure 2.2). This combined picture provides

little reassurance that traditional approaches to obesity, which were largely based around appeals to

individual lifestyle change, have had any measurable impact. It is probably too early however to

comment on more recent policy initiatives such as UK Change4Life (see chapter 7) regarding any

impact on the trend on obesity and overweight.

Figure 2.2. Obesity in OECD Countries: % adult population (>=15 years) with a BMI>= 30 kg/m2

(Source: OECD health data, 2006.)

Given the adverse consequences for individual and population health, the current estimated direct

linked costs of obesity to the NHS in the UK are estimated to be around £4.2 billion [2] (the last

available estimate for total NHS treatment costs in Scotland was in 2001 at £171 million).

Additionally, international evidence suggests that the risk of death among obese people is two to

three times higher than people of normal weight due to ‘all-cause mortality’ across all age ranges

[7]. The Foresight Report on likely future challenges of obesity gave an estimate of around £16

19

2.4 Key drivers of obesity

Conceptually,thecausesofobesityattheindividuallevelareintuitivelyselfexplanatory.Weightgainandeventuallyobesityoccurwhenenergyintakefromfoodanddrinkisgreaterthanallenergyexpenditurethroughthebody’smetabolismandphysicalactivityoveraprolongedperiodoftime,resultingintheaccumulationofexcessbodyfat.Whilethereissomeevidencethatsomeindividualsmaybegeneticallymoresusceptibletodevelopingobesity,thesteeplyrisingprevalenceofobesityandoverweightinthepastthirtyyearscannotbegintobeaccountedforbyheritable/geneticfactors.

Indeedtheevolutionofcapacitytoefficientlystoreexcessfoodenergyintimesofscarcityhasnodoubtplayedapivotalroleinhumanevolutionarysuccess.Suchcapabilitieshoweverareclearlymaladaptiveinmodernwesternisedsocietieswhereenergydenserichfoodsareplentiful,affordableandheavilypromotedbysophisticatedcommercialinterests.Addtothistheriseofmotorisedtransport,sedentaryemploymentpatternsandthediminishingrequirementsforphysicaleffortinthehomeandatwork,anditishardlysurprisingthatratesofobesityandoverweightcontinuetoriseateverystageinthelife-course.

Animprovingunderstandingofcausalfactorshoweverhasnotledsofartothedevelopmentofanynotablysuccessfulsolutionsorpreventativestrategiesthathavedemonstratedanygreatpromiseinreversingtheunderlyingtrendtowardsanincreasinglyoverweightpopulation.TheproblemisalsonolongerconfinedtodevelopedeconomiessuchasEuropeandtheUS,sincesomeofthemostdramaticincreasesarecurrentlyoccurringindevelopingcountriesandinthenewlyemergenteconomiesofIndiaandChina[8,9].Inspiteofthenowwidespreadinternationalacknowledgementofthetruescaleoftheproblem,withmanygovernmentsmakingproclamationsabouttheneedforurgentaction,nocountryintheworldhasyetmanagedtosuccessfullyhaltorreversetherisingobesitytrend.

Theemphasistodateinmanycountries,includingtheUK,hasbeenquitestronglyfocusedonaspectsofindividualbehaviour,withoutaddressingthepowerfulunderlyingsocietaldriverswhichpermeateeveryaspectofmodernlife.TheForesightReport[2]forinstancereferstoa‘complexwebofsocietalandbiologicalfactorsthathaveinrecentdecades,exposedourinherenthumanvulnerabilitytoweightgain’.Thereportpresentedanobesitysystemsmap5,onwhichoveronehundredvariablesareidentifiedthatdirectlyorindirectlyinfluenceenergybalanceatthecentreofthediagram.ForsimplicitytheForesightmaphasbeendividedinto7cross-cuttingpredominantthemes:

• Biology:anindividual’sstartingpointreflectingtheinfluenceofgeneticsandbaselinephysicalhealthstatus,aswellasearlylifeprogrammingeffectsandinternalappetitecontrolmechanisms

• Activityenvironment:theinfluenceoftheenvironmentonanindividual’sactivitybehaviour,forexampleadecisiontocycletoworkmaybeinfluencedbyroadsafety,airpollutionortheprovisionofacycleshelterandshowersatwork

• Physicalactivity:thetype,frequencyandintensityofactivitiesanindividualcarriesout,suchascyclingvigorouslytoworkeveryday

• Societalinfluences:theimpactofsocietyonindividualbehaviour,forexampletheinfluenceofthemedia,education,peerpressureorculture

• Individualpsychology:forexampleaperson’sindividualpsychologicaldriveforparticularfoodsandconsumptionpatterns,orphysicalactivitypatternsorpreferences.Alsoincludesissuesaroundstresscopingskill,self-esteemandself-efficacy

• Foodenvironment:theinfluenceofthelocal,nationalandevenglobalfoodenvironmentonanindividual’sfoodchoices.Atthelocallevelforexample,adecisiontoeatmorefruitandvegetablesmaybeinfluencedbytheavailabilityandqualityoffruitandvegetablesnearthehome.Regionalandnationalinfluencescoverallarrangementsforfoodproductionanddistributionaswellastradeagreementsandincentiveswhichinfluencethem

• Foodconsumption:thequality,quantity(portionsizes)andfrequency(snackingpatterns)ofanindividual’sdiet.

5 The full obesity systems map (Figure 8.4 in Foresight Report): http://www.bis.gov.uk/assets/bispartners/foresight/docs/obesity/obesity_final_part5.pdf

Chapter2

20


ThesystemsmapdevelopedintheForesightdocumentcertainlyillustratesthecomplexityofthetaskfacingpolicymakersintryingtodevelopsolutionstoincreasingobesityprevalence.InadditiontothelargelyindividuallyorientedbehaviouralmeasuresadoptedtodateintheUK(suchastheDepartmentofHealthinEngland’sChange4Lifecampaign6),policydevelopmentitselfisconstrainedbyagreatdiversityofanalysesastowhatmightbethemostcriticalleveragepoints.LangandRayner[10]havereferredtothissituationasa‘policycacophony’wherethe‘noise’ofcompetingproclamationsofwhereactionneedstobetaken,‘drownsoutthesymphonyofeffort’.Theyhighlightthatitistheinnateconservatismofmostgovernmentsthatdrivesthemtoresorttoindividualbehaviour-basedmodels,butthatwhatisactuallyrequiredisacomprehensivecoherentapproachlookingatallsectorsofsociety,whichisalsostronglyadvocatedbytheForesightteam.Encouragingly,policyinitiativeswhichwillbediscussedinsubsequentchapters(e.g.foodlabellinginsection5.2andcyclingdemonstrationtownsinsection5.4),couldhavebeenseen(untilrecentlyatleast),assignsthatthecaseformoreenvironmentallyorientatedinterventionsmaybestartingtobeheard.

2.5 The obesogenic environment

ThetermobesogenicenvironmentwasfirstcoinedbyEggerandSwinburnin1997[11]todescribethenumerousembeddedsocietaldriversattherootofincreasingpopulationweightgaininmodernwesternisedsocieties.Thesamereportalsointroducedasimpleecologicalmodelbasedontheepidemiologicaltriadwhichwasoriginallyintroducedformodellinginfectiousdiseases.

Theconceptualparallelsbetweentheobesitypandemicandthe‘triad’modelhelptoillustratethatthedrivingforceswhichareresponsibleforincreasingobesityprevalencearepredominantlyortwo-thirds‘external’totheindividual,asopposedtobeingsubstantiallyattributabletohostfactors.Mostimportantly,theclosecomparisonthatthismodelthenencourageswithothermajorpublichealthissuessuchassmokingreduction,injurypreventionandinfectiousdiseases[12]reinforcesthepointthatsuccessisnotlikelytooccuruntilenvironmentalinfluencesareaddressed.Swinburnandcolleagues

Figure 2.3 Theepidemiologicaltriadappliedtoobesity.Forobesity,‘host’encompassesthebiologicalandbehaviouralinfluences,plusphysiologicaladjustment.‘Environment’issimilarinthetwomodels,and‘vehicle’(or‘proximatedrivers’)canbeseenasthecombinationofallenergyintake(food/drink)andallenergyexpenditure(physicalactivity).

(Source:EggerandSwinburn,1997[11])

20

Lang and Rayner [10] have referred to this situation as a ‘policy cacophony’ where the ‘noise’ of

competing proclamations of where action needs to be taken, ‘drowns out the symphony of effort’.

They highlight that it is the innate conservatism of most governments that drives them to resort to

individual behaviour-based models, but that what is actually required is a comprehensive coherent

approach looking at all sectors of society, which is also strongly advocated by the Foresight team.

Encouragingly, more recent policy initiatives which will be discussed in subsequent chapters (e.g.

food labelling in section 5.2 and cycling demonstration towns in section 5.4), could be considered as

signs that the case for more environmentally orientated interventions may be starting to be heard.

2.5 The obesogenic environment

The term obesogenic environment was first coined by Egger and Swinburn in 1997 [11] to describe

the numerous embedded societal drivers at the root of increasing population weight gain in modern

westernised societies. The same report also introduced a simple ecological model based on the

epidemiological triad which was originally introduced for modelling infectious diseases.

Figure 2.3 The epidemiological triad applied to obesity. For obesity, ‘host’ encompasses the biological and behavioural influences, plus physiological adjustment. ‘Environment’ is similar in the two models, and ‘vehicle’ (or ‘proximate drivers’)

can be seen as the combination of all energy intake (food/drink) and all energy expenditure (physical activity). (Source: Egger and Swinburn, 1997)

The conceptual parallels between the obesity pandemic and the ‘triad’ model help to illustrate that

the driving forces which are responsible for increasing obesity prevalence are predominantly

‘environmental’, as opposed to arising from any individual pathologies or susceptibilities. Most

importantly, the close comparison that this model then encourages with other major public health

issues such as smoking reduction, injury prevention and infectious diseases [12] reinforces the point

6 Change4life - Eat Well, Move More, Live Longer http://www.dh.gov.uk/en/Publichealth/Change4Life/index.htm

21

Chapter2

alsodevelopedacategorisationsystemforthedifferentaspectsoftheobesogenicenvironment,whichhasbeenusedtoclassifyinterventionmeasuresaimedataddressingobesity[13].The‘analysisgridforenvironmentslinkedtoobesity’orANGELOframework,providesameansofidentifyingandcategorisingobesogeniccharacteristicsoftheexternalenvironment,sothattheirrelativeimportanceinanyparticularsettingcanbeexaminedasapreludetoprioritisinginterventions.Theframeworkdistinguishesfourbroadenvironmentalcategoriesordomainsofinfluence(physical;economic;legislativeandsociocultural)andtwolevelsofscale:micro(local/institutional)andmacro(regional/national).

Furtherdetaileddefinitionsandexamplesofwhatconstituteseachenvironmentaldomain,areexploredinchapters3to6ofthisreport,butinbrieftheycanbethoughtofas:

• Physical:Notjustthephysicalworld,butalsorelatestoavailabilityofsofterresourcesliketrainingandinformation,technologicalinnovationsandexpertise

• Economic:Allmonetaryconsiderationsassociatedwithnutritionalandphysicalactivityenvironmentsincludingincentives,penaltiesandsocietalcosts

• Legislative7:Allrulesandregulations(e.g.microcanbehouseholdorschool/workplaceandmacroreferstoregional/nationallegislation)

• Sociocultural:Referstosocialandculturalnormsinrelationtofoodandphysicalactivity(subjecttovariationatalllevelsfromindividual/householdtoethnic/religious/cultural).

TheintroductorypaperappliesthisframeworkinseveralPacificIslandcommunitieswhichareacknowledgedashavingsomeofthehighestlevelsofobesityandoverweightintheworld.Whilethereareanumberofdifferentframeworksavailableforcategorisingpolicyandenvironmentalinterventions[14–16,]ANGELOenablespolicymakerstoensurethattheyhaveabalancedapproachacrossallfourdomains,methodsofinterventionandsettings.MostimportantlyANGELOhasbeenpilotedatthepopulationlevelforuseinprioritisinginterventionsbyratingforvalidity(evidenceofimpact),relevance(tolocalcontext)andpotentialmagnitudeofeffect[13].Theapproachhasalsonowbeenappliedfor‘whole-community’demonstrationprojectsacrossdiversepopulationgroups[17].Arecenthigh-qualitysystematicreviewfromCanada[18]ontheinfluenceoftheurbanenvironmentonhealthyweightswasalsostructuredaroundtheANGELOframework.

Sincetheultimategoalofobesitypreventionandcontrolatthepopulationlevelistoengineer‘ashiftinthecurve’inthepopulationdistributionofobesity[19],thereisanemergingconsensusthatpublichealtheffortsneedtobeuniversal,ratherthantargetinganyparticularriskgroups,andthatthegreatestchanceofsustainablesuccesslieswithan‘incrementalsmallchangesstrategy’[20].Becauseweightgaincanoccurovertimewithveryminordailyenergysurpluses,smallscaleenergydeficitsmightbemorepracticableandhabit-formingthanmajorlifestylealterations.Ofcoursesmallchangesbydefinitionaredifficulttomeasure,whichbecomesproblematicwhentryingtoevaluatetheireffectivenessatthepopulationlevel.

(Source:adaptedfromSwinburnet al,1997[13])

7 Within the original ANGELO classification, the term Policy is used for the Legislative domain used to describe laws and regulations. For the purposes of categorizing interventions in this document however, ‘legislative’ was deemed to be more specific, since policy measures in a UK context could equally apply to any domain.

Scale

Domain

Physical

Economic

Legislative

Sociocultural

Whatisavailable?Forexample,buildings,amenitiesandlandusepatterns.

Whatarethemonetarycostfactors/influences/consequences?

Whataretherules/legalguidance/policymessages?

Whataretheattitudes,beliefs,perceptionsandvalues?

Micro-environment (settings) (e.g. household, community) Food Physical activity

Macro-environment (sectors) (e.g. regional, national) Food Physical activity

Table 2.3 Analysis grid for environments linked to obesity (ANGELO)

22


2.6 Appraising evidence for obesity prevention

Thequestionofhowbesttotackleobesityhasbeendescribedasaperfectillustrationofthemagnitudeofthemismatchthatisoftenseeninpublichealthbetweenthescaleofaproblemandtheadequacyofevidenceontheeffectivenessofinterventionstotackleit[21].Anincreasingsenseofurgencytoundertakesomeformofaction,cancompoundtheproblembyneglectingtoallowforproperconsiderationofhownewprogrammesshouldbeevaluated.Thoseinterventionswhichhavehighcapitalinvestmentcosts(e.g.changestotransportinfrastructure),orwhichinvolvechallengingvestedinterests(e.g.thefoodindustry)alsoneedtobeabletodemonstratestrongevidenceoflikelyeffectivenessiftheyaretobeimplemented[22].Theterm‘evidence-based’isitselfinonesenseproblematic,sinceitisgenerallyunderstoodtobeanalogoustotheevidence-basedmedicine(EBM)frameofreference.AnEBMperspectivestronglyweightsinternalvalidity(robustanswersinacontrolledenvironmentsuchasaclinicaltrial),overexternalvalidity(i.e.generalisabilityacrossdifferentpopulations/settingsandwhichtakesaccountofsocial,cultural,politicalandcommercialconsiderations).Manypublichealthexpertspointtotheoverwhelminginfluenceofthelatterintheirworkatthepopulationlevelandsuggestthattheoverridingquestionneedstobenot‘whatshouldwork?’butrather‘whatdoesworksustainably,undertheprevailingconditions?’.

Giventhatthefocusofthisreportisobesityprevention,therearethreefundamentalconsiderationswhicharecentraltothesearchforevidencewhicharesummedupverysuccinctlyinchapter2oftheUSIntstituteofMedicine’srecentreportentitled‘BridgingtheEvidenceGapinObesityPrevention[23]:Firstistheneedtodistinguishpreventionfromtreatmentinorderthatthepopulationlevelfocusismaintainedratherthantargetingthealreadyoverweight(atwhichpoint‘weightloss’risksbecomingthemainobjective).Second,theultimateaimofpreventionisareductionorstabilisationinpopulationBMIlevelswhichimpliesthattheabsenceofanincreaseorareducedrateofincreasecanbothbevalidmeasuresofsuccess;third,favourableimpactsonBMIoutcomesareachievedthrougheffectsonfourtypesofintermediateoutcomes:organisational;environmental;socio-cultural(includesprevailingbeliefsandvalues)andbehavioural.Byimplicationtherefore,manystrategiesaimedatobesitypreventionmaynotbeexpectedtohaveadirectimpactonBMI,butratheronpathwaysthatwillalterthecontextinwhicheating,physicalactivityandweightcontroloccur.Anyrestrictionontheconceptofasuccessfuloutcome,toeitherweight-maintenanceorBMImeasuresalone,isthereforelikelytooverlookmanypossibleinterventionmeasuresthatcouldcontributetoobesityprevention.

Followingtheabovelogic,thecurrentreportdrawsuponawiderangeofstudiesandtypesofinvestigation.Insomeareasofprevention,evidenceisrestrictedtoaetiologicalstudiesinwhichthefocusisattemptingtoquantifythecontributionofcertainbehavioursorenvironmentalcharacteristicstopopulationobesityandtherebydesignlogicalinterventions.Formoreadvancedareasofenquiry,itispossibletoreportonlarge-scaleprospectivestudiesandinterventiontrials,aswellasrobustinstitutionalstudieswithdefinedsub-populationssuchasthoseinworkplaces.Thedifficultyofmeasuringsomeofthecriticalintermediateoutcomes(suchassmallchangesinconsumptionoractivity)combinedwithaverybroadrangeofinvestigationmethodologies,meansthattraditionalhierarchiesbasedonstudydesign,suchasEBMmentionedabove,aregenerallytoobluntaninstrumenttoassessthelikelypotentialforobesityprevention.Theneedtoproceedonthebasisofanimperfectevidencebasealsocallsforaframeworkthatcanadequatelyaccomodatediversesourcesofevidence(inrelationtooutcomesbeingmeasured),aswellasscientificuncertainty.

The‘portfoliomatrix’developedbySwinburnandcolleagues[24],representsoneofthemostpromisingmethodologiesforassistingpolicymakersinjudgingthemeritsofnewpolicysuggestions,inthatitisverymuchdesignedtotakeaccountofthelikelylevelofuncertaintyandbalancethisagainstthepotentialpopulationimpactofanyproposalofinterest.Essentiallyfollowingthesamelogicasafinancialinvestmentportfolio,itprovidesatheoreticalmeansforplanninginterventionsor‘publichealthinvestments’acrossarangeofoptionsinsuchawayastobeabletomaximisereturns.Withinthematrixitself,‘certaintyofeffectiveness’asjudgedonthebasisofexperimentalandobservationalstudies,

23

equatesto‘levelofrisk’andpotentialpopulationimpactisinterpretedasthepotentialscaleofreturnsorbenefitsovertime.Theapproachallowsforastraightforwardcross-tabulationwheretheendjudgementsaboutinterventionsarecategorisedonastepwisescalefrom‘mostpromising’to’leastpromising’(table2.4).Theuseoftheportfoliomatrixisdiscussedfurtherinchapter8,whereithasbeenusedtocategorisetheinterventionscoveredintheevidencereviewsectionsofthisreport.

2.7 Towards a coherent obesity strategy

Themostcomprehensive‘obesityprevention’manifestoproducedtodateatanationallevelisarguablytheUKGovernment’sHealthy Weight, Healthy LivesstrategyforEngland,8firstpublishedin2008.Thedocumentsetsoutfivepriorityareasforgovernmentactionbasedaroundreducingtheconsumptionofhighenergyfoods,incorporatingphysicalactivityintoeverydaylifeandafocusonearlyyears,withtargetedsupportforthosemostatrisk.Swedenhasalsodevelopedanactionplansettingoutaseriesofcostedproposals[25],althoughitismoreastatementofintentionthanasetofplannedinterventions.Thereisalsoanincreasinglysophisticatedbodyofevidencefromobservationalstudies,aroundthepotentialforaddressingenvironmentalfactorsthatcouldpotentiallycontributetoobesitypreventioneffortsbyclosingthesurplusenergygap[26].Anumberofrobuststudiesandreviewshavegonefurtherandlinkedsustainedpopulationweightbenefitswithdeliberateenvironmentalinterventions.Internationalcomparisonshavealsoshownthatevenrelativelyimpoverishedcountriescansubstantiallyimprovetheirpopulation’seatingbehaviours(e.g.Ghanaianimportcontrolsdiscussedinsection5.2)andthetakeupofopportunitiesforincreasingphysicalactivity(e.g.masspubliccyclinginColumbiadiscussedinsection6.4),wherethereisawilltocreatethem.

Thisreportwillpresenttheresultsofarapidliteraturereviewinaformatthatwehopewillbeausefulresourcefordecisionmakersandpolicyanalystsatalllevels.UsingtheANGELOframeworktogetherwiththeportfoliomatrixtocategorisepotentialinterventionsaccordingtosector,settingandnutrition/activityfocus,thereportwillsummarisethecurrentevidenceandprospectsforaseriesofenvironmentalandpolicyoptionsthatcouldbedirectedatobesitypreventioninScotland.Thelevelofscientificcertaintyassociatedwitheachpotentialintervention,willbetabulatedagainstitslikelypopulationimpact,basedonevidenceretrievedfrompublishedstudies,anditslikelytransferabilitytoaScottishcontext.

Certainty of effectiveness*

Potential population impact#

Low Moderate High

High

Moderate

Low

Promising

Lesspromising

Leastpromising

Verypromising

Promising

Lesspromising

Mostpromising

Verypromising

Promising

Table 2.4 Portfolio matrix for categorising potential interventions

*Certaintyofeffectiveness–judgedbythequalityoftheevidence,thestrengthoftheprogrammelogicaswellasthesensitivityanduncertaintyparametersinthemodellingofthepopulationimpact(adaptedfromSwinburnet al,2005[25]).

#Potentialpopulationimpacttakesintoaccountinterventionefficacy(impactunderidealconditions),combinedwith‘real-world’reachanduptakeandgenerallyreflectseffectivenessatthesocietallevel,weightedforrelativebaseline‘burdenofattributableillness’.

8 Healthy Weight, Healthy Lives: A Cross Government Strategy for England. Department of Health (2008); http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082378

Chapter2

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3

25

Chapter3

Chapter3

3 Chapter 3 – The physical environment

3.1 Ecological model for physical environment

Thephysicalenvironmentinthisreviewwillbebroadlyinterpretedascoveringallresidentialandactivityspaceaswellastheconnectionsbetweenthesetwospheres.Foradultsthiswillincludehome,workandrecreationenvironments,aswellasthemeansoftravelbetweenthem.Onerelativelycomprehensiveecologicalmodelwhichillustratesthebasicinterrelationshipsthatconnectaspectsofthebuiltenvironmenttoobesity,isthatproducedbyPowellet alattheUniversityofIllinois(figure3.1):

3.2 Nutrition interventions (macro-level)

Featuresofphysicalsurroundingswhichaffectfoodpurchasingandconsumptionatthemacro-level,includeregionalandnationaldistributionofretailpremisesandothersectorlevelgroupingsofindustries,servicesorsupportinginfrastructure.EarlyobservationalresearchinthisareawasdominatedbyUS-basedstudies,whichshowedthatlowersocioeconomicgroupshadpooreraccesstosupermarketsandbyextensiontoaffordablehealthyfood.Moredeprivedareasalsohadincreasedconcentrationsofsmallergrocerystoresandnonchainsupermarkets,whichtraditionallyhaveapoorerrangeoffreshproduceandwhereitemsaregenerallymoreexpensive[27].PronouncedethnicandracialdisparitiesinaccesswerealsouncoveredintheUSstudies,withethnicminorityareashavingamuchreducedconcentrationofsupermarkets,whichinturnisassociatedwithanincreasedprevalenceofobesity[28].Follow-upinvestigationsof‘fooddesert’areasdemonstratedthatAfrican-Americanfruitandvegetableintakeshowedasignificantstepwiseincreasewitheachadditionalsupermarketinthelocalcensustract(e.g.fortwoormoresupermarketswithincensustrack,thelikelihoodofAfrican-Americansconsumingfruitandvegetableswasovertwo-foldhigherRR=2.18;95%CI:1.57to3.03)[29].Converselyneighbourhoodswithhigherlevelsofethnicityandsocialdeprivationalsohadhigherconcentrationsoffastfoodrestaurants[30].Inastatelevelcross-sectionalanalysis,Maddockfoundasignificantcorrelationbetweenthenumberofresidentsperfastfoodoutletandobesityprevalence(r=-0.53;P<0.001)[31].

Chapter3

Figure 3.1 Ecologicalmodelrelatingthephysicalenvironmenttophysicalactivity,dietandbodyweight,BMI(bodymassindex)9.

9 Reproduced with the permission of Lisa Powell et al, Bridging the Gap Program Office, Institute for Health Research and Policy, University of Illinois at Chicago http://www.impacteen.org/otherpapers.htm.

BMI(Bodyweightstatus)

IndividualFactors

SocialFactors

Genetics

SocioeconomicCharacteristics

FamilyandPeerInfluences

FoodConsumption(EnergyIntake)

PhysicalActivity(EnergyExpenditure)

OtherIndividualCharacteristics

EnvironmentalFactorsLifestyle/BehaviouralFactors

BuiltEnvironment

EconomicInfluences(costandaccess)

NeighbourhoodSafety(perceived/objective)

Transportationopportunities

BEHAVIORS

BEHAVIORS

26


Inspiteofgovernmentdeclarationsandpolicyannouncementstothecontrary[32],attemptstoextrapolatethe‘fooddesert’hypothesistoaUKsettinghavefoundthesituationtobealotlessclearcut.AlthoughonereportfrominnerLondondiddemonstraterestrictedaccesstorecommendedfoodsinmoredeprivedareas[33],largerscalestudiesinothermajorcitiesdidnotfindanysignificantassociation.AFoodStandardsAgencycommissionedreportin2004,foundthatthevastmajorityofhouseholdsinamajorcityinthenortheastofEngland,didtheirfoodshoppingatlargesupermarketsandthatlocalretailprovisionwasnotakeydeterminantofdietquality[34].AmorerecentGlasgowbasedstudy[35],foundthatthemostdeprivedquintileofareashadthegreatestmeannumberoftotalfoodretailersper1,000residents,whilequintile1(leastdeprived)hadtheleast.Inrelationtotypesofoutlet,theinvestigatorsalsofoundnosignificantdifferencesbetweenthemeannumbersofbakers,fruitandvegetableshops,fishmongers,supermarketsordelicatessensper1,000residents.Theyalsonotedhowever,thatvariationwithintheircategoriesofpremisescouldnotberuledoutandthatfurtherworkwasongoingtocharacterisemorefullythenutritionalvalueoffoodsfromdifferenttypesofoutlet.

AlthoughthedensityoffastfoodoutletswasnotassociatedwithdeprivationinGlasgow[36],across-sectionalsurvey,whichfocusedontwelvefreshfruitandvegetableitemsin288foodstoresfromtencommunitiesacrossScotland,foundthatthefreshproduceinmoredeprivedareastendedtobeofalowerquality[37].Thesurveyalsoexaminedvariationbystoretypeandbyrural-urbanlocation,thesecondofwhichhasparticularrelevanceoutsideofScotland’scentralbeltandisoftenoverlookedinstudiesofthistype.Althoughtheoverallqualityoffruitandvegetableswashigh,therewasanotablevariabilitybystoretypeandlocationwiththebestqualityfoundinmediumsizedstores,storesinsmalltownsandinruralareas,aswellasthoseinmoreaffluentareas.Whilenotalldifferencesinqualitywerestatisticallysignificant,thepatternswereconsistentforthemajorityofthetwelveselectedfruitandvegetableitems[37].

Aquasi-experimentalstudyintheeastendofGlasgowsoughttoassesstheeffectsofnewlargescaleretailprovisiononthepurchasingfrequenciesoffruitandvegetables[38].Theauthorswerenotabletoreplicatefindingsfromanearlieruncontrolledstudyandtherewasnoevidenceforanetinterventioneffectonfruitandvegetableconsumption,althoughalowresponsetotheinitialquestionnaire(lessthan20%)andarelativelyhighbaselineconsumptionleveloffruitandvegetables,gaverisetodoubtsoverthecapacityofthesurveyinstrumenttodetectanincrease.Intriguingly,fromtheresultsongeneralhealthmeasures,therewasasignificantreductionintheprevalenceof‘fairtopoor’and‘poor’self-reportedpsychologicalhealthintheinterventiongroupasassessedbythestandardhealthsurveytoolGHQ-12.Ontheotherhand,regression-to-the-meanand'attentionor'learning'effectscannotberuledoutwiththisstudydesign.

Neighborhoodwalkability(highvslow)a

High

Low

Densityoffastfoodrestaurants(highvslow)b

Weight(kg) Waistcircumference(cm)

High Low High Low

Table 3.1 Study participants (N=1,145) measure of weight and waist circumference at baseline (2006–07) by neighborhood walkability and density of fast food restaurants

82.83 84.08 96.09 98.54

88.46 85.43 100.36 98.62

(Source:Li,Harmer&Cardinalet al,2009[39])

a Defined by percentile scores: high walkability= 75th percentile, low walkability=<75th percentile; high=34 neighbourhoods, low=86 neighbourhoods.b Defined by percentile scores: high density= 75th percentile, low density=<75th percentile; high=30 neighbourhoods, low=90 neighbourhoods.

27

ReturningtoUS-basedevidence,arecenthighlypoweredfollow-upstudyreportedonactualweightchangesoverthecourseofoneyear,inrelationtobothfeaturesoftheneighbourhoodenvironmentandunderlyingbehaviouralpreferences[39].Specifically,amongpeoplewhoreportedfrequentvisitstofastfoodoutlets,residenceinaneighbourhoodwithahighdensityoffastfoodoutletswasassociatedwithasignificantincreaseinweight(mean=+1.4kg)andwaistcircumference(mean=+2.06cm)(table3.1).Whilethestrengthofevidenceisgreaterthanforcross-sectionalstudiesandservestohighlightthesubtleinterplaybetweenbehaviouralandenvironmentalfactors,thereisstillthepotentialforself-selection,wherethoseinclinedtowardslesshealthierbehavioursseekoutsurroundingsthatwillsupportthosechoices[40].Asimilarchickenandegg‘feedback’conundrumsurroundsthelikelytendencyofshopssellingunhealthyfoodstolocatethemselvesinmoredeprivedareas,ormodifytheirstockaccordingtolocaldemand[41].Thefollowingsectiononmicro-foodenvironments(3.3)picksuponsomeoftheseissues.

Summary

Nutritioninterventions(macro-level)

• HigherdensitiesoffastfoodoutletsinsociallydeprivedandinAfrican-AmericanneighbourhoodsintheUS,arenotseentothesameextentinrelativelydeprivedareas/predominantlyethnicminoritylocalitiesofUKtownsandcities.

• PhysicalproximitytoaffordablefoodchoicesdoesnotappeartobeastrongdeterminantofahealthydietinUKsettings,althoughthereissomeevidenceforScotlandthatlocalvariationsinthequalityofavailablefreshproducemayinfluencedietaryintake.

• AnimprovinginternationalandUKevidencebaseinthisareaclearlydemonstratesaninfluenceonspecifiedweightoutcomesoflocalenvironmentalcharacteristics,butonlyinsofarastheyfacilitateorexacerbateexistingpreferencesandbehaviours.

3.3 Nutrition interventions (micro-level)

Glanzet aldescribefourbroadsettingsintheirecologicalmodeloffoodavailabilityandchoices[42],thesebeing:(i)community,(ii)organisational,(iii)consumerand(iv)information‘nutritionenvironments’.Sinceconsumer(retail),communityandinformationaspectsarediscussedelsewhereinthisreport,thecurrentsectionwillfocusonwhattheycollectivelyrefertoasthe‘organisationalnutritionenvironment’whichencompasseshome,work,educationalsettingsandother‘definedenvironments’suchasrestaurantsandtakeaway/fastfoodvendors.Thefocushereisonthetypesoffoodanditsnutritionalvalueasopposedtothelocationanddensityofoutletsperheadofpopulation,whichwasdiscussedpreviouslyundermacro-levelfactorsin3.2.Theimportantinfluenceofportionsize(mainlyinrestaurants)hasalsobeenthesubjectofanumberofwellconductedstudies,thefindingsofwhichneedtobeconsidered.Inrelationtoadultobesitypreventionandmicro-foodenvironments,threeadditionalsubheadingsarehelpfultoorganisethemajorfindings,thesebeing:(i)restaurantsandfastfoodpremises;(ii)portionsizeandenergydensity;and(iii)educationalsettingsandworkplaces.

Chapter3

28


i. Restaurants and fast food outlets

AlmostonethirdofallmealsconsumedbyBritishadultsareconsumedoutsidethehome[43],aproportionwhichhasbeenrisingsteadilyoverthelastthirtyyearsandissimilartothatseenintheUS[44].Whilefastfoodmealsareknowntobetypicallyhighinenergydensity,foodconsumedatfullservicerestaurantscanbeashighorhigherinfat,sugarandsalt.Consumernutritionenvironmentswithinrestaurantsandotherfoodcateringpremisesareobviouslysubjecttosubstantialvariability,dependingonthetypeofestablishmentandtargetcustomergroup,althoughgenerallyspeakingtheresearchinthisareaislimited.Partlyinrecognitionoftherestaurantknowledgegap,Saelensatalrecentlydevelopedanutritionalsurveillance/assessmenttoolforusewithcommercialcateringpremisesandusedittocharacterise217sitdownrestaurantsandfastfoodoutletsacrossseveralUSstatesin2004and2005[45].Thetwotypesofpremisesdifferedonmanynutritionenvironmentvariables,demonstratingthatthefrequentpracticeofnotconsideringthemseparatelycouldbeconcealingmeaningfulvariation.Fastfoodoutletsforinstancehadhealthierscoresonseveralitemsthansitdownrestaurants,includingtheavailabilityofhealthystartersormaindishsalads.Fastfoodoutletswerealsomorelikelytodisplaysignageprovidingnutritioninformationandpromotinghealthyoptions,butequally,weremorelikelytohavedisplayspromotingunhealthyeatingandovereating.Whilesitdownrestaurantsweresomewhatmorelikelytohavehealthierindividualitemoptions,fewerthan9%oftheirmaindishesand12%oftheirsaladmaindisheswereconsideredhealthyintheSaleanspilotstudy.Theauthorsalsohighlightedverylowratesofinformationprovisiononthenutritionalvalueofmenuitems.Thiscouldconceivablyexacerbateover-consumptioninrestaurantswherethereisevidencethatconsumersroutinelyunderestimateenergyandfatcontent,especiallyofstarterdishes[46].

ii. Portion size and energy density

Steadilyincreasingfoodportionsizesinbothout-of-homeeatingenvironmentsandcommerciallypre-preparedmeals,arewidelyconsideredtohavecontributedtorisingobesitylevels,particularlyintheUSandotherdevelopedeconomies[47]andseveralwellconductedstudieshaveconfirmedtheinfluenceofincreasingportionsizeonincreasedconsumption[48].ThereviewbyEllo-Martinandcolleaguesalsohighlightedstudieswhichhadconsideredtheinteractionsbetweenportionsizeandenergydensityandfoundthemtohaveindependenteffectsthatcombinesynergisticallytoaffectoverallenergyintake.Specifically,restaurantdinersconsumedthemostenergywhenservedthelargestportionofthehighestenergydensestarter-mealandtheleastwhenservedthesmallestportionofthelowestenergydensestarter,despitetheirbeingnodifferencesinself-ratedhunger,orfullnessbetweenthetwoconditions(seefigure3.2)[49].

Figure 3.2 Mean±SEMmealenergyintakeafterconsumptionofcompulsoryfirstcoursesaladsthatdifferedinportionsize(ingrams)andenergydensity(inkilojoulespergram).Differenceinmealintakecomparedwithconsumingnosalad:*p<0.05;***p<0.0001.

31

Figure 3.2 Mean ± SEM meal energy intake after consumption of compulsory first course salads that differed in portion size (in grams) and energy density (in kilojoules per gram). Difference in meal intake compared with consuming no salad: *p< 0.05; ***p < 0.0001. (Rolls et al, 2004) [49].

The apparent independence of these influences with respect to fullness does, the authors suggest,

indicate that smaller size portions of less energy dense dishes need not affect satiety and could

present a useful means of reducing energy intake in restaurants. Steenhuis and Vermeer recently

confirmed the clear relationship between portion size and energy intake in a 2009 review across a

wide range of settings [50], but regretted that so far there have been relatively few intervention

studies to examine the effectiveness of reducing portion size. They cite a qualitative study of

consumer attitudes which found that the provision of a wider range of portion sizes and prices was

the most acceptable ‘facilitator’ of lower energy intake [51]. They also recognise however that the

effectors of larger portion sizes are integrated into many aspects of the food, consumer and

behavioural environments, as well as being underpinned by commercial imperatives and economic

considerations. As a result, their suggested model for implementing food portion interventions

employs a similar multi-level framework as the current report, covering individual, physical,

economic, legislative and sociocultural factors.

iii. Educational settings and workplaces

In spite of recent high profile one-offs such as the banning of trans fats in New York catering

establishments [52], the extent to which nutritional environments in commercial food premises are

subject to controls and restrictions is always going to be fairly limited within the current liberal

political climate. Thankfully, there are other major types of organisational setting where there is a

greater scope for providing a healthier range of options, the most notable and most researched

being schools (and other educational establishments) and workplaces. Environmental changes in

(Source:(Rollset al,2004)[49]).

29

Theapparentindependenceoftheseinfluenceswithrespecttofullnessdoes,theauthorssuggest,indicatethatsmallersizeportionsoflessenergydensedishesneednotaffectsatietyandcouldpresentausefulmeansofreducingenergyintakeinrestaurants.SteenhuisandVermeerrecentlyconfirmedtheclearrelationshipbetweenportionsizeandenergyintakeina2009reviewacrossawiderangeofsettings[50],butregrettedthatsofartherehavebeenrelativelyfewinterventionstudiestoexaminetheeffectivenessofreducingportionsize.Theyciteaqualitativestudyofconsumerattitudeswhichfoundthattheprovisionofawiderrangeofportionsizesandpriceswasthemostacceptable‘facilitator’oflowerenergyintake[51].Theyalsorecognisehoweverthattheeffectorsoflargerportionsizesareintegratedintomanyaspectsofthefood,consumerandbehaviouralenvironments,aswellasbeingunderpinnedbycommercialimperativesandeconomicconsiderations.Asaresult,theirsuggestedmodelforimplementingfoodportioninterventionsemploysasimilarmulti-levelframeworkasthecurrentreport,coveringindividual,physical,economic,legislativeandsocioculturalfactors.

iii. Educational settings and workplaces

Inspiteofsomerecenthighprofileone-offssuchasthebanningoftransfatsinNewYorkcateringestablishments[52],theextenttowhichnutritionalenvironmentsincommercialfoodpremisesaresubjecttocontrolsandrestrictionsisalwaysgoingtobefairlylimitedwithinthecurrentliberalpoliticalclimate.Thankfully,thereareothermajortypesoforganisationalsettingwherethereisagreaterscopeforprovidingahealthierrangeofoptions,themostnotableandmostresearchedbeingschools(andothereducationalestablishments)andworkplaces.Environmentalchangesinsuch‘captivepopulation’spacesareessentiallyaboutmakinghealthierchoicesmoreattractivethantheusualordefaultmoreobesogenicoption(seefigure3.3).

(Source:Andersonet al,2009[53])

Figure 3.3 Analyticalframeworkforworksitenutritionandphysicalactivityinterventions,toimproveweightstatus.

32

such ‘captive population’ spaces are essentially about making healthier choices more attractive than

the usual or default obesogenic option (see figure 3.3).

Figure 3.3 Analytical framework for worksite nutrition and physical activity interventions, to improve weight status. (Source: Anderson et al, 2009 [53])

Greater control over ‘exposures’ also means of course that such environments are more amenable

to research orientated interventions. The two drawbacks from the point of view of this report are,

firstly, that evidence from schools is not likely to be easily transferable to adult settings and

secondly, that the vast majority of workplace studies are based in the US. In spite of these concerns,

the literature around such ‘contained interventions’ remains relatively robust, consisting of a

number of well conducted studies and, as such, it is important not to overlook.

In a comprehensive Canadian review of the evidence around urban environments and healthy

weight, 71 notable findings were described in relation to physical settings and food/diet/nutrition, of

which 58% dealt with school environments [18]. While the most useful positive findings related to

price and behavioural interventions (to be discussed in sections 4.2 and 6.4), straightforward

availability factors also exerted a significant effect on dietary quality. Specifically, there were adverse

negative associations between diet quality and the provision of á la carte menus, the availability of

snack vending machines and the availability of fried potatoes. A recent systematic review of

workplace dietary interventions by Ni Mhurchu and colleagues [54] found that workplace

interventions are associated with moderate improvements in dietary intake. They also noted that

there was currently a lack of well designed research studies that could reliably be used to inform

Chapter3

30


Greatercontrolover‘exposures’alsomeansofcoursethatsuchenvironmentsaremoreamenabletoresearchorientatedinterventions.Thetwodrawbacksfromthepointofviewofthisreportare,firstly,thatevidencefromschoolsisnotlikelytobeeasilytransferabletoadultsettingsandsecondly,thatthevastmajorityofworkplacestudiesarebasedintheUS.Inspiteoftheseconcerns,theliteraturearoundsuch‘containedinterventions’remainsrelativelyrobust,consistingofanumberofwellconductedstudiesand,assuch,itisimportantnottooverlook.

InacomprehensiveCanadianreviewoftheevidencearoundurbanenvironmentsandhealthyweight,71notablefindingsweredescribedinrelationtophysicalsettingsandfood/diet/nutrition,ofwhich58%dealtwithschoolenvironments[18].Whilethemostusefulpositivefindingsrelatedtopriceandbehaviouralinterventions(tobediscussedinsections4.2and6.4),straightforwardavailabilityfactorsalsoexertedasignificanteffectondietaryquality.Specifically,therewereadversenegativeassociationsbetweendietqualityandtheprovisionofálacartemenus,theavailabilityofsnackvendingmachinesandtheavailabilityoffriedpotatoes.ArecentsystematicreviewofworkplacedietaryinterventionsbyNiMhurchuandcolleagues[54],foundthatworkplaceinterventionsareassociatedwithmoderateimprovementsindietaryintake.Theyalsonotedthattherewascurrentlyalackofwelldesignedresearchstudiesthatcouldreliablybeusedtoinformestimatesofeffectivenessandcosteffectiveness.Inparticular,thereisaneedtoaddresstheeconomic,policyandsocioculturalaspectsoftheworkenvironmentwhichimpactondiet.Workcanteensforinstance,whichincorporateanelementoffoodsubsidisation,offeranidealenvironmentinwhichtotestthepotentialofeconomicincentivestochangefoodpurchasingbehaviour[55].AseriesofstudiesbySimoneFrenchandcolleagueswhichfocusspecificallyonworkplacepriceincentivesisdiscussedinchapter4.Therehavealsobeenseveralotherrecenthighqualityreviewsspecificallydealingwithhealthinitiativesinaworkenvironmentsetting,twoofwhichfocusonobesityprevention[53,56]withthemostrecentadoptingabroad-basedhealthpromotionapproach[57].Inthefirstofthereviews,sevenseparatestudiesfundedbytheNationalHeartBloodandLungInstitute(NHBLI)intheUS,involvingatotalof114workplaces,werereviewedbyPrattet al[56].Thenutritionfocusedenvironmentalstrategiesincludedreducingportionsizesandmodifyingcafeteriarecipestolowerfatcontents.

Fromanobesitypreventionperspective,aparticularlypromisingfeatureofthedesignoftheNHBLIstudies,wastheirstatedprimaryoutcomemeasureofchangesinBMIorbodyweightaftertwoyearsofintervention.Theobservedchangesineitheroftheseindiceshowever,didnotrevealanyconsistentpatternofassociationinresponsetoenvironmentalinterventions.Theassumptionthatpeoplewillloseweightastheyincreasetheirconsumptionofhealthysnacksalsodependsofcourseonsubstitution,inthatthenewsnackchoiceisdirectlyreplacingamoreenergydenseoption.

TheWork,WeightandWellness(3W)Studywasagrouprandomisedclinicaltrialofamulti-componentinterventionprogramconductedovertwoyearsat30hotelsites,including11,559employeesontheIslandofO’ahuinHawaii[58].Usingavalidatedenvironmentalchecklistforworkplacehealthpromotioncomponents(theCHEWprotocol10),therewerenooverallmediumorlargecorrelations(table3.2)withanyofthesixenvironmentalvariablesthathadbeenincluded(activitysigns,numberofstairs,stairfacilitation,lunchroomnutrition,hotelnutritionsignsandhealthyeatingprompts/posters).Stratificationbyhotelsizehowever,didrevealseveralsignificantcorrelations,thesebeingpositive(i.e.associatedwithincreasedBMI)inmedium-sizedhotelsfornumberofstairs,stairfacilitationandhealthyeatingvariables(table3.2).Negativecorrelations(i.e.associatedwithdecreasedBMI;0.50to1.00),wereonlynotedforstairfacilitationinsmall-sizedhotelsandlunchroomsignsinlarge-sizedhotels.Itisalsoworthbearinginmindthatthemultitudeoftestsinthisstudydoesraiseconcernsoverhowmanysignificantcorrelationsmightthemselveshavearisenbychance.

10 Checklist of Health Promotion Environments at Work (CHEW). http://www.drjamessallis.sdsu.edu/measures.html

31

Chapter3

AlthoughtheuseofthehotelastheunitofBMIanalysisremainsarecogniseddrawbackwiththisstudy(sincestratificationbyemployeecharacteristicsmighthavebeenmoreinformative),theauthorswereneverthelesssurprisedtofindrealcorrelationswithBMI,sinceenvironmentalindicatorsintheCHEWchecklistareexpectedtobelinkedinthefirstinstancetoproximaloutcomessuchasactivityandhealthyeating.ThesefindingsforBMItherefore,suggestthatthesameenvironmentalfactorsarecapableofexertingasignificantinfluenceontherelevantunderlyingbehavioursofhealthyeatingandphysicalactivity.

Andersonet alfoundstillmoreencouragingresultswithregardtochangesinbodyweight/BMIinacomprehensivesystematicreviewofworkplaceinterventionspublishedundertheUSCentreforDiseaseControls’(CDC)highlyregardedguidetocommunitypreventativeservicesprogramme[53].Specifically,apooledeffectestimateof-2.8Ibs(95%CI:-4.6to-1.0)wasderivedfromninerandomisedcontrolledtrials(RCTs)(seefigure3.3)andadecreaseinBMIof-0.5(95%CI:-0.8to-0.2)fromsixRCTs(seetables3.2aand3.2b).Themeta-analysiscomponentofthisreviewisparticularlyusefulandarareadditiontoreviewsofobesityprevention,duetothepreviouslymentionedcomplexityofthefieldandheterogeneityofprimaryoutcomesacrossstudies.ThepooledeffectfromthethreeRCTswhichfocusedonphysicalbehavioursalonewas-2.24Ibs(95%CI:-6.49to+2.00)comparedwith-3.18Ibs(95%CI:-5.88to-0.50)infiveRCTswherebothphysicalactivityanddietarybehaviourswereaddressed.

TheintrinsicdifficultiesinseparatingoutdietandexerciseeffectsarealsoillustratedbytheNHBLItrials,whichhadthelargesteffectsize(pooledeffectof-10.33Ibsina12-monthinterventionformiddleagedmenwithBMIover25)[59].Inthisstudy,thebenefittothegrouponalowfatdietwastwicethatofthegroupadvisedtoengageinunsupervisedmoderateexercise.Forthereviewasawhole,theauthorswereunabletodrawfirmconclusionsaboutanydifferentialeffectsbyprogrammefocus(activityordiet)orprogrammecomponent(environmental,policy,informationorskills).

Table 3.2 Correlations for environmental variables in relation to BMI

(Source:Nigget al,2010[58])

PAsigns

Overall

Size

<100

100-500

>500

Union:No

Yes

Mean(SD)1.30(2.74)

1.00(1.50)1.17(3.46)

1.78(2.76

1.29(2.85)1.33(2.65)

r-BMI-0.07

0.11

0.07

-0.65*

0.01

-0.45#

r-BMI0.15

0.27

0.46

-0.18

0.21

0.07

r-BMI-0.21

-0.59*

0.35#

-0.20

-0.26

-0.09

r-BMI-0.12

-0.20

0.22

-0.60*

-0.16

-0.28

r-BMI0.09

-0.20

0.14

-0.46#

-0.12

-0.18

r-BMI0.17

0.21

0.35*

0.23

0.05

0.52*

Mean(SD)4.63(3.02)

3.00(1.12)4.17(2.69)6.89(3.59)

3.57(1.86)7.11(3.82)

Mean(SD)3.49(0.91)

3.81(0.99)3.36(0.80)3.34(0.98)

3.62(1.01)3.18(0.54)

Mean(SD)0.47(0.90)

0.11(0.33)0.33(0.65)1.00(1.32)

0.24(0.54)1.00(1.32)

Mean(SD)0.63(1.27)

0.11(0.33)0.50(1.00)1.33(1.87)

0.38(0.92)1.22(1.79)

Mean(SD)3.11(1.23)

03.39(0.53)2.91(0.92)3.11(1.99)

2.98(0.94)3.41(1.78)

NumberofStairs

StairFacilitation

LunchroomNutritionSigns

HotelNutritionSigns

Healthyeating

facilitation

Correlationcoefficient(r)interpretationguide:small=0.10to0.029;#medium=0.30to0.49;*large=0.50to1.00

32


Table 3.3a Impact on weight in Ibs at 6–12 months in 9 RCTs

Table 3.3b Impact on BMI at 6–12 months in 6 RCTs

(Source:Andersonet al,2009[53]Ms=differenceinmeanbodyweight(Ibs)

(Source:Andersonet al,2009[53]Ms=differenceinmeanBMI(kg/m2))

35

middle aged men with BMI over 25) [59]. In this study, the benefit to the group on a low fat diet was

twice that of the group advised to engage in unsupervised moderate exercise. For the review as a

whole, the authors were unable to draw firm conclusions about any differential effects by

programme focus (activity or diet) or programme component (environmental, policy, information or

skills).

Table 3.3a Impact on weight in Ibs at 6–12 months in 9 RCTs. (Source: Anderson et al, 2009 [53]) Ms=difference in mean bodyweight (Ibs) (P values not reported)

bold type and =overall estimate

Table 3.3b Impact on BMI at 6–12 months in 6 RCTs. (Source: Anderson et al, 2009 [53]) Ms=difference in mean BMI (kg/m2) (P values not reported)


Multi-component approaches and structured programmes were more beneficial in general than

single component and unstructured (self directed approaches). The very marginal benefits seen in a

recently published, hospital-based (RCT cluster design) multi-component intervention, which was

also part of the NHLBI funded workplace programme, are somewhat less encouraging [60]. Lemon et

al found no impact of the intervention on change in BMI where the estimated group difference was

0.272 (95% CI: -0.271 to 0.782) at 12 months and 0.276 (95% CI: -0.338 to 0.890) at 24 months. The

35

middle aged men with BMI over 25) [59]. In this study, the benefit to the group on a low fat diet was

twice that of the group advised to engage in unsupervised moderate exercise. For the review as a

whole, the authors were unable to draw firm conclusions about any differential effects by

programme focus (activity or diet) or programme component (environmental, policy, information or

skills).

Table 3.3a Impact on weight in Ibs at 6–12 months in 9 RCTs. (Source: Anderson et al, 2009 [53]) Ms=difference in mean bodyweight (Ibs) (P values not reported)


Table 3.3b Impact on BMI at 6–12 months in 6 RCTs. (Source: Anderson et al, 2009 [53]) Ms=difference in mean BMI (kg/m2) (P values not reported)


Multi-component approaches and structured programmes were more beneficial in general than

single component and unstructured (self directed approaches). The very marginal benefits seen in a

recently published, hospital-based (RCT cluster design) multi-component intervention, which was

also part of the NHLBI funded workplace programme, are somewhat less encouraging [60]. Lemon et

al found no impact of the intervention on change in BMI where the estimated group difference was

0.272 (95% CI: -0.271 to 0.782) at 12 months and 0.276 (95% CI: -0.338 to 0.890) at 24 months. The

Multi-componentapproachesandstructuredprogrammesweremorebeneficialingeneralthansinglecomponentandunstructured(selfdirectedapproaches).Theverymarginalbenefitsseeninarecentlypublished,hospitalbased(RCTclusterdesign)multi-componentintervention,whichwasalsopartoftheNHLBIfundedworkplaceprogramme,aresomewhatlessencouraging[60].Lemonet alfoundnoimpactoftheinterventiononchangeinBMIwheretheestimatedgroupdifferencewas0.272(95%CI:-0.271to0.782)at12monthsand0.276(95%CI:-0.338to0.890)at24months.Thepredominantenvironmentalinterventionsemployedcouldcertainlybedescribedas‘lowintensity’,howeverwithcafeteriasigns(andstairwaysigns)beingthemostfrequentmeasures.Lastlyofcourseanover-relianceonworkplaceinterventionstopreventandcontrolobesity,runstheobviousriskofexcludingthosenotinregularemployment,whoforavarietyofreasonscanbeatincreasedriskofapoordietandlowlevelsofphysicalactivity.Thehealthinequalitiesdimensiontoobesityisdiscussedfurtherinsection8.6.

33

Summary

Nutritioninterventions(micro-level)

• Theclearestassociationsforincreasedfoodenergyconsumptioninrestaurantsandothercateringoutletshavebeenforincreasesinservingportionsizeandenergydensity.

• Asastrategyforreducingoverallconsumption,consumersandrestaurantgoershaveexpressedconsistentpreferencesforawiderrangeofportionsizestobemadeavailable,althoughitdoesnotnecessarilyfollowthatthiswillresultinmorechoosingsmallerportions.

• Inspiteofvariablestudyquality,workplaceenvironmentalinterventions,includingincreasedhealthyfoodavailabilitywithinformation,havenowbeendemonstratedtoresultinsignificantmeanreductionsinBMIandbodyweightfortargetedgroupsofworkers,acrossawiderangeofemploymentsectors.

• Perhapsunsurprisingly,andinkeepingwithecologicalmodels,multi-componentandmoreintensivelystructuredinterventionsareassociatedwiththebestoutcomesintheworkplace,althoughsocioculturalaspectsremainunderresearched.

• Separatingoutthecontributionsofmultipleprogrammecomponentscanbehighlyproblematicandisalsolikelytobefurthercomplicatedbyindividualvariabilityinresponsivenesstodifferentmeasures.

• Lowintensityenvironmentalinterventionsbythemselves(e.g.informationnoticesonhealthyeating),havelimitedbenefitswithinworkplacesettings.

3.4 Physical activity interventions (macro-level)

Thewidespreadinternationalconsensus,thatincreasingpopulationlevelsofphysicalactivitywillrequiremorethanmerelyeducatingindividuals,hasstimulatedconsiderableresearchinterestinthecapacityofthebuiltenvironmenttoencourageactiveliving[61].Specifically,transportationinfrastructureswhichheavilyfavourprivatecartravel,landusezoningpolicieswhichintroduceprohibitiveseparationdistancesforwalkingandcycling,andaninequitabledistributionofwellmaintainedparksandrecreationfacilities,areallbelievedtocontributetoinadequatelevelsofphysicalactivityinmanyurbanareas[62].Thissectionwillbrieflyreviewthemajorcorrelationstudiesthathavehelpedclarifytherelativestrengthsoftheseenvironmentalassociations,includingtheextenttowhichtheymightapplyinScotland.Forthepurposesofthisreview,allcharacteristicsoftheexternalurbaninfrastructuresuchaslanduseandtransportationroutesareconsideredtobemacro-levelfeatures.Designfeatureswithinbuildings,campusesorlargeinstitutionssuchashospitalswillbeconsideredinturnasmicro-levelcharacteristics.Anadditionaldistinctionbetween‘leisurebased’or‘recreational’physicalactivityandphysicalactivitythatisintegraltodailyliving/working/travelhasalsoprovenusefulincategorisingthepublishedevidence.

Investigatingthepotentialenvironmentaldeterminantsofobesityisstillarelativelynewfield,withfewpublicationsbeforetheyear2000.Theoneaspectwhichcontinuestoimprove,fromanexposureassessmentperspective,isthedegreeofsophisticationwithwhichbuiltenvironmentmeasurementsaremade.Figure3.4showsthecontinuumofmethodsforassessmentpresentedbyBoothet alintheirwiderangingreview:

Chapter3

34


(Source:Boothet al,2005[63])

Figure 3.4 Continuumofmethodsformeasuringthebuiltenvironment.

37

the extent to which they might apply in Scotland. For the purposes of this review, all characteristics

of the external urban infrastructure such as land use and transportation routes are considered to be

macro-level features. Design features within buildings, campuses or large institutions such as

hospitals will be considered in turn as micro-level characteristics. An additional distinction between

‘leisure based’ or ‘recreational’ physical activity and physical activity that is integral to daily

living/working/travel has also proven useful in categorising the published evidence.

Investigating the potential environmental determinants of obesity is still a relatively new field, with

few publications before the year 2000. The one aspect which continues to improve, from an

exposure-assessment perspective, is the degree of sophistication with which built environment

measurements are made. Figure 3.4 shows the continuum of methods for assessment presented by

Booth et al in their wide ranging review:

Figure 3.4 Continuum of methods for measuring the built environment. (Source: Booth et al, 2005 [63]). i . Recreational physical activity

In one of the typical early Australian studies, Giles-Corti et al [64] made use of both indirect and

intermediate measures (figure 3.4) to show that, while controlling for social group and demographic

factors in healthy working Australian adults, those who were overweight were more likely to live

near highways. Both overweight and obese adults were also more likely to live in areas that lacked

adequate sidewalks and nearby places for physical activity, with subjects without good access to

recreational facilities having a 68% greater chance of being obese. Saelans et al [65] followed this up

with one of the first investigations to use direct measures of activity (personal accelerometers) to

find that residents of more ‘walkable’9

9 Assessed using an eight item walkability index called the Neighbourhood Environment Walkability Scale (NEWS) available at http//www.drjamessallis.sdsu.edu/NEWSpdf

neighbourhoods engaged in 52 more minutes of weekly

physical activity and had lower body weights.

i . Recreational physical activity

InoneofthetypicalearlyAustralianstudies,Giles-Cortiet al[64]madeuseofbothindirectandintermediatemeasures(figure3.4)toshowthat,whilecontrollingforsocialgroupanddemographicfactorsinhealthyworkingAustralianadults,thosewhowereoverweightweremorelikelytolivenearhighways.Bothoverweightandobeseadultswerealsomorelikelytoliveinareasthatlackedadequatesidewalksandnearbyplacesforphysicalactivity,withsubjectswithoutgoodaccesstorecreationalfacilitieshavinga68%greaterchanceofbeingobese.Saelanset al[65]followedthisupwithoneofthefirstinvestigationstousedirectmeasuresofactivity(personalaccelerometers),tofindthatresidentsofmore‘walkable’11neighbourhoodsengagedin52moreminutesofweeklyphysicalactivityandhadlowerbodyweights.

Betteraccesstoqualitygreenspacehasalsobeenassociatedwithincreasedwalkingandphysicalactivity,andproximalaccesstoparksandrecreationalfacilitieshasasignificantimpactonexercisebehaviouracrossallagegroups[66].Theaddition,forexample,ofonefitnessfacilityper1,000peopleperzipcodeandmaximum‘mixedlanduse’areassociatedwitha1.39and2.60kg/m2decreaseinBMIrespectivelyamonglowincomewomenintheUS[67].AmorerecentAustralianstudy[68]foundthat,foreachinterquartileincreasein‘urbansprawl’,theoddsratiosofbeingoverweight(aftercontrollingforindividualandareaco-variates),were1.26(95%CI:1.10to1.44)and1.38(95%CI:1.10to1.44)forbeingobese.Similarincreasedoddsratioswerereportedforthemediatoroutcomesofinadequatephysicalactivity1.38(CI:1.21to1.57)andfor‘notspendinganytimewalkinginthepreviousweek’1.58(CI:1.28to1.93).

Franket al[69]confirmedtheimportanceofattitudesinfindingthat,forAtlantaresidentswhoprefercarorientatedsurroundings,theavailabilityofalocalwalkableenvironmentmadelittledifferencetotheiractivitylevelsorobesityprevalence.Incontrast,individualswhobothpreferredandlivedinwalkableenvironmentswalkedthemost,drovetheleastandhadanobesityprevalence(at11.7%)ofabouthalfofthosewhopreferredmorecarorientatedneighbourhoods(21.6%).TheintroductionofalongitudinalcomponentinaHarvardAlumnistudy[70]increasedthelevelofsophisticationbylookingforchangesinactivitylevelsinresponsetochangesinresidenceandtherefore‘exposure’.Whilecomparablesignificantassociationswerefoundforsprawlandactivityasinpreviousstudies,thefollowupworkwithpersonswhomoved,didnotdemonstrateanyincreaseinphysicalactivityordecreasedBMIforreductionsinurbansprawl.Theselatterfindingswerecertainlylimitedbythesmallnumbersofmenchangingresidenceandwhatintheendweremostlymarginalchangesinassociatedlevelsofsprawl.Thisislikelytobea

11 Assessed using an eight item walkability index called the Neighbourhood Environment Walkability Scale (NEWS) available at http//www.drjamessallis.sdsu.edu/NEWSpdf

35

Chapter3

reflection,theauthorsconcede,ofpeople’spreferencesformovingtocomparableareas,therebyalsoillustratingtheproblemofself-selection,whichremainamajorthreattovalidityinallstudiesofthistype.

Lastly,thePortlandneighbourhoodenvironmentstudydeservesfurthermention,sincejustastheylinkedfoodenvironmentfeatureswithbehaviourmediatedchangesinweightstatus,Liet alalsodidthesameforlocalwalkabilitycharacteristics[39].Specifically,highwalkabilityneighbourhoodswereassociatedwithdecreasesof1.2kginweight(P<0.05)and1.57cminwaistcircumference(P<0.05)amongresidentswhoincreasedtheirlevelsofvigorousphysicalactivityduringthe1-yearassessmentperiod.ThissubgroupspecificeffectcouldwellexplainthefindingsofauthorssuchasLovasiet al[71],whofoundthatindividualbuiltenvironmentcharacteristicswerenotsignificantlyassociatedwith‘walkingforexercise’,inanindependentpopulationsampleof1,608participants.

Whilethemanycorrelationstudiestodatereportfairlyconsistentphysicalactivityandweightbenefitsfromsupportivesurroundings[72],thefactthattheyhavepredominantlybeenundertakenintheUSandAustralia[62],presentsrealchallengesforgeneralisability,especiallywithregardtorelativelydenselypopulatedareaslikecentralScotland.Thisisparticularlyrelevantformeasurementconceptswhichhavearisensuchas‘walkability’and‘urbansprawl’,sincethesearefarmoreeasilyappliedtoUSandAustraliancitiesthantheirEuropeanorUKequivalents.Theotherkeyissuewithneighbourhoodandactivitystudiesisthatofself-selectionortheextenttowhichpeoplewhoarealreadypredisposedtogreaterlevelsofphysicalactivity,forexample,deliberatelychoosetoliveinareaswherethisisbettersupported.Atamorefundamentallevel,movingfromaetiologicalstudieswhichfocusoncausation,tointerventionproposalsaimedatobesityprevention,introducesanotherseriesofchallenges.Thenowacknowledgedextentoftheincreaseinphysicalactivitythatwouldberequiredtohaveanimpactonbodymass,raisessignificantquestionsaboutthefeasibilityofenvironmentalinterventionstoleadtofavourablechangesinpopulationweightstatus.Incorporatingmoreactivitydemandsintodailylivingmightbeonewaytoaddressthisdeficitandmeasurestoincreaseactiveliving(particularlyactivetravel)arediscussedinthenextsection.

Summary

Recreationalactivity

• Consistentassociationshavenowbeendemonstratedinanumberofcountriesbetweenfeaturesoftheexternalbuiltenvironmentandthelikelihoodofundertakingregularphysicalactivity,aswellastherelativeprevalenceofobesityandoverweight.

• SincethemajorityofthisworkisbasedonUSandAustralianstudies,thereareveryvalidconcernsaboutthetransferabilityofthesefindingstoaUK/Scottishcontext.

• Publishedreportsinthisareaarecharacterisedbyincreasinglysophisticatedmethodsofenquiry,includingnaturalexperiments,longitudinalstudydesignsandstratificationbydominantpreferencesandbehaviours.

• Anincreasingacknowledgementofthesecondaryroleforphysicalinactivity,comparedwithexcessenergyintake,asadriverofthemodernobesityepidemic,highlightstheneedtoavoidrelianceonactivitymeasuresalone(particularlyrecreationalmeasures),asameansoftacklingexcesspopulationweightgain.

36


ii. Physical activity associated with ‘active living’

Oneofthefivekey’mostpromisingpolicyresponse‘optionsoftheUKGovernment’sForesightReportwastherecognitionthattheremaybesubstantialopportunitiesforincreasingphysicalactivitylevelsacrossthewholepopulationthroughsubtlebehaviourchangesineverydayliving,workingandtravelling.Thisrationaleisunderpinnedbyanumberofcharacteristicsofthecurrentobesityepidemic,bothintheUKandinternationally:firstly,fromanaetiologicalstandpoint,physicalactivitylevelsinrelationtoleisure(whileadmittedlybeinglargelybasedonselfreporting),havebeenrelativelystableincomparisontothedeclinesassociatedwithemploymentpatternsandtravelchoices[73].Secondly,majorlifestylechangestopreventorreduceexcessweightareoftennotrealisticforthemajorityofthepopulationandcrucially,evenwherethereareinitialhealthgains,theyareunlikelytobesustainable,withmostsubjectsregainingtheweightlostovertime[74].Lastly,themechanismofgradualweightgainovertimeisgenerallyattributabletoaverysmalldailyexcess,overmanyyears,inenergyintakeoverexpenditure[20].Thissituationhasledanumberofcommentatorstoconcludethatthepreventionoffurtherpopulationlevelincreasesinobesitycanmostusefullybetackledbyinterventionswhichproducemarginalrisesinenergyoutput(aswellasmarginalreductionsinenergyintake),therebyaddressingthe‘energygap’attherootofweightaccumulation[75].Someofthemoretechnologicallysophisticatedstudies(whichdirectlytrackenergyexpenditurelevels),havehighlightedthatthemagnitudeoftheenergygapissuchthatnothingotherthansubstantialchangesinintakeandexpenditure(e.g.decreasedintakeintheregionof400kcalperdayordailymoderatelyintenseexerciseof110minutesduration),wouldbesufficienttoclosethegaponsurplusenergyaccumulationandpreventfurtherweightgain[76].

Aswithleisurebasedphysicalactivity,betweencountryvariationsinbaselinelevelsofactivetravelcancauseproblemswhenconsideringthetransferabilityofpolicyandenvironmentalinterventions.Internationalstudieshowevercanbeextremelyinformativesincetheyallowformeaningfulcomparisonsbetweendiverseaspectsofurbandesignaspotentialdeterminantsofactivitylevels.InonerecentlypublishedScottishinvestigationOgilvieet al[77]examinedcorrelatesofactivetravelandphysicalactivityusinga14-itemneighbourhoodratingscaleandtheinternationallyvalidatedIPAQ12questionnaire[78].Apartfromaccesstolocalamenities,environmentalcharacteristicsprovedtohavealimitedinfluenceonactivetravelforthisrelativelydeprivedGlasgowpopulation.Theonlyotherstatisticallysignificantenvironmentalassociationwasaninverserelationshipbetween‘perceptionoftrafficvolume’andlikelihoodofphysicalactivity.Thisapparentlycounterintuitiveresulthasbeenreportedbyotherauthorsandhasbeenexplainedbythesuggestionthatmorefrequentcyclistsaremoreconsciousoftrafficvolumes[79].Figure3.5(fromOgilvieet al),illustratestheestimatedproportionofvarianceforbothactivetravelandphysicalactivityingeneral,explainedbyenvironmentalcorrelates.

12 International Physical Activity Questionnaire (IPAQ) http://www.ipaq.ki.se/ipaq.htm

37

Chapter3

(Y-axis:Nagelkerke’sR2isamodificationoftheCoxandSnellcoefficienttotransformtherangetoa0–1scale).

Figure 3.5 Estimatedproportionsofvarianceinactivetravelandphysicalactivityexplainedbypersonalandenvironmentalcharacteristics

41

suggestion that more frequent cyclists are more conscious of traffic volumes [79]. Figure 3.5 (from

Ogilvie et al) illustrates the estimated proportion of variance for both active travel and physical

activity in general, explained by environmental correlates.

Figure 3.5 Estimated proportions of variance in active travel and physical activity explained by personal and environmental characteristics (Y-axis: Nagelkerke’s R2 is a modification of the Cox and Snell coefficient to transform the range to a 0–1 scale). While Ogilvie’s study was in a particularly deprived Glasgow population and was also obliged to

disregard a substantial number of returned questionnaires (IPAQ methodology requires that one

‘don’t know’ answer means that the whole return is void), the predominance of personal over

environmental correlates was also seen in a San Francisco Bay study [80]. Using factor analysis to

represent urban design and land use diversity dimensions, Cervero and Duncan found built

environment factors to exert far weaker, though not inconsequential, influences on walking and

bicycling than control variables such as demographics, household income and car access. The

undisputed car dominance in this study, even for trips under one mile (60.7% by car and 34.3%

walking), also highlights the true scale of the ‘active travel’ challenge, in the US at least.

Stafford et al also used sub-factor analysis to quantify the contributions of environmental and

individual variables to both waist–hip ratio (WHR) and BMI [81]. Based on routine data from both

the Scottish Health Survey and Health Survey for England, the only statistically valid associations for

environmental characteristics were ‘high-street facilities’ (pharmacies, opticians, dentists and banks)

WhileOgilvie’sstudywasinaparticularlydeprivedGlasgowpopulationandwasalsoobligedtodisregardasubstantialnumberofreturnedquestionnaires(IPAQmethodologyrequiresthatone‘don’tknow’answermeansthatthewholereturnisvoid),thepredominanceofpersonaloverenvironmentalcorrelateswasalsoseeninaSanFranciscoBaystudy[80].Usingfactoranalysistorepresenturbandesignandlandusediversitydimensions,CerveroandDuncanfoundbuiltenvironmentfactorstoexertfarweaker,thoughnotinconsequential,influencesonwalkingandbicyclingthancontrolvariablessuchasdemographics,householdincomeandcaraccess.Theundisputedcardominanceinthisstudy,evenfortripsunderonemile(60.7%bycarand34.3%walking),alsohighlightsthetruescaleofthe‘activetravel’challenge,intheUSatleast.

Staffordet alalsousedsub-factoranalysistoquantifythecontributionsofenvironmentalandindividualvariablestobothwaist–hipratio(WHR)andBMI[81].BasedonroutinedatafromboththeScottishHealthSurveyandHealthSurveyforEngland,theonlystatisticallyvalidassociationsforenvironmentalcharacteristicswere‘high-streetfacilities’(pharmacies,opticians,dentistsandbanks)associatedwithverymarginaleffects:(OR=0.96forBMI13)andfor‘neighbourhooddisorder’(acompositevariableofperceivedneighbourtrustworthiness,fearofwalkingaloneafterdark,amountofvandalismandlitter)(OR=0.74for‘sportsparticipationrate’).ThesportsparticipationratehadonlyinturnaveryminorinfluenceonBMI(OR=0.96)andanegligibleimpactonWHR(OR=1.005).Theequivalentoddsratiosforeachten-yearincreaseinagewere1.22forBMIand1.37forWHR;formalegender0.72(BMI)and0.89(WHR)andforsocialclass(basedonoccupationgroupsItoV),BMI(1.08)andWHR(1.06).TheverymarginalnatureofallthemodelledassociationsfromtheEnglishandScottishdatasets,otherthantheinfluenceofneighbourhooddisorderonsportsparticipation(OR=0.74),isnotespeciallyencouragingfortheprospectsofidentifyingpromisinginterventionsforpromotingphysicalactivityinalocal/communitysetting.Anumberofothercountries,mostnotablythoseinnorthernEurope,doinfacthaveaconsiderablyhigherproportionofalljourneystakenbybicycle(table3.4)andthediscrepancyhasbeenthesubjectofarecentdetailedinvestigationbyPucherandBuehler[82].

13 OR values from Stafford paper derived from standardised path coefficients using natural log transformation from values in paper (hence absence of confidence intervals).

(Source:Ogilvieet al2008[77])

38


Country

USA

Canada

UK

France

Germany

Netherlands

Denmark

Austria

Switzerland

Sweden

Car

84%

74%

62%

54%

52%

44%

42%

39%

38%

36%

PublicTransport

3%

14%

14%

12%

11%

8%

14%

13%

20%

11%

Cycling

1%

1%

8%

4%

10%

27%

20%

9%

10%

10%

Walking

9%

10%

12%

30%

27%

19%

21%

31%

29%

39%

Other

2%

1%

4%

0%

0%

1%

3%

8%

3%

4%

Table 3.4 Transport mode split in urban areas.

(Source:PucherandLefevre,1996[83])

DrawingalsoonPucher’searlierreview,whichlookedindetailatbothwalkingandcyclingintheNetherlandsandGermany[84],theauthorshighlightthesubstantialgapsinactivetravelrates,particularlycomparedtotheUS,althoughtheUKcertainlyhasthelowestinNorthernEurope.Evencontrollingfortripdistance,AmericansandBritonsmakejust1%oftripsbetween2.5kmand4.4kmbybicycle,comparedtomuchhighercyclingratesforthesametripdistanceinGermany(11%),Denmark(24%)andtheNetherlands(37%)[82].PerhapsthemostcompellingaspectofthesecomparisonsisthatliketheUSandtheUK,GermanyandtheNetherlandsarebothwealthy,technologicallyadvancedcapitalistdemocracieswithhighlevelsofcarownership.TheadditionofahistoricalperspectivealsoshowsquiteclearlythatGermany,DenmarkandtheNetherlandswereallclearlyoriginallyheadinginthesamedirectionontransportinfrastructureandpreferencesafterthesecondworldwar,withcyclingratesinallthreeplummetingbetween1950andthemid-1970s,ascarownershipbecamewidespread.AtthebeginningofthisperiodcyclingrateswereactuallyhigherintheUKthaninGermany,at15%ofalltrips.WhileBritishcyclingcontinuedonadownwardtrajectoryafter1975,amassivereversaloftransportandurbanplanningpoliciesinthethreecomparisoncountriessuccessfullyrevivedbicycletraveltoitscurrentlevels[84].Insimpleterms,cyclinghasprosperedinGermany,DenmarkandtheNetherlandspreciselybecausethesecountrieshave‘givenifnottheredlight,atleasttheamberwarninglight,toprivatecars’.Whiletherewascertainlynoexplicitobesitypreventionobjectiveoverthirtyyearsago,simplequalityoflife,congestionandpollutionconsiderations(possiblycombinedwiththe1974oilpricehike),weresufficienttomotivatedecisionmakerstotakestepstoreduceprivatecardominance.

AdetailedexpositionofthemultipleleversandpoliciesusedtoengineerthisactivetravelincreaseinourNorthernEuropeanneighboursisoutsidethescopeofthisreport,andinanycaseisexpertlydescribedinthetwodiscursivereviewsfirst-authoredbyPucher[82,84].Sufficetosay,ithasbeenaconcertedcombinationofinfrastructureprovision,integratedtransportplanninganddisincentivesforprivatecarswhichhashelpedbringaboutthehigheractivetravelrates.Withoutdoubt‘safety’and‘perceptionofsafety’alsoseemtohavesubstantialrolesandcanprobablyberegardedasthemajormediatoroutcomesbetweenbuilt-environmentinterventionsandincreasedparticipationinactivetravel.FortheUSinparticularandtoaslightlylesserextentintheUK,walkingandcyclingarecomparativelydangeroustraveloptions.Figure3.6showscyclistdeathsandseriousinjuriesfortheNetherlands,Denmark,Germany,theUKandtheUSA.

39

Chapter3

WhilethecyclistinjuryratefortheUSAisbyfarthehighest,itisbasedpurelyonpolicereportsandislikelytorepresentaconsiderableunderestimate(byafactorofatleasttenincomparisonswithCDChospitalsurveillancefigures[82]).Forsimilarreasons,theofficialaccidentstatisticsofothercountriesarelikelytobeunderestimates,althoughtherank-orderandrelativedifferencewouldbeexpectedtomirrorfatalities.Thedramaticresponsivenessofcyclingratestorealrisksiswellillustratedbyfigure3.7fromtheNetherlandsMinistryofTransport,showingtheclearinverserelationshipbetweentrendsovertime(1950–2005)incyclingfatalitiesandreadinesstotravelbybike.Thisespeciallyappliestotheperiod1978to1985,whencyclingratesfirstroseinresponsetomassiveurbandesignchanges.

Figure 3.6 Fatalityandinjuryratebydistanceforfivecountriesin2004–2005(righthandaxis=USAonly).

Figure 3.7 InversetrendsincyclingfatalityratesandannualkilometrescycledperinhabitantintheNetherlands(1950–2005).

(Source:Pucheret al[82])

(Source:NetherlandsMinistryofTransport,2007;andPucher[82])

44

While the cyclist injury rate for the USA is by far the highest, it is based purely on police reports and

is therefore a considerable underestimate (by a factor of at least ten in comparisons with CDC

hospital surveillance figures [82]). For similar reasons, the official accident statistics of other

countries are likely to be underestimates, although the rank-order and relative difference would be

expected to mirror fatalities. The dramatic responsiveness of cycling rates to real risks is well

illustrated by figure 3.7 from the Netherlands Ministry of Transport, showing the clear inverse

relationship between trends over time (1950–2005) in cycling fatalities and readiness to travel by

bike. This especially applies to the period 1978 to 1985, when cycling rates first rose in response to

massive urban design changes.

Figure 3.7 Inverse trends in cycling fatality rates and annual kilometres cycled per inhabitant in the Netherlands (1950–2005). (Source: Netherlands Ministry of Transport, 2007; and Pucher [82].)

Indeed, such is the current perceived levels of cycling safety in the Netherlands, that there is a high

participation across all age-groups, including women and the elderly. Cyclists also rarely wear safety

helmets or special visibility enhancements. Any reservation that this clear association between

cycling safety and uptake is unique to the Netherlands ought to be dispelled by recent developments

in New York, in the world’s ‘league leader’ country for cycling deaths. A US news article published in

Figure 3.6 Substitute

0

5

10

15

20

25

30

35

40

45

50

0

1

2

3

4

5

6

Holland Denmark Germany UK USA

Cyclists killed / 100M km

Cyclists injured / 10M km

40


Indeed,suchisthecurrentperceivedlevelsofcyclingsafetyintheNetherlands,thatthereisahighparticipationacrossallage-groups,includingwomenandtheelderly.Cyclistsalsorarelywearsafetyhelmetsorspecialvisibilityenhancements.AnyreservationthatthisclearassociationbetweencyclingsafetyanduptakeisuniquetotheNetherlandsoughttobedispelledbyrecentdevelopmentsinNewYork,intheworld’s‘leagueleader’countryforcyclingdeaths.AUSnewsarticlepublishedinJune200914reportedthatthenumberofcyclistshadincreasedbymorethanathirdinthepreviousfouryearsto185,000dailycommuters.Thiswasattributedtoacombinationofinfrastructureimprovementsandincreasedattentiontocyclingsafetythroughoutthecity.Figure3.8illustratestheincreasinguptakeincyclinginNewYorkascasualtyratesfall(althoughitwasnotclearfromthesourcearticlehowtheestimated‘dailyridership’totalhadbeenestimated).

TheoverridingimportanceofmakingactivetravelasafeoptionhasalreadybeenacknowledgedinUKgovernmentguidancefromtheNationalInstituteofClinicalExcellence(NICE),onpromotingandcreatingenvironmentstosupportphysicalactivity15.Intheirrecentreviewoftheevidence,theyidentifiedthreemediumtohighqualitystudiesthatsupportedtrafficcalmingasameansofenablingchildrentobenefitfromoutdoorplay(seeAppendix2).Theyadditionallyfoundevidencefromtwoincludedstudies(onehighqualityandonelowquality),tosupportaroleforcyclinginfrastructureimprovementsinpromotinghigherratesofcyclingandreductionsincasualties.Drawingalsoontheconclusionsofarecentexpertreview[85],theyfoundsufficientlyconvincingevidenceapplicabletoaUKsetting,torecommendthefollowingmeasuresasameansofincentivisingmoreactivetraveloptions:

• re-allocatingroadspacetosupportphysicallyactivemodesoftransport(forexample,wideningpavementsandintroducingcyclelanes)

• restrictingmotorvehicleaccess(forexample,byclosingornarrowingroadstoreducecapacity)

• introducingroaduserchargingschemes

• introducingtrafficcalmingschemes.

Figure 3.8 EstimateddailybikeridershipandannualcasualtiesinNewYorkCity1998–2008

45

June 200912 reported that the number of cyclists had increased by more than a third in the previous

four years to 185,000 daily commuters. This was attributed to a combination of infrastructure

improvements and increased attention to cycling safety throughout the city. Figure 3.8 illustrates the

increasing uptake in cycling in New York as casualty rates fall (although it was not clear from the

source article how the estimated ‘daily ridership’ total had been estimated).

Figure 3.8 Estimated daily bike ridership and annual casualties in New York City 1998–2008

The overriding importance of making active travel a safe option has already been acknowledged in

UK government guidance from the National Institute of Clinical Excellence (NICE), on promoting and

creating environments to support physical activity13

12 StreetBeat, 4 June 2009. Transportation Alternatives

. In their recent review of the evidence, they

identified three medium- to high-quality studies that supported traffic calming as a means of

enabling children to benefit from outdoor play (see Appendix 2). They additionally found evidence

from two included studies (one high-quality and one low-quality), to support a role for cycling

infrastructure improvements in promoting higher rates of cycling and reductions in casualties.

Drawing also on the conclusions of a recent expert review [85], they found sufficiently convincing

http://www.transalt.org/files/newsroom/streetbeat/2009/June/0604.html#safety_in_numbers 13 Promoting and Creating Built or Natural Environments that Encourage and Support Physical Activity: NICE Public Health Guidance 8. NICE; 2008. http://guidance.nice.org.uk/PH8

14 StreetBeat, 4 June 2009. Transportation Alternatives http://www.transalt.org/files/newsroom/streetbeat/2009/June/0604.html#safety_in_numbers15 Promoting and Creating Built or Natural Environments that Encourage and Support Physical Activity: NICE Public Health Guidance 8. NICE; 2008. http://

guidance.nice.org.uk/PH8

(Source:TransportationAlternatives,200914)

41

Chapter3

NICE’spredecessororganisation,theHealthDevelopmentAgency,hadalsocommissionedawide-rangingreviewentitledTransportInterventionsPromotingSafeCyclingandWalking[86].Theinitialbriefingwastwo-foldnamely:(i)whattransportinterventionsareeffectiveinincreasingactivetravel?;and(ii)whattransportinterventionsareeffectiveinincreasingthesafetyofwalkingandcycling?.Thefactthattheeventualtitlechoicefocusesprincipallyonthesafetyaspectisprobablyareflectionofasafetyengineeringdominatedliterature,whichtendstoemphasisethesafetyoutcomesoftransportinterventions,ratherthan‘modalswitching’ortheuptakeofactivetravel.Theauthorsalsonotedthatwhilevariablesintheurbanenvironmentdoinfluencewalkingandcycling,itremainsunclearwhichcharacteristicsofthebuiltenvironmentarethemostimportant.

Carownershipandindividualmotivationlevelscertainlyremainstrongconfoundingfactorsintherelationshipbetweentravelchoicesandfeaturesofthebuiltenvironment.Onactivetravelspecifically,thereviewlevelevidencewasinconclusiveontheeffectivenessofengineering/builtenvironmentmeasures(suchastrafficcalmingetc),inpromotingashiftawayfromcaruse,butdidfindthatthesemeasureswereeffectiveinreducingaccidents[86].Combiningthesefindingswiththealreadyestablishedimportanceofsafety,highlightedabove,atleastmakesacircumstantialcaseforproposingthatbuiltenvironmentimprovementswhichimproveactivetravelsafetyarealegitimatemeansofattemptingtoincreasetheuptakeofwalkingandcycling,althoughproperevaluationoftheirhealthenhancingeffectsisstillwarranted.

Summary

Activetravel

• LimitedevidenceforenvironmentalinfluencesonactivetravelisnotparticularlysurprisinginaUKsetting,wherebaselinelevelsarelowandlargelyconfinedtoselfselectedpopulationsub-groups.

• Internationalcomparisonswithcountriesthathaveequallyhighlevelsofcarownershipandsimilarclimates,givegroundsforoptimismthatactivetravelcouldbepromotedbybuilt-environmentmodifications,althoughsignificantinfrastructuralinvestmentwouldberequired.

• Thefindingthatmuchoftheexistingevidencebaserelatestothecapacityofbuiltenvironmentinterventionstoimprovesafety,shouldnotbediscouragingtopolicymakers,inthelightoftheclearimportanceofimprovedsafetyinencouragingwiderparticipationinactivetravel.

• Althoughanydirectimpactofincreasedactivetravelonobesityhasyettobedemonstrated,conservativeestimatesofgeneralhealthbenefitscorrespondwithahighcost-effectivenssinthemediumtolongterm(seesection5.4).

3.5 Physical activity interventions (micro-level)

i. Point of decision prompts

Physicalsurroundingswhicharerelevanttomicro-levelinterventionscanbethoughtofasincreasinginscalefromfirstly,thehomeorworksetting;secondly,theintermediate-scaleenvironmentofpubliclyaccessiblefacilities/buildings;andthirdly,theentirelocalcommunityorimmediateneighbourhood.Allthreeoftheselevelshavebeenestablishedashavinganimpactorinfluenceonlevelsofphysicalactivity,includingtheuseofspecificadaptations,designfeaturesorawarenessprompts.Awarenesscuesor‘point-of-decisionprompts’(PODPs),representthemoststraightforwardandleastcostlyoftheseadaptationstoimplement.ThusitisperhapsunsurprisingthatthegreatestquantityofpublishedevidenceisrelatedtoPODPs.PODPsaredefinedas:‘motivationalsignsplacedatornearstairwellsoratthebaseofelevatorsorescalatorstoencourageindividualstoincreasestairuse’[87].Usefully,theCDC’sGuidetoCommunityPreventativeServices,whichisoneofthemostrespectedinternationalreviewbodiesforpublichealthinterventions,veryrecentlyupdatedtheirreviewoftheeffectivenessofPODPstoincludeaseparateanalysisonstudieswhichhadcombinedsuchpromptswithothercomplementaryenvironmentalfeatures[88].TheCDCtaskforcewereable,onthebasisof13qualifyingstudies,to

42


recommendtheuseofPODPsonthebasisof‘strongevidenceofeffectivenessinmoderatelyincreasinglevelsofphysicalactivity,asmeasuredbyanincreaseinthepercentageofpeoplechoosingtotakethestairsratherthananelevatororescalator’.Therewasinsufficientevidencehowevertorecommendadditionalenvironmentalenhancements(onlytwoqualifyingstudieswereidentified).Thereviewshowsawiderangeofeffectsizesfortherelativepercentagechangeintheproportionofsubjectsmakinghealthyactivitychoices(overallmedian=50.0%increase,butwithahugeintra-quartileinterval5.4to90.6)andincludesonestudycarriedoutinaGlasgowundergroundstationinScotland[89].Signssaying‘StayHealthy,SaveTime,UsetheStairs’wereplacedbeforestationexits,wherestairs(twoflightsof15steps)andescalatorswereadjacent(figure3.9).

Themotivationalsignssignificantlyincreasedthepercentageofmenusingthestairsfrom12%atbaselineto21%throughoutthedurationoftheinterventionandthecorrespondingfiguresforwomenwere5%to12%.Stairusedecreasedduringthetwoweeksafterthesignwasremovedbutremainedsignificantlyhigherthanbaselineafterthefulltwelveweeksoffollowup(P=0.01).Theongoingrecidivisttrendbacktobaselineontheotherhand,isveryevidentfromfigure3.9(takenfromthepublishedreport),andcontinuestobeaconcernwiththistypeofstudy.TheCDCreviewthereforehighlightstheneedforongoingresearchintowhichparticularcombinationsofinterventionsmighthelpsustainbehaviourchange,suchthatitbecomeshabitual.

Figure 3.9 Patternofstairuseamongmenandwomenduring'stairsign'study,inGlasgowundergroundstation(valuesareweeklysamplepercentageswith95%confidenceintervals)

(Source:Blameyet al,1995[89])

5

30

25

20

15

10

0

Time (weeks)

MenWomen

Use

of S

tairs

(%)

Base

line

Post

er u

p

Post

er w

ithdr

awn

0 5 10 15

43

Chapter3

ii. Building design features

Aswellasmotivationalposters,anothertypeofinterventionwhichhasdemonstrablyincreasedstairuseisstructuralalterationstobuildings,inwhichforexampletheliftdoesnotstoponallfloors.MoresuitedtoaUSemployersetting,whereitisnotunusualforcompaniestooccupyanumberoffloorsinanofficeblock,thespecificexampleofthe‘stair-skip’design[90]probablyhaslimitedrelevancetotheUK,buttheprinciplesandtheprocessmayhaveimplicationsformodificationswhichhaveasimilarobjective(namelytoencourageactivityaspartofdailyroutine).Inanevaluationofthestair-skipdesign,NicollandZimringexploitedanaturalexperimentinwhichtheideawasimplementedintheCaliforniaDepartmentofTransportbuildinginLosAngeles[90].Describedmoreasa‘push’strategythat‘mandates’physicalactivitythroughstairusebyreducingaccesstoelevators,theauthorscontrasttheapproachwithmoretraditional‘pull’strategiessuchasPODPsdescribedabove.Sincethebuildinginquestionhadtwo‘circulationcores’itwasrelativelystraightforwardtosetupareal-timecontrolintheotherhalfofthebuilding.The‘skip-stop’elevatorsonlystoppedateverythirdfloorandwereadjacenttoanopenstaircase.Whileinterpretationoftheresultsishighlyproblematicduetoaverylowresponserate(17.4%),theopenskip-stopstairwasused33timesmorethantheenclosedfirestairinthecomparisonpartofthebuilding.Themostilluminatingfindingrelatedtotheattitudesofstudyparticipantstowardsthe‘skip-stop’stair,withtheproportionexpressingsatisfactionwiththearrangementincreasingfrom32.4%to47.5%(299participants).Thispositivechangeinattitudehasparallelswiththefindingsofotherstructuralandfiscalinterventions,mostnotablytheLondoncongestioncharge,whereinitialresistancedeclineswhenthebenefitsbecomeapparent16.

Summary

Physicalsurroundings

• Simplemotivationalsignscanbeaneffectivemeansofincreasingphysicalactivityinpublicsettingssuchasshopsandpublictransporthubs.

• Asinotherareasofhealthpromotion,thebestmeansofsustaininganypositivebehaviourchangecontinuestobeanareaofconsiderableuncertaintyandislikelytoremainanactiveresearchpriorityfortheforeseeablefuture.

• Structuralinterventionssuchasengineered‘stair-skip’measuresinbuildingscanalsoincreaseroutinedailyphysicalactivityandtheinitiallevelsofemployee/publicresistancetotheseinterventionsappeartodeclineovertime.

16 London’s Congestion Charge is a success. Institute of Environmental Management and Assessment News. Oct. 2003. http://www.iema.net/news/envnews?aid=4291

44


4

45

Chapter5

4 Chapter 4 – Interventions to the economic environment 4.1 Introduction

Recentsuccessesinthedevelopedworldwithtobaccocontrol,usingacombinationofsalestaxesandenvironmentallegislation,havestimulatedthedebateonwhetherasimilarapproachmightbepossiblewithobesitypromotingfoodstuffs[91].Astheintroductoryquoteillustrates,taxationiscertainlybynomeansanovelideaandthereismuchrecentepidemiologicalevidencetosuggestthatitcouldbeausefulandeffectivemeansofaddressingtherelentlesspopulationrisesinobesityandoverweightinScotlandandtheUK.MaintainingtheANGELOframeworkstructure,thefollowingsectionontheeconomicdomainwillfirstconsidernationallyimposedfiscalmeasuresundermacro-levelinterventionsandlocal/institutional/sitespecificinterventionsunderthemicro-levelcategory.Thequalityofevidenceinbothoftheseareashasrecentlyadvancedconsiderably,althoughtheimplementationofeconomicleversandincentiveswillalwayspresentsignificantevaluationchallengesandthepotentialforunintendedconsequences[92].Researchfindingsonfiscalmeasurestopromote/incentivisephysicalactivity,althoughtheyaregenerallyrestrictedtoparticularriskgroups(suchastheelderly),arealsobrieflyreviewedattheendofthissection.

4.2 Nutrition interventions (macro-level)

Sugarsweetenedbeveragesaredrinkswhichcontainnaturallyderivedcaloricsweetenerssuchassucrose(tablesugar),highfructosecornsyrup,orfruitjuiceconcentrates.Althoughthedifferenttypesofdrinkgenerallycontaincomparablecaloriesgramforgram,theydohavedifferencesintheirrespectivemetabolicprofiles,whichareoutsidethescopeofthisreport.Thepast30yearshasseendramaticincreasesinsugaredbeverageconsumptioninmanypartsoftheworld,mostnotablyintheUS,wherepercapitaintakedoubledacrossallagegroupsbetween1977and2002[93].Althoughmostoftheevidenceforanassociationbetweensoftdrinksandweightgainisobservationalinnature,therehavealsobeenshorttermclinicaltrials,whichhavehelpedprogressunderstandingaboutthewayinwhichsugaredbeverageconsumptionmaybelinkedtoadiposity.Indeedtheextentandvolumeofcircumstantial,longitudinalandexperimentalevidencestronglylinkingthistypeofdrinktothecurrentobesitypandemic,makesacompellingcaseintheopinionofsomeexpertcommentatorsforsomeformofgovernmentintervention[93].Athree-levelrationalehasrecentlybeenputforwardbyKimandcolleaguesinsupportofadedicatedtaxonsoftdrinks/snackfooditems[94],theprincipalcomponentsofwhichare:

i. Agrowingbodyofevidence,includingprospectivestudies,linkinganincreasedconsumptionofhigh-energy/low-nutrientfoodanddrinkwithweightgainandotheradversehealtheffects

ii. Extensiveconfirmationfromaroundtheworldthatsugaredbeveragepurchasingbyconsumersisstronglysensitivetoprice

iii. Thedutyofgovernmenttoprotectconsumerswheremassivelevelsofinvestmentintheadvertisingandpromotionofunhealthyfoodanddrink,makeitdifficultforthepublictotakeproperlyinformeddecisionsabouthealthrisks.

Chapter4

‘Sugar, rum and tobacco are commodities which are nowhere necessities of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation.’

Adam Smith, The Wealth of Nations, 1776.

46


i. Effects of consumption on health

Since40statesintheUSnowimposesomeformofsalestaxonatleastoneofsugareddrinks,sweetsorsnackitems[95],severalauthorshavelookedatbetween-statevariationsinthepatternsofconsumptionandcorrelationswithcrudehealthindicatorssuchasBMI.Havingbeenintroducedwithoutanyexplicithealthobjective,thesereportsaremore‘opportunisticobservations’than‘naturalexperiments’,buttheyneverthelessgivesomegroundsforoptimismaboutthepotentialbenefitsoffiscallymediatedreductionsinconsumption.KimandKawachiforinstancewereabletodemonstratestrongpositiveassociationsbetweenthepresenceofstateleveltaxationonsoftdrinks(andsnackfoods),between1991and1998andrelativechangesinobesityprevalence[94](table4.1).Theirmoststrikingresultisthatseenforthesmallnumberofstateswitharepealedtax,whichwereover13timesmorelikelythanstateswithatax(OR=13.3;95%CI:0.7to262.0)toexperienceahighrelativeincrease(top25%)inobesityprevalence,duringthesevenyearfollowup.Thewideconfidenceintervalandtheborderlinenatureofthestatisticalresult(Pnotreaching<0.05for95%significance),isduetothesmallnumberofstatesinthiscategory,anddoesnotnegatethemagnitudeoftheresult.Ofcoursetheinterpretationofecologicalstudiessuchastheseisalwaysintrinsicallyhazardousandothermeasuresfavourabletothefoodindustrycannotberuledoutinstateswithoutatax,orinthosewhereithasbeenrepealed.

Table 4.1 USA state-level associations between presence of taxes on soft drinks or snack foods and relative increases in obesity prevalence, 1991–1998 (CI=confidence interval)

(Source:KimandKawachi,2006[94])

a≥75thpercentileinrelativeincreaseinstateobesityprevalencebetween1991and1998.bOddsratioforbeing≥75thpercentile,adjustedforstatemedianage,meanincome,and%black(allfrom1990USAcensus),andpoliticalpartycarryingthestateinthe1992USApresidentialelection(nooddsratiostatisticallysignificantat0.05level).cReferencegroup.

Withataxc

Withoutatax

Repealedtax

Witha5%taxc

Withoutanytax

Totalnoofstates

14

23

6

10

33

Noofstates≥75%ilea

1

7

3

1

10

Multivariate-adjustedoddsratiob(95%CI)

1.0

4.2(0.4–48.3)

13.3(0.7–262.0)

1.0

3.0(0.3–33.1)

pvalue

—

0.25

0.09

—

0.38

47

Chapter4

Aseriesoflongitudinalstudieshavealsoshownclearassociationsbetweensugarsweetenedsoftdrink(SSSD)consumptionandobesitylevels.Inonetwotermfollowupof548childreninMassachusettsforexample,foreachadditionaldailyconsumedunitofSSSD,theriskofbeingobeseincreasedby60%,aftercontrollingforallotherdietary,demographicandotherlifestylefactors[96].Ameta-analysispublishedin2007,foundthattheintakeofSSSDsisassociatedwithhigherbodyweight,poorernutrition,displacementofhealthierbeveragesandincreasedrisksofclinicalobesityanddiabetes[97].Theoveralleffectsizefromthelongitudinalstudiesinthisreviewwas0.09(P<0.001)fortheeffectonBMIofaunitchangeinSSSDintake.

AneducationalinterventiontrialfocusingonSSSDsusedarandomisedclusterdesigninsixprimaryschoolsinsouthwestEngland[98].MarginalreductionswerereportedfortheinterventiongroupinSSSDconsumptionof0.6(250ml)glassesoverathreedayperiod,comparedwithariseinconsumptionof0.2glassesforthecontrolgroup.Figure4.1showsthedifferencesintherelativeprevalenceofobesityandoverweightbetweentheintervention(0.2%decrease)andcontrolgroups(7.5%increase)overthecourseofthe12monthintervention(meandifference:7.7%;95%CI:2.2%to13.1%).Afollowupstudycarriedouttwoyearsaftertheendoftheintervention[99]showedthatwhiletheprevalenceofoverweightwasstillhigherinthecontrolgroup(30.2%vs25.6%),thedifferencewasnolongerstatisticallysignificant(95%confidenceinterval:-4.3%to10.6%;P=0.28).

Thenotablerisesinobesityprevalenceinthecontrolarmsofthestudy,togetherwithanumberofmethodologicalconcerns(e.g.arelianceonaccuratediarycompletionbyyoungchildren),haveledsomecommentatorstorecommendacautiousinterpretationoftheresults(seeBMJresponsestoJameset al[98]).Afollowupstudycarriedouttwoyearsaftertheendoftheintervention[99]showedthatwhiletheprevalenceofoverweightwasstillhigherinthecontrolgroup(30.2%vs25.6%),thedifferencewasnolongerstatisticallysignificant(95%;CI:-4.3%to10.6%;P=0.28).Ina‘substitution’studywithUSadolescentswhohadhigherbaselinelevelsofsugaredbeverageconsumptionthantheJamestrial,thenetdifferenceinBMIwasnotsignificantoverall,butcruciallytherewasarealdifferenceforthoseintheupperBMIbaselinetertile(specifically,BMIchangedifferedsignificantlybetweentheintervention[-0.63

Figure 4.1 Meanchangeinprevalenceofoverweightandobesechildrenfrombaselinetofollowupat12monthsaccordingtoclusters.Interventiongroupsreceivedafocusededucationalnutritionprogrammeaimedatreducingsugarsweetenedsoftdrinksinaschoolbasedrandomisedclusterdesign.

(Source:Jameset al,2004[98])

53

Figure 4.1 Mean change in prevalence of overweight and obese children from baseline to follow up at 12 months according to clusters. Intervention groups received a focused educational nutrition programme aimed at reducing sugar sweetened soft drinks in a school based randomised cluster

design. (Source: James et al, 2004 [98].)

The notable rises in obesity prevalence in the control arms of the study, together with a number of

methodological concerns (e.g. a reliance on accurate diary completion by young children), have led

some commentators to recommend a cautious interpretation of the results (see BMJ responses to

James at al [98]). A follow up study carried out two years after the end of the intervention [99]

showed that while the prevalence of overweight was still higher in the control group (30.2% vs

25.6%), the difference was no longer statistically significant (95%; CI: -4.3% to 10.6%; P=0.28). In a

‘substitution’ study with US adolescents who had higher baseline levels of sugared beverage

consumption than the James trial, the net difference in BMI was not significant overall, but crucially

there was a real difference for those in the upper BMI baseline tertile (specifically, BMI change

differed significantly between the intervention [-0.63 +- 0.23 kg/m2] and control [+0.12 +- 0.26

kg/m2] groups for those with a baseline BMI>=25.6 kg/m2, resulting in a net effect of -0.75 +- 0.34

kg/m2) [100]. Furthermore, the interaction between weight change and baseline BMI was not

attributable to baseline consumption of sugared sweetend beverages. Characterised by a diverse

cohort and a reassuringly high retention rate of 83%, this USA study by Ebbeling and colleagues

holds out the serious prospect of an intervention that by itself targets those most at risk, possibly

involving underlying increased susceptibilities unrelated to baseline consumption.

Since the extrapolation of findings from school and adolescent trials to working age adults is not

without risks, it is worth comparing these results with those obtained for SSSD consumption in one

of the largest ongoing US cohort studies [101]. The Nurses Health Study II is a large prospective

cohort of 116,671 female US nurses aged 24 to 44 years at study initiation in 1989, and who are

followed up by biennial mailed questionnaires. The questionnaire includes multiple lifestyle

48


+-0.23kg/m2]andcontrol[+0.12+-0.26kg/m2]groupsforthosewithabaselineBMI>=25.6kg/m2,resultinginaneteffectof-0.75+-0.34kg/m2)[100].Furthermore,theinteractionbetweenweightchangeandbaselineBMIwasnotattributabletobaselineconsumptionofsugaredsweetendbeverages.Characterisedbyadiversecohortandareassuringlyhighretentionrateof83%,thisUSAstudybyEbbelingandcolleaguesholdsouttheseriousprospectofaninterventionthatbyitselftargetsthosemostatrisk,possiblyinvolvingunderlyingincreasedsusceptibilities,unrelatedtobaselineconsumption.

Sincetheextrapolationoffindingsfromschoolandadolescenttrialstoworkingageadultsisnotwithoutrisks,itisworthcomparingtheseresultswiththoseobtainedforSSSDconsumptioninoneofthelargestongoingUScohortstudies[101].TheNursesHealthStudyIIisalargeprospectivecohortof116,671femaleUSnursesaged24to44yearsatstudyinitiationin1989,andwhoarefollowedupbybiennialmailedquestionnaires.Thequestionnaireincludesmultiplelifestyleindicatorsincludingdietaryintake,physicalactivityandhealthstatusandgenerallyhasafollowupinexcessof90%foreach2-yearperiod.Anestedcohortof51,603womenforwhomcompletedietaryandbodyweightinformationwereavailablefor1991,1995and1999wereanalysedfortheincidenceoftypeIIdiabetesaccordingtopatternsofSSSDconsumption.Thestudy’smostelegantfeatureistheanalysisofsubgroupeffectsaccordingtochangesinconsumptionhabits.Weightgain,forinstance,overa4yearperiodwashighestamongwomenwhoincreasedtheirSSSDconsumptionfrom1orfewerdrinksperweekto1ormoredrinksperday(multivariate-adjustedmeans,4.69kgfor1991to1995and4.20kgfor1995to1999)andwassmallestamongwomenwhodecreasedtheirintake(1.34and0.15kgforthetwoperiods,respectively)afteradjustingforlifestyleanddietaryconfounders.TheauthorsproposethattheexcessivecaloriesandlargeamountsofrapidlyabsorbablesugarscouldexplainthelargerweightgainandincreasedriskoftypeIIdiabetes,associatedwiththehigherconsumptionofSSSDs.Nissinenaet alalsoreportedadirectcorrelationbetweenanincreaseintheconsumptionofsugarsweeteneddrinksfromchildhoodtoadulthoodandadultBMI17(ORforbeingoverweight=1.90;95%CI:1.38to2.61)inyoungFinnishwomen,butnotinmen[102].

ii. Price elasticity

Thegrowingcase,inmanycountries,forsupplementarytaxesonsugaredbeveragesonhealthgrounds,haspromptedresearcherstoexaminehowresponsivepurchase(i.e.presumedconsumption)mightbe,inrelationtopricechanges.Theeconomictermthatdescribesconsumersensitivitytothepriceofaparticularproductis‘priceelasticity’,whichisadimensionlessconstructdefinedasthepercentagechangeinpurchasedquantity(i.e.demand)associatedwitha1%changeinprice[103].Priceelasticityisdeterminedbyamultitudeoffactorsincludinghouseholdincome,availabilityofsubstitutes,consumerpreferencesetc.Whentherelativechangeinpurchasedquantityisbelowtherelativechangeinprice,demandissaidtobe‘inelastic’(numericallyexpressedasavaluebelow1.0).Changesindemandgreaterthantherelativepricechangehaveavaluegreaterthan1.0andarecalled‘elastic’.Theresultsofarecentcomprehensivereviewof160studiesontherelativepriceelasticitiesofmajorfoodstuffsareshownintable4.2.Priceelasticitiesforfoodsandnon-alcoholicbeveragesrangedfrom0.27to0.81(absolutevalues)withsoftdrinks(0.79;95%CI:0.33to1.24)beingsecondonlyto‘foodawayfromhome’(0.81;95%CI:0.23to1.76)forthehighestrelativepriceelasticityoftheitemsincluded.

17 Effect size in Nissenen et al: b=0.45; p=0.0001 i.e. BMI increased by 0.45 kg/m2 for every 10 unit increase in soft drink consumption per month.

49

Table 4.2 US price elasticity estimates, by food and beverage category from 1938–2007

Fromapublichealthperspectiveofcourse,arelativelyhighelasticityforaparticularfooditemisgoodnewsifpriceincentivesaretobeusedtoinfluencedemand.Theaboveresultssuggestthata10%taxonsoftdrinkscouldleadtoan8%to10%reductioninpurchasesoftheseitems.Onthisbasis,sugarsweetenedbeverageswouldmakeidealcandidatesfortargetedtaxation.Thereisalsoevidencetosuggestthatthepricedisincentivesforsoftdrinksandunhealthysnackfoodsaremoreeffectiveinthosewhoalreadyare,ormostatriskofbecoming,obese[104].SturmandDatarforinstancefoundthatchildrenfrommoreeconomicallydeprivedbackgroundsandthoseidentifiedasbeingatriskofbecomingoverweightorobese,wereroughly50%and39%,respectively,morepricesensitivecomparedwiththeirnon-poorandnot-at-riskcounterparts[105].Higherfastfoodpriceelasticitieshavealsobeenreportedforadultsattheupperendoftheweightdistributionspectrum[106].

iii. Economic imbalance

Thedecliningcostsintherealpriceoffood,andtherelativelylowerpricesofenergydensefoodsinparticular,arewidelyheldasakeydriverofthecurrentobesityepidemic,basedonthesubstantialhistoricalreductionsinthecostofconsumingacalorie[107].Clearlyifalargeproportionofthepopulationisoverconsumingenergydensesnacksandhighcaloriedrinkstothedetrimentoftheiridealbodyweightandhealthstatus,theyarenotmakingoptimaldecisionsfortheirhealth,eveniftheirdecisionsareconsistentwithotherperceivedpriorities.Transactionswhichharboursuchanotableimbalanceintheknowledgeofbenefitsandharms,aresometimesreferredtoasexamplesof‘marketfailure’,sincethe

Foodawayfromhome

Softdrinks

Juice

Beef

Pork

Fruit

Poultry

Dairy

Cereals

Milk

Vegetables

Fish

Fats/Oils

Cheese

Sweets/Sugars

Eggs

Food/BeverageCategory AbsoluteValueofMeanPriceElasticity(95%CI)#

#Note:Valueswerecalculatedbasedonthe160studiesreviewed

Range No.ofEstimates

0.81(0.56,1.07)

0.79(0.33,1.24)

0.76(0.55,0.98)

0.75(0.67,0.83)

0.72(0.66,0.78)

0.70(0.41,0.98)

0.68(0.44,0.92)

0.65(0.46,0.84)

0.60(0.43,0.77)

0.59(0.40,0.79)

0.58(0.44,0.71)

0.50(0.30,0.69)

0.48(0.29,0.66)

0.44(0.25,0.63)

0.34(0.14,0.53)

0.27(0.08,0.45)

0.23-1.76

0.13–3.18

0.33–1.77

0.29-1.42

0.17-1.23

0.16-3.02

0.16-2.72

0.19-1.16

0.07-1.67

0.02-1.68

0.21-1.11

0.05-1.41

0.14-1.00

0.01-1.95

0.05-1.00

0.06-1.28

13

14

14

51

49

20

23

13

24

26

20

18

13

20

13

14

(Source:Andreyevaetal2010[103])

Chapter4

50


bestinterestsofallpartiesisevidentlynotbeingserved.IntheopinionofeconomistJohnCawley,marketfailurerepresentstheonlylegitimateeconomicbasisforgovernmentimposedregulation[108].Whilemanywhoworkinpreventativehealthmightconsiderthatpublichealthgainshouldbetheguidingprincipleindecisionmaking,theeconomicrationalealsoneedstobekeptinmindsincethatcanoftenbethestartingpointforthemajorityofelectedofficialsandpolicymakers.ThethirdprincipleofKim’soriginalframeworkforjustifyingfiscalinterventions,namelythatgovernmentshouldseektoprotectconsumers,wheremassiveinvestmentinthepromotionofunhealthyproductsmakesitdifficultforthemtotakeproperlyinformeddecisions,couldyetthereforebethemostpersuasive.

Asameansoftryingtoinfluencefooddecisionstobemoreoptimal,intermsofconsumerhealth,priceincentiveshaveaveryrealadvantageovermoreinformationbasedmeasuressuchasfoodlabelling,inthattheyarestructuralanddonotrelyonanindividualconsumer’simperfectknowledgetomakegoodchoices[94].Ofcourse,priceincentivesarealreadymuchusedinfoodmarketingandarealmostalwaysaimedatencouraginghigherconsumption(e.g.buyonegetonefree,kingsize/megamealdeals).Cheap,mass-producedfoodandsoftdrinksarehighlyprofitableindustries,buttheirrealcostsinhealthtermsareusuallydeferredandfallonwidersociety,includingpubliclyfundedhealthcaresystems.Inthiscontext,governmentimposedstructuralinterventionssuchassalestaxesonsugaredbeverages,areaveryrationalmeansofredress,particularlysincethosewhoarethemostpricesensitivetendtobegroupswhoaremostatriskorleastempoweredtomakegoodinformedchoices(e.g.theyoungandtherelativelysocioeconomicallydeprived).PowellandChaloupka’srecentexcellentreviewoftheprospectsforsuchmeasures[104],concludedthatnontrivialpricinginterventionshavearealpotentialtorealisemeasurableeffectsonpopulationlevelweightoutcomes.Whilethebalanceoftheevidenceatthemomentsuggeststhatanyresultingbehaviourchangeattheindividuallevelwouldbemarginalatbest,theproposaliseasilyrecognisableasaclassicpreventionparadox[109],withsignificantpotentialforpopulationandsocietallevelgains,inspiteofsmalleffectsattheindividuallevel.Inaddition,smalldecreasesindailyorweeklyenergyintakearethemselvesrecognisedasaneffectivemeansofachievingfavourablechangesinbodyweightandreducedrisksfromobesityrelateddiseasessuchasdiabetes[20].Ofcoursetheextenttowhichgovernmentsandregulatorybodiesmightbeinclinedtoadoptsuchstructuralfiscalmeasureswillnecessarilyberelatedtotheirperspectiveondecidingforconsumerswhattheirprioritiesshouldbe.Chapter8ofthisreportintroducesaframeworkwhichstakeholdersandpolicymakerscouldusetoexploresomeofthemoreinvolvedconsiderationsaroundimplementation,suchasethicsandsustainability.

4.3 Nutrition Interventions (micro-level)

PossiblythemostconclusiveevidenceofthecapacityofworkplaceinterventionstoimpactontypesoffoodconsumedcomesfromFrenchet al’smultiplevendingmachineinterventionbasedinfourlargebusgarages,whichhasstrongsimilaritiestothegroups’previous‘changingindividual’spurchaseofsnacks’or‘CHIPS’studyoncollegecampussites[110].Increasesintheavailabilityofhealthysnacksby50%,combinedwithaveragepricereductionsof31%,resultedin10%to42%highersalesoftheseitems[111]acrossthegarages.Astheauthorsthemselvespointout,therelianceonaggregatedatawasamajorlimitationofthestudy,meaningthatitwasnotpossibletoknowifindividualschangedtheirvendingmachineusefrequencyortheirchoices.Indeedthelackofanysignificantdifferencesbetweentheinterventionandcontrolgroupsintheselfreportingsurveyarmoftheevaluation,servestoraisesignificantquestionsovertheinterpretationoftheresults.Thepictureisfurthercomplicatedbytheuseofthemachinesnotbeingrestrictedtobusdriversbutavailabletoallgaragestaff.Theincreasedpurchasescouldsimplybeareflectionofmoreattractivepricingtoallgarageusers,orevenexistingusersmakingmultiplepurchaseswhichwouldcertainlyexplainthemagnitudeoftheincreases.

ArecentlypublishedelaboraterandomisedtrialfromNewZealandbyNiMhurchuandcolleagues,impressivelydemonstrateshowthesamepriceincentiveprinciplesthatweresuccessfullyemployedinworkplaceenvironmentscanbetransferredtothemoregeneralfoodretailingsetupofthesupermarketchain[112].Thetrialinvolvedeightsupermarketsand1,104shopperswhowererandomlyassignedtooneoffourinterventions(12.5%discountsonhealthierfoods;tailorednutritionadviceonly;12.5%discountplusnutritionadviceandfourthly,acontrolarmwithnointervention),deliveredover6months.Althoughtherewasnosignificantdifferenceintheprimaryoutcomeofamountofsaturatedfatpurchased

51

Chapter4

at6months(orothernutrientsintheassessment),thoseassignedtoreceivepricediscountsonhealthierfoodsbought11%moreofthesefoodsat6months(meandifference=0.79kg/wk;95%CI:0.43to1.16;P<0.001)and5%moreat12months(meandifference=0.38kg/wk;95%CI:0.01to0.76;P=0.045).Thecomplicateddesignoftheinterventiontendstosupporttheauthors’viewsthatthesearelikelytobeconservativeestimatesofthepotentialforimprovedpurchasing,sinceexploitingthediscountsreliedonshoppersconsultingalargelistofeligibleproductssenttothembypost.ThedesignalsonecessitatedtheusebyshoppersofhandheldscannerswhichindigenousNewZealandersinparticular,didnotparticularlyfeelcomfortablewith(NiMhurchu,personalcommunication).Thesignificanceofthe12.5%discountisthatthiscorrespondstothecurrentrateofsalestaxinNewZealand,leadingtothepotentialrecommendationofremovingthischargefromfruitandvegetablesasameansofimprovingconsumption.Theresultant11%increaseinpurchasingat6monthscorrespondstoanalmostunitarypriceelasticityof1.0andishigherthananyoftheotheritemsgivenintable4.2.

Summary

Economicinterventions–nutrition(macroandmicro)

• Substantialincreasesintheworldwideconsumptionofhighenergyfoodsandsugaredbeverageshaveparalleledthecurrentinternationalobesityepidemic.

• Evidencefromawidevarietyofstudies,includingrandomisedtrials,haveshownstrongassociationsbetweenpopulationlevelweightgainandtheconsumptionofhighenergyfoodsanddrinks.

• Althoughthereremainsomemethodologicalconcernsaroundfooddiaryreportingandlongtermsustainability,restrictionandsubstitutionstudiesinchildrenandadolescentshavereportedrealdifferencesinweightoutcomes,withthosewhoaremostoverweightseeingthegreatestbenefits.

• Softdrinkshavearelativelyhigh‘priceelasticity’,inthattheirpurchasebyconsumers,particularlythoseatriskfromobesity,orfrommoreeconomicallydisadvantagedgroups,ismorepricesensitivecomparedwithothertypesoffoods.

• Softdrinktaxationfulfilsallthecriteriaforgovernmentstoaddressa‘marketfailure’andreapsignificantpublichealthbenefits.

• Consumerpurchasinglevelsofhealthyfoodssuchasfruitandvegetablescanbeenhancedbymodestpricereductions.


Atthemacro-economiclevel,thecaseforinfrastructureinvestmentstosupportthesafetyandconvenienceofactivemodesoftravelhasbeencoveredinsomedetailpreviouslyinsection3.4.Chapter6furtherexploreshowmassmediacommunicationandlargescalepublicparticipationeventscanhelpchangeattitudesandencouragehigherparticipationratesinwalkingandcycling.Ofcourse,aswasalsohighlightedinchapter3,anincreasedprovisionofpublictransportcanalsoencouragetheuseofthesemoreactiveformsoftravel.Bythesametoken,increasingthecostsofprivatecartransport(e.g.parkingchargesetc),islikelytobeamajorcomponentofsuccessfulactivetravelpromotioninnorthernEuropeancountries(seesection3.4).


Thedifficultyinchangingthesedentaryhabitsofpersonswhoarerelativelyinactive,bothattheindividualandpopulationlevel,oftenrelatestothefactthatexerciseisnotseen,atleastinitially,asintrinsicallyrewardingenoughtomakeitanattractiveoption.Oneobviousandimmediatewayofaddressingtheapparent‘lackofreward’istoprovidefinancialincentivesforthetargetgrouptoundertakethenewbehaviour.Asdiscussedintheprecedingsection,financialdisincentivesintheformofadditionaltaxesontobaccoandalcoholareaprovenmeansofreducingconsumption,buttheeffectofpositivefinancialincentivesremainslessclear[55].Noneofthe17trials,inarecentCochraneReviewoftheeffectof

52


5incentivesonsmokingcessationforexample,showedhigherquit-ratesatsixmonths,whenincentiveswhereused[113].Tworecentrandomisedtrialslookedatfinancialincentivesforobesitypreventativemeasures,thefirstofwhichwasfocusedonincreasingphysicalactivityinsedentaryolderadults[114],andinthesecond,incentiveswereusedasameansofhelpingobeseadultsachieveweightloss[115].Strictlyspeaking,weightlossinobeseadultscouldmoreaccuratelybeconsideredastreatmentratherthanprevention,althoughanyeffectonestablishedelevatedBMIinthisgroupwouldcertainlybeofsignificantinteresttothosewithaninterestinobesityprevention.Althoughtheactivitypromotiontrialwasrestrictedtoaveryshortfollow-upperiodof4weeksandtheconveniencesamplemethodraisesconcernsovergeneralisability,theinterventiongrouploggedanaverageof4.1hoursperweekaerobicactivity(pedometermeasured),asopposedtothe2.3hoursperweekinthecontrolgroup.

Intheweightlosstargetstudy,reportedbyVolppandcolleagues[115],thereweretwoincentivisedgroups:onegroupreceivedlotteryticketswhentheyreachedmonthlyweightlosstargets,whiletheotherreceivedsupplementarypaymentsafterthemselvesmakingasmallfinancialcommitmentattheoutset(depositcontractgroup).Abouthalfofthesubjectsinbothcontrolgroupsmetthe16lbweightlosstargetat4months,comparedwithonlyaround1-in-10ofthecontrolgroup.Bothinterventiongroupshadregainedweightattheendoftheintervention,althoughatthe7monthfollowuptheywerestillsignificantlylighteronaveragethanatthestartofthestudy(figure4.3).Sinceweightre-gainisanalmostuniversalfeatureofsuccessfulinitialweightreductionprogrammes,theresultsinthiscasedoraisequestionsoverhowlongparticipantswouldneedtobe‘incentivised’tomaintainahealthyweight.

Figure 4.2 Weightlossfromenrolmentthroughinterventionand7-monthfollowup[115]

60

Figure 4.3 Weight loss from enrolment through intervention and 7-month follow up [115]

SUMMARY Financial incentives – physical activity • The evidence around financial incentive schemes and physical activity is largely restricted to

particular population subgroups, such as older adults and is difficult to separate from weight loss

interventions.

• As with incentive work in other areas, long term behaviour change remains elusive and the

sustainability of any benefits remain uncertain.

Formatted: Bulleted + Level: 1 +Aligned at: 0 cm + Indent at: 0.63cm

Summary

Financialincentives–physicalactivity

• Theevidencearoundfinancialincentiveschemesandphysicalactivityislargelyrestrictedtoparticularpopulationsubgroups,suchasolderadultsandisdifficulttoseparatefromweightlossinterventions.

• Aswithincentiveworkinotherareas,longtermbehaviourchangeremainselusiveandthesustainabilityofanybenefitsuncertain.

(Source:Volppet al2008[115])

53

Chapter6

5 Chapter 5 – Interventions in the legislative environment

5.1 Introduction

TheoriginalANGELOframeworkforprioritisingobesityinterventionsdefinesthelegislative(policy)environmentas‘encompassingthesumtotalofrulesandregulationswhichdealwithallaspectsoffoodandphysicalactivity’[13].ArecentCanadiansystematicreviewwhichalsousedtheANGELOcategorisationframeworkwasnotabletoidentifyanymacro-levelstudiesinthelegislativedomain[18].Thisislikelytobemoreareflectionofthedearthofpublishableevaluationsmeetingpeerreviewqualitycriteria,ratherthananyabsenceofideasormotivationbygovernmentstoimplementsolutionstorisingpopulationlevelsofoverweightandobesity.IndeedtheUKGovernment’sHealthyWeight,HealthyLives(HWHL)document18canbeconsideredtohavegenuinelytakenupthechallengesetoutintheForesightReportandpresentsacross-governmentstrategyforEnglandwithfourmajorpriorityareasforaction(aschapterheadings):

1. Helpingpeoplemakehealthierchoices

2. Creatinganenvironmentthatpromoteshealthyweight

3. Effectiveservicesforthoseatrisk

4. Strengtheningdelivery(includingsurveillance).

Althoughthestrategyhasastrongchildfocus,thechapteroncreatinganenvironmentthatpromoteshealthyweighttouchesonmanyofthesameissuesasthisreport(e.g.foodlabellingatpointofsale,coveredinsection5.2andincreasingopportunitiesfordailyactivitydiscussedindetailinsection3.3).ThereissomepreliminaryevidencealsotosuggestthattheHWHLprogrammemaybehavingabeneficialimpact,althoughtheauthorsofaoneyearevaluationconcedethatitisearlydaysandsomeapparentlevellingoffinthepopulationprevalenceofobesitygivesnoroomforcomplacency19.TheSwedishMinistryofHealthalsorecentlysetoutacomprehensivesetofcostedpolicyproposalsacrossallsectorsofgovernment,aimedattacklingobesity[26],althoughtherehaveasyetbeennopublishedupdatesonimplementationorevaluationatthetimeofwriting.Across-governmentstrategyforScotlandhasalsobeenpublishedearlierthisyear.EntitledtheRouteMaptowardsHealthyWeight20,thestrategyadoptedtakesaleadfromtheForesightReportandspecificallyfocusesonobesityprevention.BoththeForesightReportandtheRouteMaparediscussedinmoredetailinchapter7.

Theevolutionofgovernments’perceptionsoftheobesityepidemic,awayfromwhatwasinitiallyalifestyleissue,towardsitslaterrecognitionasapublichealthproblemwithstrongculturalandeconomicdrivers,hadbeguntoinfluencethepolicyplanninglandscapearoundobesityprevention.Cruciallyfromalegislativeperspective,onceobesityisrecognisedasapublichealththreat,itbecomeslegitimatetoconsiderregulatorymeasuresthatmayimpactonthelivesofprivatecitizens,inananalogousmannertothewaythatthelawisusedfor

Chapter5

18 Healthy Weight, Healthy Lives: A Cross Government Strategy for England, Dept of Health; 2009: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082378

19 Healthy Weight, Healthy Lives: One Year On, Dept of Health; 2009: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_097523

20 Preventing Overweight and Obesity in Scotland: A Route Map towards Healthy Weight. The Scottish Government; 2010. http://www.scotland.gov.uk/Publications/2010/02/17140721/

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thecontrolofcommunicablediseaseandrecentrestrictionsonsecondhandsmokinginpublicplacesarearelatedexample.Outrightsanctionsonbehaviourarenotfeasibleofcoursewitheitherdietorphysicalactivity,solegislativeinterventionsinthecaseofobesitypreventionneedtobedirectedatenvironmentalandstructuralenablers,suchasfinancialincentivesandtheimprovedavailabilityofhealthieralternativescombinedwithtargetedinformationapproaches.

5.2 Nutrition intervention (macro-level)

Atthemacro-levelofinfluence,thelegislativeenvironmentconcerningfoodreferstogovernmentfoodandnutritionpolicies,regulationsandlaws,andfoodindustrypracticesandstandards.Forthedevelopedwesternworldatleast,itisbecomingincreasinglyacceptedthatlegislationhasaroletoplayintacklingobesogenicaspectsofthenutritionenvironment[116].Legalsanctionscanpotentiallybeusedtocontrolcommercialfoodactivities,tomodifyphysicalandeconomicfactors(asdescribedinsections3and4),toregulatemediapractices(discussedinsection6)andtosupportinformedconsentbyrequiringtheprovisionofinformation.Thefourmacro-levellegislativeinterventionswhichhaveattractedthemostattentionandforwhichthereissomeevidencearoundtheirpotentialeffectivenessare:

(i) tradetariffs/restrictionsonspecificfooditemsoringredients

(ii) foodlabellingregulations

(iii) industrialandagriculturalpolicyframeworks

(iv)foodmarketingandadvertising(discussedinchapter6).

i. Trade tariffs/restrictions on specific food items or ingredients

Thepotentialforpricingcontrolsasameansofinfluencingpurchasingpatternshasalreadybeenexploredinrelationtosugaredbeverages(section4).Forcountrieswiththecapabilityandwillingnesstomakeuseofthem,tradetariffsandrestrictionscouldformthebasisofamuchbroader,proactiveapproachtoimprovepopulationdiets.Inprincipleforexample,traderestrictionscouldbeusedtoreducetheamountimported,orincreasethequalityofparticularfoodstuffs,dependingontheirrelative‘obesogenicity’.InthelightofFrenchandcolleagues’vending-machinestudiesdiscussedinchapter4,thereisalsothepossibilityofreducedimporttariffsforhealthierfoods,althoughtodatethishasnotbeenimplementedinanyknownjurisdiction[117].OneofthemostnotableexamplesofwheretraderegulationshaverecentlybeenusedtotryandreducesupplyatsourceistheattemptbythePacificIslandofFijitobanaparticulartypeofmeatimport(muttonflaps).Withover60%oftheadultpopulationeitheroverweightorobese,FijiistypicalamongPacificIslandcommunitiesinhavingamajorproblemwithchildhoodandadultobesity,aswellasepidemicleveldiabetes[118]andpoordietisacknowledgedtobeanimportantpartoftheexplanation.SincethePacificislandsnowimportmostoftheirfood,controllingwhatisavailableshouldinprinciplebestraightforwardandcheapfattymeatsfromNewZealandandAustraliawereanidentifiablecontributiontotheexcessivelyhighfatdietofFijians.Anattempttobanimportedmuttonflaps(seefigure5.1)in2000usingaprohibitionorderunderFairTradelegislation,hasonlybeenpartiallyeffective,sincewholecarcassescanstillbeimportedgivingimportersanotherrouteofentry.Themeasurewasalsochallengedasanunfairtraderestrictionsinceothersimilarlyhighfatmeatimportswerenottreatedsimilarly.Thecaseillustratesthecomplexityofusingtraderestrictionstocontrolfoodproducts.WhiletheWorldTradeOrganisation’sGATT21provisionsallowtrademeasurestobeadoptedthatare:‘necessarytoprotecthuman/animalhealth’,anysuchproposednewmeasuremustyetfulfilwhatisessentiallyaveryoneroustwostagetest,inwhichthetraderestrictingcountrymustbeabletodemonstratethat:

1. Thehealthmeasureisbotheffectiveandthatnolessrestrictivetrademeasure(s)couldbeusedtoachievethesamepublichealthpurpose

2. Theproposaldoesnotconstitutea‘disguisedrestriction’oninternationaltradeor‘arbitraryorunjustifiablediscrimination’.

21 General Agreement on Tariffs and Trade. World Trade Organization; 1994 http://www.wto.org/english/tratop_e/gatt_e/gatt_e.htm

55

Chapter5

Figure 5.1 MuttonflapswhichFijiattemptedtobanasanimport

63

depending on their relative ‘obesogenicity’. In the light of French and colleagues’ vending-machine

studies discussed in chapter 4, there is also the possibility of reduced import tariffs for healthier

foods, although to date this has not been implemented in any known jurisdiction [117]. One of the

most notable examples of where trade regulations have recently been used to try and reduce supply

at source is the attempt by the Pacific Island of Fiji to ban a particular type of meat import (mutton

flaps). With over 60% of the adult population either overweight or obese, Fiji is typical among Pacific

Island communities in having a major problem with childhood and adult obesity, as well as epidemic

level diabetes [118] and poor diet is acknowledged to be an important part of the explanation. Since

the Pacific islands now import most of their food, controlling what is available should in principle be

straightforward and cheap fatty meats from New Zealand and Australia were an identifiable

contribution to the excessively high fat diet of Fijians. An attempt to ban imported mutton flaps (see

figure 5.1) in 2000 using a prohibition order under Fair Trade legislation, has only been partially

effective, since whole carcasses can still be imported giving importers another route of entry. The

measure was also challenged as an unfair trade restriction since other similarly high fat meat

imports were not treated similarly. The case illustrates the complexity of using trade restrictions to

control food products. While the World Trade Organisation’s GATT19

1. The health measure is both effective and that no less restrictive trade measure(s) could be

used to achieve the same public health purpose.

provisions allow trade

measures to be adopted that are: ‘necessary to protect human/animal health’, any such proposed

new measure must yet fulfil what is essentially a very onerous two stage test, in which the trade

restricting country must be able to demonstrate that:

2. The proposal does not constitute a ‘disguised restriction’ on international trade or ‘arbitrary

or unjustifiable discrimination’.

Figure 5.1 (Right) Mutton flaps which Fiji attempted to

ban as an import

While the application of trade agreements to health

regulation can be complex and challenging, as

discovered in Fiji, there have been more successful

strategies in other parts of the world. The West African

19 General Agreement on Tariffs and Trade. World Trade Organization; 1994 http://www.wto.org/english/tratop_e/gatt_e/gatt_e.htm

Whiletheapplicationoftradeagreementstohealthregulationcanbecomplexandchallenging,asdiscoveredinFiji,therehavebeenmoresuccessfulstrategiesinotherpartsoftheworld.TheWestAfricanstateofGhanaforinstance,hasimplementedaneffectivebanonfattymeatimportsbysettingnutrientcompositionthresholdsforbeef,porkandmutton(maximumfatcontentsof25%,42%and35%respectively).WhiletheUSGovernmentinitiallyraisedanobjectionoverthistrademeasure,thenon-profitCSPI(CenterforScienceinthePublicInterest)hastakenthepositionthatGhana’sactionsconstitute‘alegitimateattempttoprotecthumanhealth’[119].AlthoughtherearecurrentlyUKrestrictionsontheminimummeatcontentofcommercialfoodproducts,theseoriginateinthemainfromtradedescriptionrequirements,andarenotgenerallyinformedbyhealthconsiderations.Sincemeatproductsrepresentoneofthelargestsourcesofdietaryfats(particularlysaturatedfats),itmakessensetoconsiderthresholdsforfatcontentonhealthgrounds.

AlthoughtheimplementationofanyimportrestrictionsinthiscountrywouldalmostcertainlyneedfullUKintegrationbeyondScotlandaswellasEUtradeclearance,theimpositionofaneffective‘fattymeat’baninarelativelyimpoverishedWestAfricanstatesuchasGhana,atleastoffersanexampleofwhatmightbepossible.Closertohome,Denmarkimplementedabanontrans-fats(fatsandoilswhichhavebeenchemicallyprocessedtoincreasetheirhardnessandshelflife)in200322.Whilethesefatsarenotnecessarilyproventobemoreobesogenicthannaturalsaturatedfats,thereisnowastrongscientificconsensusthattheyarepotentpromotersofcardiovasculardiseasetotheextentthattheremaybenosafeminimumthresholdforconsumption[120].Whiletherewasinitiallyagreatdealofoppositionasfoodproducersexperimentedwithalternatives,theseproblemshavelargelybeenresolvedandthereisalreadypreliminaryevidence(todatenotscientificallyverified)thatthebanhasbeenassociatedwithareductioninheartdiseasemortality23.Crucially,Denmark’sactionsalsodemonstratethatthereisnothinginEUlawtostopotherEUcountries(includingtheUK),fromundertakingsimilarmeasures.Thefulleconomicimplicationsofanysuchbansorfoodqualitythresholds,suchastheGhanianrestrictions,wouldofcourseneedtobecarefullyconsideredanddomesticmeatsourcesofpoorqualitysubjectedtosimilarrestrictions.

22 Denmark's trans fat law. Executive Order No 160 of 11 March 2003 on the Content of Trans Fatty Acids in Oils and Fats etc, (English Translation) http://www.tfx.org.uk/page116.html

23 Trans Fat Restriction in Denmark Offers Success Story for Similar Initiative in New York City. http://www.naturalnews.com/020788.html

(Source:Bookfrontcoverimage:DeborahGewertzandFrederickErrington,Cheap Meat: Flap Food Nations in the Pacific Islands.©2010bytheRegentsoftheUniversityofCalifornia.PublishedbytheUniversityofCaliforniaPress[photocourtesyofC.Keleba([email protected])].

56


ii. Food labelling regulations

Thecomplexitiesinvolvedinrestrictinglesshealthyfoodsatsource,combinedwithageneralreluctancetoimpingeonconsumerchoiceinwesterndevelopedeconomies,meansthatthemajorityoflegislativecontrolmeasureshavebeenaroundobligationstoprovideinformationonthenutritionalqualityoffoods.Pre-packagedfoodsinparticulargenerallycontainhighlevelsofsugar,saturatedfat,andsalt,allofwhichtheWHOhasrecommendedreducingtohelpreduceobesityandnutritionrelateddiseases24.FoodlabellingintheUKisgovernedbytheFoodLabellingRegulations199625,inaccordancewithEuropeanlaw.Informationonthenutritionalcontentoffoodproductsisonlyrequiredwhenanutritionalclaimismadebythemanufacturer,andfoodcontents/ingredientsarerequiredtobelabelledinaprescribedformat.Theinformationgivenisnotnecessarilyaddressedtothelaypurchaserandisnotalwayseasytointerpret,withmany‘lowfat’foodsforexample,notspecifyingtheirhighsugarcontent.Asaresult,campaignershavebeencallingfornewfoodlabellingprovisionsthatwouldhelpconsumersmakehealthierchoiceswithouthavingtoundertake‘mathematicalcalculationsatthepointofpurchase’[116].SinceatpresenttherearenobindingagreementsoranystandardEuropeanguidelinesonfrontofpacklabelling,anumberofdifferentformatsarecurrentlyinuseincludingthe‘trafficlight’system26favouredbytheUKFoodStandardsAgency(FSA)andsupportedbytheFacultyofPublicHealthandleadingconsumerprotectionorganisations.

TheongoinglackofafullconsensusontheformatofnutritionlabellingpromptedtheFSAtorecentlyundertakesomequalitativeresearchonwhatconsumersarelookingforfrominformationlabels[121].Consistingof10focusgroupstylesessionswithasocioeconomicallyrepresentativesampleofparticipants,thefindingsconfirmedthattherewereissuesoverlegibility,anddifficultiesarisingfromthevariedsystemsusedbydifferentmanufacturers.Consumerswerehowevergenerallykeentoretainmostoftheinformationthatisshowncurrentlyonfoodpackaging,astheyclaimtouseitateither‘pointofpurchase’or‘pointofusage’.Identifiedprioritiesforimprovinglabellingpracticesfromaconsumerperspectivewerearoundstandardisingarangeofaspectsofpackdesign,specifically:

• Placingrelatedinformationtogetheringroups(toassistintuitivesearching)

• Standardisingwheregroupsofinformationarefound(suchasonthefront,backorinsideofpacks)andhowitisdisplayed(e.g.consistentuseoficonsora‘contains’box)

• Usingbestpracticedesignprinciples(suchas,useofboxesandcolourcodingfordelineatingdifferentinformation).

BasedoncoreprinciplesdevelopedbytheFSAandusedbyavarietyofmanufacturersandretailers,trafficlightfoodlabelshelpconsumersmakehealthierfoodchoicesbychoosingmoreproductswithgreenoramberlightsthanred(seefigure5.2).Theyalsoenablecomparisonsbetweensimilarproductsandthesystemhasbeenfoundtobeparticularlyusefulforpre-preparedandprocessedfoodssuchasreadymeals,breakfastcerealsandprocessedmeatproducts,whichcanoftencontainunexpectedlyhighlevelsofconcealedfat,sugarsandsalt27.

24 Diet, Nutrition and the Prevention of Chronic Diseases. World Health Organization. Report of the Joint WHO/FAO Expert Consultation. http://www.who.int/dietphysicalactivity/publications/trs916/en/

25 The Food Labelling Regulations 1996 [Statutory Instrument No1499] http://www.opsi.gov.uk/si/si1996/Uksi_19961499_en_1.htm#end26 Traffic light labelling. Food Standards Agency. Eat Well, Be Well http://www.eatwell.gov.uk/foodlables/trafficlights27 Traffic Light Food Labelling: A Position Statement for the Faculty of Public Health; August 2008. http://www.fphm.org.uk/resources/AtoZ/ps_food_labelling.pdf

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Chapter5

Figure 5.2 Multipletrafficlightlabels

ArecentrandomisedstudywithGermanconsumers[122],comparedfourdifferentformatsoffoodlabels:(1)asimple‘healthychoice’tick;(2)amultipletrafficlightlabel;(3)amonochromeGuidelineDailyAmount(GDA)label;(4)acolouredGDAlabel;and(5)a‘nolabel’condition.ConsistentwiththeFSApreferredformat,thelabelsfoundtobemostusefulwerethemultipletrafficlightlabels(figure5.2),althoughanincreaseinperceivedhealthvaluedidnotsignificantlyinfluencefoodpurchasingorconsumption.Theverywideconfidenceintervalsaroundmosteffectslistedintable5.1however,dosuggestthatthestudywasunder-poweredintermsofsamplesize.SimilarresearchwithconsumersinAustralia[123],foundstrongsupportfortheintroductionofconsistentlabellingandthatshopperswerefivetimesmorelikelytoidentifyhealthierfoodsusinganFSA-styletrafficlightsystem,comparedwithamonochromepercentagedailyintakesystem[oddsratio(OR)=5.18;p<0.001],andthreetimesmorelikelycomparedwiththecolourcodedpercentagedailyintakesystem(OR=3.01;p<0.05).Thetrafficlightlabelswereparticularlybeneficialforthoseinlowersocioeconomicgroups(table5.1),sincethiswastheformatwiththebroadestintelligibilityacrossallthreesocialgroups.

Table 5.1 The odds ratio [OR; 95% CI] of correctly identifying the healthy products from both sets of food products, according to labelling system and socioeconomic status (SES) *p<0.05

Trafficlight

Trafficlight+overallrating

Monochrome%DI

Colour-coded%DI

1.0

1.0

1.0

1.0

Tertile1(referencegroup,mostdisadvantaged)

Labellingsystem Socioeconomicstatus

Tertile2OR(95%CI)

Tertile3(leastdisadvantaged),OR(95%CI)

1.1(0.3–3.9)

4.4(0.5–39.0)

1.3(0.5–3.4)

0.8(0.2–2.9)

3.7(0.4–31.7)

0.7(0.2–2.5)

6.3(1.4–29.2)*

1.4(0.3–6.1)

(Source:Kellyetal2009[123]

(Source:FoodStandardsAgency–TrafficLightLabelling2010[ArchivedContent]).

58


Fromapublichealthperspectiveofcourse,thecasefortrafficlightlabelswouldbemostsupportedbyevidenceofanimpactonpurchasingbehaviourtowardshealthierproducts,whichtodatehasbeenconfinedtoretailindustrysourcesandanecdotalreports[124].Arecentshort-termquasi-experimentalstudyinvolvingamajorUKretailer,andfocusingonsandwichesandreadymeals,soughttoexaminewhethertheintroductionoftrafficlightfoodlabellingwouldhaveanydiscernableeffectonpurchasing[125].Whilethereweresmallbutstatisticallysignificantincreasesinpurchasesoftheselectedreadymeals,therewasnochangeinsandwichsales.Morecritically,therewasnoassociationbetweenchangesinproductsalesandtherelativehealthmeritsoftheproducts.Whileitcouldbearguedthatthefourweekinterventionwastoolimitedindurationandthattheresultsmighthavebeenbetterhadamorecomprehensiverangeofproductsbeenincluded,thefindingsareneverthelessconsistentwiththeGermanandAustralianstudies[122,123]andwouldtendtosuggestthatprovidingmoreintelligiblehealthinformationaloneisnotaparticularlyeffectivemeansofinfluencingcustomerbehaviour.

Evidencethattrafficlightlabellingformatsencouragemanufacturerstoreformulateproducts,inorderthattheyqualifyformoreamberandgreensymbols,wasuntilrecentlyconfinedtoindustrysources[126].ArecentlypublishedpersuasivereportfromtheNetherlandshoweverwasabletodocumentfavourableproductmodifications(particularlywithregardtofibreandsalt)inresponsetoalabellingscheme[127].AneditorialinTheGrocer(amajortradepublicationforfoodmanufacturersandretailers),waslessencouragingandhighlightedthelackofameasurableinfluenceonpurchasingbehaviourasareasonforabandoningthetrafficlightschemealtogether28.Withouttheauthoritytomandatetheirpreferredmodel,theFSAinalllikelihoodhadnoalternativeotherthantoadoptapragmaticcoursewithmajorretailersandmanufacturersandacceptthatsomewouldusetheirownpreferredformat.AnEUParliamentproposalforaEuropeanwidemandatetointroducecompulsorytrafficlightlabellingwasalsodefeatedinJuneofthisyear,mainlyasaresultofintenselobbyingfromfoodcompanies29.Apublishedcosteffectivenessanalysisfromahealthcareperspectivehoweverfoundthatevenmodestchangesinbuyingbehaviourthatresultedfromtrafficlightstylelabellingwouldofferexcellentvalueformoney[128].

Sincethetrafficlightlabellingsystemisnowinternationallyacknowledgedasthe‘goldstandard’forpromotingsociallyequitableconsumerawareness(basedonstudieslikethosecitedabove),thedefeatofthepolicyhasbeendescribedasaretrogradestepbyconsumergroups30.Infairnesshowever,itshouldbepointedoutthatanumberofUKretailershaveinfactintroducedfrontofpacktrafficlightstylelabellingasstandard,includingseverallargesupermarketchains.Thenatureoftheevidencehighlightsalsothatfrontofpacklabellingisonlylikelytobeeffectiveininfluencingactualpurchasingbehaviour,ifintroducedaspartofapackageofinterventions,suchasthepricingandsocialmarketingstrategiesreferredtoinchapter4.

iii. Industrial and agricultural policy frameworks

Nutritionexpertsgenerallyagreethatminimallyprocessedfoodshelpprotectagainstobesitybyvirtueoftheirlowerenergycomparedtotheirmorerefinedandprocessedequivalents[48].Industryprofitmarginsontheotherhand,arefargreaterfromhighlyprocessed,commodityderivedproductssuchassnackfoodsandbeverageswhichareprimarilycomposedofrefinedstarch,concentratedsugarsandlowqualityfats.Thesecheapfoodstuffsaremadeevenmoreinexpensivebysubstantialagriculturalsubsidiesatthenationallevel(seenextparagraph).Obesitypreventionmessagestherefore,suchascallstoeatlessoften,eatsmallerportions,andavoidhighcaloriefoodsoflow-nutritionalquality,effectivelyunderminethefundamentalbusinessmodelofmostofthecommercialfoodindustry[129].Whilethereareenlightenedfoodcompanies,societycannotgenerallyexpect

28 So consumers ignore healthy-eating labels – and get slimmer anyway. The Grocer (Editorial) Nov 2009. http://www.thegrocer.co.uk/articles.aspx?page=articles&ID=204860

29 MEPs Reject Traffic Light Scheme for Food Products. The Parliament.com (EU); June 2010 http://www.theparliament.com/latest-news/article/newsarticle/meps-reject-traffic-light-scheme-for-food-products/

30 Industry Lobbying Sees EU Reject 'Traffic Light' Food Labelling. The Ecologist; 17 June 2010. http://www.theecologist.org/News/news_round_up/511976/industry_lobbying_sees_eu_reject_traffic_light_food_labelling.html

59

longtermpublichealthbenefitstobeplacedbeforetheneedforcommercialorganisationstomakeaprofit.Itisclearthenthatthereneedstobeameasureofprotection,possiblyintheformofminimumnutritionalstandards,whichwouldallowcompaniesthataremoreinclinedtoengagewithdietaryimprovementattheveryleastnottobepenalised.Suchcompanieswouldthenbemotivatedtofocusonwhatthefoodindustryhasmanifestlyshownitcandowell,whichistofindcreativewaystosatisfygenuineconsumerneedsandinturnmakehealthfulfoodchoiceseconomical,attractive,convenientandpalatable[129].

WhileasubstantiveanalysisofpostsecondworldwaragriculturalpoliciesinEuropeandtheUSisoutsidethescopeofthisreview,theirintrinsicorientation–towardsprotectingagainstfoodshortagesandincentivisinghighlevelsofefficientfoodproduction–hassubstantiallycontributedtothecurrent‘foodenergyexcess’environmentthathashelpedfuelpopulationweightgain.TheEuropeanUnionforinstance,spendsaroundhalfofitsentirebudgetoraround€55billionperannum,financingtheCommonAgriculturalPolicy(orCAP),inaframeworkwhichmainlysupportsdairyandbeeffarmersattheexpenseoffruitandvegetableproducers.AfarsightedreviewpaperproducedbytheUKFacultyofPublicHealthin200731,highlightedtheovertlinksbetweenheavilysubsidiseddairy,redmeatandsugarproductionandpoordiet,viathemechanismsofpriceandavailability‘engineered’byCAPfundingarrangements.Relativelyhighpricesforfruitandvegetablesarealsoartificiallymaintainedthroughlargescaledisposalofsurplusesintheeventofbumpercrops.ThepaperarguesthatwhiletheoriginalaimsofCAParoundeliminatingfoodshortagesandcombatingruralpovertywerewellintentioned,theirmainlegacytodayisanexacerbationofsystemichealthinequalities,inthatfoodswithhighlevelsofsaturatedfatandrefinedsugararethemostaffordableforthoseonlowincomes.Figure5.3showsacomparisonofselectedweeklyUKhouseholdfooditempurchasesonthebasisofrelativedeprivation.

Figure 5.3 Selectedfoodpurchasesbyhouseholdincome(gramsperpersonperweek,exceptwhereotherwisestated,averageApril2002toMarch2005

(Source:DEFRA32)

31 A CAP on Health? The Impact of the EU Common Agricultural Policy on Public Health. Faculty of Public Health; 2007. http://www.fphm.org.uk/resources/atoz/r_CAP.pdf

32 Source: DEFRA Family Food 2004–2005: http://www.defra.gov.uk/evidence/statistics/foodfarm/food/familyfood/documents/familyfood-2005.pdf

Chapter5

0

500

1000

1500

2000

2500

Milk & Cream (ml)

Meat Products

Fats & Oils Sugars & Preserves

Vegetables excl.

potatoes

Fruit

Lowest Income Quintile

Highest Income Quintile

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Thefacultydiscussionpaperarguesthatbyimplication,hundredsofthousandsofprematuredeathsacrosstheEUcouldbelinkedtotheadverseeffectsofCAPsubsidiesandthatthereisapressingneedforreformofthepolicy,ifdietsaretobegenuinelyimprovedandcontributelessovertlytopopulationweightgain.TheirsummaryrecommendationstoEUpolicymakerswere:

• reducesubsidiesforbeefwhileencouragingmoreleanbeefproduction

• reducesubsidiesfordairyproductsandconvertexcessdairyfatintoindustrialproductssuchasfuelandlubricants,ratherthanfoodproducts

• ensureonlylowfatdairyproductsaresubsidisedforthe‘notforprofit’sector

• increasetheproductionofmonounsaturatedandpolyunsaturatedvegetableoils

• makegreateruseofCAPsubsidiestoincentivisetheproductionoffruitandvegetables

• increasetheavailabilityoffruitandvegetablestothe‘notforprofit’sectorthroughsubsidies

• continuetoencouragecerealgrowerssectortoproducemoreunrefinedfoodforhumanconsumption.

Obviouslythesemeasuresneedtobeseenaspartofalongtermstrategyandsubstantialconsiderationwouldhavetobegiventowardsminimisingthedisruptiontoruraleconomies,ensuringfoodsafety,facilitatingsustainableproductionandpreventinganimalcruelty.ThemeansbywhichScotlandcouldbestinfluenceEU-widepolicywouldalsobequestionable,wereitnotforthefactthattherestoftheUKandallEUcountries(aswellastherestofthedevelopedworld)are,toagreaterorlesserdegree,seeingthesameadverseimpactsofagriculturalpoliciesdesignedaroundprioritiesthatwereoriginallysetinthemiddleofthelastcentury.Thefutilityofexhortingpopulationstoeatmorehealthily,whenthewholesystemofEUandworldfoodproductionisaimingsquarelyintheotherdirection,isdifficulttooverlook.Inordertobecredibletherefore,anygovernmentapproachtoobesitypreventionneedsattheveryleasttobemindfuloftheadverseeffectsofdominantagriculturalpolicies.Asasignificantfoodanddrinkexporter,Scotlandshouldbeabletocontributetotheinternationaldebatearoundreformingagribusinesstradeagreements.SomecommentatorsforinstancehavelookedatthecaseforreducingEUsubsidiesasameansofbringingtheEUmoreintolinewiththefreetradeprinciplesofGATT[130].

5.3 Nutrition intervention (micro-level)

Asoutlinedin5.2,tacklingtheobesogenicfoodenvironmentatthenationallevelwillnecessarilyinvolvesomefundamentalchallengestothewayfoodstuffsarecurrentlydistributedandsold.ThereisalsothequestionoftheextenttowhichScotlandwouldbeabletoactindependentlyoftheUKonsuchmatters,eveniftherewasastrongpoliticalwilltodoso.Justaswitheconomicinterventionshowever,thereiscertainlyscopeformicro-legislativeinterventionsinthemoreself-containedenvironmentsinwhichpeoplespendmuchoftheirdailylives,namelyeducationalestablishmentsandworkplaces.Cateringwithinthepublicsector,particularlyincountrieslikeScotland,wherepublicemployeesaccountforarelativelyhighproportionoftheworkforce,presentsaperfectopportunitytodemonstratethatitcanbepossibletoeathealthilyonamodestdiet.NHSassociatedinformationcampaignsonhealthyeatingwillalsocarrymorecredibilityifhospitalsitecanteensandeatingpremisesarerecognisedforgoodqualitybalancedmeals33.Commercialcateringpremises(hotels,restaurantsandtakeaways)arealsosignificantlyregulatedbylocalenvironmentalhealthdepartmentsandanexpandedconceptoffoodsafetytoincorporate‘obesogenicity’couldintheorybelocallyenforceable.ThisisanapproachwhichhasbeenusedsuccessfullyinNewYorkandCaliforniawhereallcateringestablishmentsarenowrequiredtodisplaycalorieinformationatthepointofsaleandthereareplanstoextendasimilarrequirementacrossthewholeoftheUS34.Thissectionwillsummarisetheprogressofsuchmicro-legislativeapproacheswheretheyhavebeenused,andexplorewhatmightbethebestoptionstotakeforwardinaScottishcontext.Sinceworkplacenutritioninterventionshavealreadybeendiscussedinchapter4,theemphasisherewillbeonthepotentialforactionaroundcommercialfoodcaterersandoutlets.

33 Hospital Restaurant Scoops National Healthy Eating Award. News release. Scottish Consumers Council; April 2007. http://www.healthylivingaward.co.uk/press%20releases/hairmyrespr.pdf

34 Calorie Data to Be Posted at Most Chains. The New York Times (Business); Mar 2010 http://www.nytimes.com/2010/03/24/business/24menu.html

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Oneobviousstrategyforimplementingpublichealthmeasures,wherethereisalackofstrongevidence(orconsensus)oneffectiveness,issimplyto‘thinklocal’andproceedonthebasisoflocalpilotareasinthefirstinstance.Ashighlightedabove,thisisanapproachwhichisbeginningtoacquireconsiderablemomentumintheUSwhere,inananalogousmannertocommercialbusinesses,theinterventionswhichworkthebestarethemselvesthenpropagatedtootherareas.ThepreviouslymentionedeffortstocontroltheuseofartificialtransfatsinNewYorkrestaurantsisanexcellentexampleofgradedinterventionthroughtheinitialuseofeducationalandvoluntarymeasures,towardstheeventualimplementationofastatutoryrestriction.Inanengagingaccountoftheprocess,Angellandcolleaguesrecentlydescribedthekeystagesbuildinguptolegislativeenforcement,asinformationandguidancebasedmeasuresprovedlargelyineffective[52].ByJune2008,onthebasisofstatutoryinspectionreports,99%ofallrestaurantshadsuccessfullyadaptedtothetrans-fatfryoilandspreadrestrictionwithin18monthsofthelegislationbeingpassed(seefigure5.4).TwoyearsafterNewYorkCity'saction,12USAlocalgovernmentsandonestatehadadoptedsimilarmeasuresandtheimpactisbeingmonitoredatnationalgovernmentlevel[131].ThesuccessoftheNewYorkmeasurecanessentiallybeattributedtothreefactors:

(i) Theinitialinformationbasedcampaignwhichraisedindustryawarenessandgeneratedpublicsupport

(ii) Thecapacitytomakeuseofexistingpublichealthinfrastructureforimplementationandenforcement

(iii)Thelackofanyadverseeconomicimpactwhatsoever,sinceallestablishmentsweretreatedthesameandsuppliersquicklyadapted.

Themostcompellingaspectfromapublichealthpointofview,whencomparedtoaninformationbasedcampaign(asfavouredbyretailers),isthatavoidanceoftheriskisnotdependentontheindividualconsumer’sknowledge.Thisisespeciallyrelevantwhenconsideringthehealthneedsforthemorevulnerablesectorsofthepopulation,especiallychildren(whoareparticularlypronetodisregardfuture

Figure 5.4 NewYorkCityrestrictionofartificialtransfat.Reductioninuseinfrying,bakingorcookingorinspreads.

Notes:Datafrom2005to2007arefromsurveys.JulyandNovember2008dataarebasedonrestaurantcompliancedatacollectedduringregularlyscheduledinspections.Compliancedataarefurtheradjustedtobeconsistentwithsurveydenominator.*Phase1oftheregulationonlycoveredfatsusedforfryingorasaspread.Phase2coveredallotherfoodsandingredients.

100

90

80

70

60

50

40

30

20

10

0

June2005

December2005

December2006

December2007

December2008

June2005

June2007

June2008

EducationCampaign

HealthCodeRestrictionPassed Phase1

Effective*

Phase2Effective*

Survey1 Survey2 Survey3

InspectionCompliance

50% 51%43%

1.9% 1.6%

(Source:Angellet al2009[52])

62


healthrisks)andlowersocioeconomicgroups(whoaretheleastlikelytobewellinformedabouthiddenhealthrisks).Ofcourse,theassumptionthatextendingthesamelogictorestrictionsonspecificenergydensefoodproductstotackleobesitywouldbesimilarlyeffectiveisproblematicsincethereisanaddedbehaviouralcomponenttosuchfoodchoicesandissuesaroundsubstitutionwithotherhighenergy/lownutritionalvaluefoodsarerarelyexplored.

Summary

Legislativeinterventions–nutrition(macroandmicro)

• Trafficlightformat‘front-of-pack’foodlabellingisclearlythemostintelligibleandaccessiblemeansofconveyingnutritionalinformationtoconsumers,althoughitscapacitybyitself,toimpactfavourablyonpurchasingbehaviourhasyettobedemonstrated.

• RecentevidencefromwithinEuropehasprovidedpreliminaryconfirmationthattrafficlightstylefoodlabelscanencourageproductreformulationbymanufacturers.

• Foodenergyoverconsumptioninwesternadvancedsocietiesiscloselytiedupwithoverproduction,whichhasresultedfromdeliberateagriculturalsubsidyframeworksthatwereoriginallyintendedtopreventshortages.Ashiftinemphasistowardstheproductionoflessenergydensewholefoods,aswellasfruitsandvegetableswouldhelpredressthecurrentimbalance.

• Mandatorylegislation,thatmakesuseofexistingpublichealthmonitoringstructures,isaneffectiveandrapidmechanismforintroducingfavourablechangesintothecommercialcateringindustry,particularlywhereinformationbasedguidancehasnothadanyimpact.


Whilegovernmentsbynecessityexertacertainamountofcontroloverthefoodsupply,thesamecannotbesaidforpopulationlevelsofphysicalactivity.Asdiscussedpreviouslyinchapter3however,therearemanyfeaturesofthebuiltenvironmentwhichimpactonlikelylevelsofphysicalactivity,mostnotablyperceptionsofroadsafetyaswellaspersonalsafetyandaccesstolocalamenities.TheForesightReport[2],referredtoinchapter2,emphasisedtheneedforplannersandpolicymakerstoundertakespecialisedobesityfocused‘healthimpactassessments’whenintroducingnewpoliciesandchangestothebuiltenvironment.Theironespecificproposalaroundactivitycalledformeasurestoincreasethewalkabilityandcyclabilityofthebuiltenvironment.ThetransportinfrastructurecomparisonswithmainlandEurope,alsocoveredinchapter3,demonstratewhatmightbepossible,butatthesametimehighlighttheverysubstantialchangesinthinkingthatneedtotakeplaceatalllevelsofgovernment.WhilevisionaryreportslikethatproducedbytheForesightteam,allowforsomeguardedoptimism,theimplementationofsubstantialpoliticalinterventionshastodateintheUKbeeninconsistentatbest[132].Amongthemorepromisingapproaches,hasbeentheDepartmentofHealth’sChange4Lifecampaign,discussedinchapter6and,intheareaofstructuralchangestosupportactivetravel,theestablishmentofsixcyclingdemonstrationtowns(CDTs).InOctober2005,CyclingEnglandestablishedsixCDTsinEngland.Thetownswerechosenfollowingacompetitiveprocess,andwereawardedfundingtoenablethemtotakeacomprehensiveapproachtopromotingcyclingthroughacombinationofdedicatedfacilities,capitalinvestmentsandeducationalcampaigns.Thetownseachreceivedfundingof£500,000peryearwhich,withmatchedfundingfromthelocalauthority,equatedto£10perheadofpopulationperyear(detailsofthetownsandtheircyclepromotionprogrammesareavailablefromtheCyclingEnglandwebsite35).Usingdatafromautomaticcyclecounters,themeanincreaseincyclinglevelsacrossallsixtownswas27%(basedon%differencebetween2006and2008).Table5.2showschangesinthepercentagesofpeopleparticipatingincyclingcomparedtonon-demonstrationtowns.

35 http://www.dft.gov.uk/cyclingengland/cycling-cities-towns/results/

63

Chapter5

Althoughanincreaseisevident,themodestextentoftheimprovement,fromaround12%to15%,isperhapsunlikelytobeseenasaworthwhileinfrastructureinvestmentonthebasisofbehaviourchangeresultsalone.Inorderforgovernmenttobewillingtomakethesubstantialcapitalinvestmentsthatwouldberequiredtosupportwiderimplementationofsuchprogrammes,decisionmakersmightunderstandablywishtohearaboutthecosteffectivenessandcostbenefitsof‘active-travel’orientatedstructuralimprovements.Tothisend,theWHORegionalOfficeforEuroperecentlyconvenedanexpertpaneltodevelopamethodologicallyrobusttoolthatwouldbeabletoquantifythecostsavingsattributabletowalkingandcyclingimprovements[133].TheresultingHealthEconomicAssessmentTool(HEAT)forcyclingiscurrentlybeingusedinanumberofEUcountriesincludingScotland.AlthoughHEATusesonlythelikelyreductionsinmortalitywhichincreasedcyclingwouldleadto(andisthereforelikelytounderestimatethehealthbenefitsperunitcost),theresultinganticipatedhealthsavingsareneverthelesssubstantial.ResultsofapplyingthemodelinScotlandforinstance,assumingthatinterventionsareabletoincreasetheprevalenceofcyclingforalljourneyslessthan5milesby20%to40%,wouldresultinsocietalsavingsintheregionof£2billionperannum.


Micro-levelinterventions,mediatedthroughlegislativemeans,areessentiallyconcernedwithmeasurestofacilitatebehaviourchange,andarediscussedforphysicalactivityinsomedetailinsection6.5.Aswithinterventionsatthemacro-legislativelevel,therelativelyunderdevelopednatureoftheevidencebasemeansthatanysuchinterventions,includingthefinancialincentivesdiscussedbrieflyinchapter4,needtobeintroducedalongsideprovisionforrobustevaluation.Oneexceptionwherethereisanincreasinglyfavourableevidencebaseisintheareaofworkplaceactivetravelplans,discussedinsection6.5.Inmanycasessuchplansincludenumerousworkplacepoliciesandincentives,includinggovernmentsupportedinitiativeslikethe‘cycletowork’scheme36.

Summary

Physicalactivityinterventions

• Legislativeincentivestopromotephysicalactivityshouldideallybeaccompaniedbyenvironmentalandinfrastructuralimprovementsoutlinedinsection3,iftheyaretobeeffectiveinincreasingbothleisureactivityandactiveformsoftravel.

• Capitalinvestmentsinactivetravelinfrastructure,suchascyclingandwalkingroutes,havebeendemonstrablylinkedtomodestincreasesintheseformsoftravelinanumberofEnglishcyclingdemonstrationtowns.

• TheapplicationofnovelcosteffectivenessmodellingtechniquessuchasHEAT(HealthEconomicAssessmentTool),toactivetravelimprovements,illustratesthatsignificantsocietalsavingscouldresultfromincreasesincyclinginScotland,towardsthelevelsseeninotherNorthernEuropeancountries.

Table 5.2 Percentage of active people survey respondents participating in cycling for at least 30 minutes once or more per month, 2006 and 2008

36 Tax-free bikes for work. http://www.cyclescheme.co.uk/

LocalauthoritieswithaCycleDemonstrationTown

LocalauthoritieswithnoCycleDemonstrationTown

2006

11.77%

11.33%

2008

15.07%

11.85%

Difference(and95%CIs)

3.30%(1.79–4.81)

0.52%(0.34–0.70)

P-valuefordifference

0.0000

0.0000

64


6

65

Chapter7

6 Chapter 6 – Interventions in the sociocultural environment

6.1 Introduction

Accordingtoitsbroadestinterpretation,thesocioculturalenvironmentrelatestoallthecharacteristicsofindividualsandpopulationsthatinfluencebeliefsandbehaviours,aswellasthesurrounding‘informationenvironment’andtheinteractionsbetweenallthree.Forthepurposesofconceptualisingpublichealthinterventions,Maibachandcolleagues[134]haveproposedastreamlinedecologicalmodeloftheseinteractionswhichtheycalltheirPeopleandPlacesFramework(seefigure6.1).Theframeworkfirstlydescribestherelevantattributesofpeopleasoperatinginindividual,socialnetworkandcommunityorpopulationlevelsofanalysis,andsecondlytherelevantattributesofplaceasoperatinginlocalordistallevels(thelatterdistinctionbeinganalogoustothemacro-andmicro-levelsofinterventionintheoriginalANGELOframework).Theauthorssubsequentlyrefertothesefivelevelsofanalysisas‘fieldsofinfluence’inordertoexplicitlyfocusonidentifyingopportunitiesforpublichealthaction,asopposedtoelaboratingonthetheorybehindthem.The‘fieldsofinfluence’conceptisparticularlyusefulthereforefordesigningmeasurestoaffectbehaviourchange,aimedatthesocial/culturalenvironment.

Individualbasedfactorsthatinfluencehealthandhealthbehaviourhavebeensubjectedtoconsiderableresearchactivitysincetheoriginsofpsychology,anditsapplicationtocommunicationandhealtheducation.Withtheexceptionofbiologicalpredispositionanddemographics,mostoftheindividuallevelattributesinfigure6.1(cognition,mood,skills,

Chapter6

Figure 6.1 Apeopleandplacesframeworkforpublichealthinfluence

76

Chapter 6: Interventions in the sociocultural environment

6.1 Introduction According to its broadest interpretation, the sociocultural environment relates to all the

characteristics of individuals and populations that influence beliefs and behaviours, as well as the

surrounding ‘information environment’ and the interactions between all three. For the purposes of

conceptualising public health interventions, Maibach and colleagues [134] have proposed a

streamlined ecological model of these interactions which they call their People and Places

Framework (see figure 6.1). The framework firstly describes the relevant attributes of people as

operating in individual, social network and community or population levels of analysis, and secondly

the relevant attributes of place as operating in local or distal levels (the latter distinction being

analogous to the macro- and micro- levels of intervention in the original ANGELO framework). The

authors subsequently refer to these five levels of analysis as ‘fields of influence’ in order to explicitly

focus on identifying opportunities for public health action, as opposed to elaborating on the theory

behind them. The ‘fields of influence’ concept is particularly useful therefore for designing measures

to affect behaviour change, aimed at the social/cultural environment.

Figure 6.1 A people and places framework for public health influence

Individual-based factors that influence health and health behaviour have been subjected to

considerable research activity since the origins of psychology, and its application to communication

(Source:Maibachet al2007[134])

66


motivationandintention)havebeenshowntobeamenabletochangethroughexternalintervention.Thereisalsoanextensiveliteraturearoundtheinfluenceofsocialnetworksandhealth[135],themostrelevantattributesbeingthesizeandconnectednessofaperson’ssocialnetwork,thediversityoftiesandthedegreetowhichthevariousrelationsinasocialnetworkprovidesocialsupportandpositivemodelling.Themostsignificantdeterminantsofhealthbehaviourincommunitiesandlocalpopulationsremainperhapstheleastwellunderstood[134],althoughmuchattentionhasrecentlyfocusedoncollectiveresourcessuchassocialcapitalandcommunitycohesion.Theextentofsocioeconomicdisparityortheincomegapbetweenthemostaffluentandleastwell-off,hasofitselfanindependenteffectonhealthbehavioursandoutcomes[136].‘Place-based’fieldsofinfluencecanbesubdividedintofourfactors,threeofwhichhavealreadybeencoveredinpreviouschaptersofthisreport:

i. Availabilityofproductsandservices(Chapter3:Physicalenvironment(micro-level))

ii. Physicalstructures(Chapter3:Physicalenvironment(macro-level))

iii. Socialstructures/lawsandpolicies(Chapters4and5)

iv. Mediaandculturalmessages(Chapter6:Current).

Usingtheconventionadoptedinpreviouschapters,macro-levelfactors(e.g.masscommunication)willbeconsideredbeforeindividualormicro-levelinfluences.Ofcoursethepredominantculturalattitudestowardsobesityitselfaresubjecttosubstantialvariationthroughouttheworld,whichinevitablyinfluencesthepreferredapproachtoprevention.Certaincommerciallyengineeredcultural‘norms’suchastheassociationsforchildrenbetweenfastfoodandfun,orbetweenconfectionaryandinnocentpleasuresforadults,alsohighlightcertainstronglyembeddedculturalattitudeswhichneedtobeacknowledgedbypreventativestrategies,ifnotdirectlychallenged.

6.2 Nutrition Interventions (macro-level)

Althoughmassmediaisundoubtedlyasignificantreflectorandpotentialframe-setteroftheadultsocioculturalenvironment,thevastmajorityofpublishedevidenceinrelationtomediaandnutritionisheavilyfocusedaroundchildren.Researchhasalsoconfirmedthathoursspentviewingtelevisioncorrelatewithmeasuresofpoordiet,poorhealthandobesityamongbothchildrenandadults.Threeexplanationsforthishavebeenoffered[137]:

i televisionviewingisasedentaryactivitythatdisplacesmoreactivepursuits

ii televisionviewingisassociatedwithfrequentsnacking,pre-preparedmealsand/orfastfoodconsumption

iii televisionviewingincludesexposuretoadvertisementsforunhealthyfoodproducts.

Whileeachoftheseexplanationsissupportedbyobservationalstudies,therehasbeenashortageofempiricalresearchaimedatdisentanglingthemfromeachother.Theoneinterventiontodatehasbeenaprogressivebanintheschedulingofadvertisementsforfoodanddrinkthatishighinfat,sugarandsalt(HFSS)introducedbythebroadcastregulatorOFCOMafterextensiveconsultationin2006.ThephasedreductioninHFSSadvertisingbeganinApril2007withabanonHFSSadvertisementsinprogrammesaimedatchildrenaged4–9yearsandculminatedinabanonallHFSSadvertisingonchildren’schannelswiththeagegroupextendedtoincludethoseaged5–15years.Apreliminaryevaluationofthebannotedexpectedlevelsofreductionintheamountofadvertisingthatchildrensee,althoughtherehadbeensomemigrationofHFSSadvertisingtoprogrammeswatchedbybothadultsandchildren37.Inspiteofthesedrawbacks,theUK’sapproachhasreceivedinternationalcommendationandstatutorymeasureshavebeenclearlyshowntobemoreeffectivethanselfregulatoryregimes[138].

ArecentUSstudyhasprovidedadditionalretrospectivejustificationforthetargetingofcommercials,wheretheextentofexposuretocommercialtelevisionwassignificantlyassociatedwithBMIevenafteradjustmentforlevelsofexerciseandeatingwhilewatchingtelevision[139].Amulti-countrycomparisonbyGorisandcolleaguesusedanattributablefractionmodeltoestimatetherelativereductionsinchildobesitythatwouldresultfromahypotheticalcompleteabsenceoffoodadvertisingontelevision[140].

37 Update on Impact of Restrictions on Food and Drink Advertising to Children. OfCOM; 2008. http://stakeholders.ofcom.org.uk/market-data-research/tv-research/update/

67

Unsurprisinglyperhaps,thegreatestscopeforreductionswereforthecountrieswiththehighestdailyTVadvertisingexposuresuchastheUSandItaly(11.5and6.2minutesoftotaladvertexposureperdayrespectively).Ofcoursethewidespreaddistributionofpromotionalmaterialforunhealthyfoodinthemodernconsumerenvironment,meansthatassumptionsaboutreducedoverallmessageexposurearenecessarilycrude.Furthermore,extrapolatinganyimplicationsforadultobesitypreventionfromfamilyorientatedinterventions,involvesmakinganumberofsignificantassumptionsandcallsforacautiousinterpretation.

6.3 Nutrition interventions (micro-level)

Micro-levelinterventionsaroundtheculturalenvironmentandfoodhavealreadybeentoucheduponwhendescribingtheworksandcollegecanteenstudiesinchapters3and4,wherethemosteffectivelevertobringaboutimprovedpurchasingbehaviour,atleastintheshorttomediumterm,wasidentifiedaspricedifferentials.Thereareofcourseawholehostofstronglyembeddedculturalassociationsaroundlessthanhealthyfoodpractices,whichisparticularlythecaseforScotlandandoftenofmostrelevancewithinthefamilyorhomeenvironment.ThankfullythishasrecentlybeenthesubjectofacomprehensivereviewcommissionedbyNHSHealthScotlandandundertakenbytheFoodEthicsCouncil[141].Thereporttakesabroaddefinitionoffoodcultureas‘sharedpracticesandmeaningsrelatingtofood’,andmakingcomparisonswiththreeotherEuropeancountries(France,FinlandandGreece)examinestheculturallyspecificfactorsandattitudesthatinfluencedietarypracticesinScotland.Notablythereviewshowshowcertainpracticesandmeaningspeopleattachtofoodcanreflectandreinforcetheirmembershipofsocio-economicgroups,aswellasdirectlyaffectingtheirdietandhealth.Thereportalsoexploredthereasonsbehindgreatertendenciestowardsunhealthierpractices,suchasskippingbreakfastorrelianceontake-awaymealsandfoundthattimepressures(actualorperceived)wereoneofthehighestcitedfactors.Intermsofpreviouspolicyinterventionsandtheirrationale,theauthorshighlighthowtheculturalpracticeswhichunderpinmuchoftheScottishpopulation’sdietaryhabitsarerarelyunpackedmeaningthatinterventionmessagesandinitiativesmighthavelimitedrelevancetothetargetpopulation.CurrentnutritionrelatedpolicymeasuresinScotlandarediscussedinsection7.2.

Summary

Nutritionfocusedinterventions

• Thehighlyembeddednatureofobesogenicdriversinmodernsocietyisparticularlyevidentwithinthepredominantmediaandculturalmessageswhichassociateenergydensefoodswithpleasureandreward.

• Controlsonhighfat/highsugar(HFHS)foodadvertisingtochildrenmightbeoneinterventionthatcanhelpunpickthelargelyunchallengedpositiveassociationsthatthesefoodsgenerallyenjoy,althoughadvertisershaveshownthemselvestobeadeptatworkingaroundsuchrestrictions.

• Multi-componentnutritioninterventions,discussedinpreviouschapters,havehadsomesuccessinchangingworkplaceandinstitutionalfoodcultures.

• ThecomplexculturalcontextunderlyingmuchofScotland’spoordietaryhabitsandpracticesisrarelyexplored,whichcouldundermineeffortsatimprovement.


Thevastmajorityofeffortsaroundfacilitatingbehaviourchangeatthemacro-levelarecentredonmoderatetolargescalemediacampaigns.AbromsandMaibachdescribetwofeaturesofeffectivepublichealthmediacampaigns[142]:theyfeaturewelldefinedmessagesandthosemessagesaredeliveredtotheirintendedaudienceswithsufficientreachandfrequencytobeseenorheardandremembered.Fromexistingreviewsofmassmediacampaigns,whichfocusforthemostpartonchangingindividualbehaviours,itisalsoclearthateffectsizesinwelldesignedstudiesaremodestatbest[142].Snyderand

Chapter6

68


Hamilton’smeta-analysisof48published,communitywidecampaigns,forexample,foundaneffectonpopulationbehaviourintheshorttermtobeanattributableriskdifferenceof0.09(i.e.9%morepeopleadoptthebehaviourthandidsobeforethecampaign)[143].Perhapsnotsurprisingly,largereffectswereseenforbehavioursthatwereenforceablebylaw(e.g.seatbeltuse=0.17)thanfor‘purelypersuasivecampaigns’(oftheorderof0.05).Largerimpactswerealsoassociatedwithcampaignsthathadahigherreach(i.e.alargerproportionofthetargetaudiencewereexposed)andforthosethatpresentednewinformation[142,143].Virtuallyallcontemporarymediacampaignsnowincludethecreationandpromotionofwebsites,themoresophisticatedofwhichalsousuallyincludeinteractivefeatures.Althoughrobustevaluationsofweb-basedcampaignsarestillrelativelyrare,theycanbeaveryeffectivemeansofachievingahighlevelofreachandengagementinsettingswithwidespreadinternetconnectedness.TheCDC’s‘VERB’campaignisanationwideinitiativeaimedatincreasingphysicalactivityamongchildrenaged9–13years,whichbeganin2002andgeneratedmorethan10millionvisitstoitswebsite[142,144]overthefirsttwoyears.Subsequentevaluationoftheprogrammeshowedanimpressivedose-responseincreaseinselfreported,free-timephysicalactivitywithincreasingfrequencyofexposuretotheVERBsite(figure6.2)[145].

AlthoughVERBresultsarelargelybasedonselfreports,theevaluationistiedtoanationallyrepresentativelongitudinalcohortsurvey(YouthMediaCampaignLongitudinalSurvey[YMCLS]).Inadditiontocorrelatingactivityreportingwithcampaignexposureasinfigure6.2,thesurveyalsolooksatthreepsycho-socialdimensionsofphysicalactivity:

i. Outcomeexpectations(i.e.beliefsaboutbenefits)

ii. Self-efficacy(i.e.confidencetoovercomebarriers)

iii. Social/familyinfluences(householdandpeer-groupattitudes).

Theselfreportedactivitydatawasalsocross-correlatedwithdetailedlogsfororganisedandfreetimeactivity;thevaliditycoefficientsfoundtobeashighas(orhigherthan),similarsevendayrecallinstruments[145].TheVERBevaluationthereforeissophisticatedenoughtoassessanyunderlyingchangesinattitudes,aswellaseffectsonphysicalactivity.Althoughmeasurableeffectsinthefirstyearwereconfinedtofreetimephysicalactivityindefinedsub-populations(e.g.9to10-yearoldgirls),

Figure 6.2 Mediannumberoffreetimephysicalactivitysessions(selfreported)amongchildrenaged9–13yearsinpast7days,byfrequencyofexposuretoVERB,2004.*p<0.05

(Source:Huhmanet al,2007[145])

γ (gamma) statistic for dose response, range: +1.0 (denoting perfect +ve correlation) to -0.1 (denoting perfect negative correlation).

4.5

4.0

3.5

3.0

2.5

γ=0.09*

4.1

2.83

None Lessthanonceperweek

Frequencyofexposures

Aboutonceperweek

Severaltimesperweek

Everyday

Medfian#weekly

sessions

4.2 4.2

69

Chapter6

thesecondyearsawanexpansionofeffectstotheentiretargetpopulationonthreeoutcomes(freetimeactivityinpastweek;anyphysicalactivityonthedaypriortointerview;andexpectationsaroundoutcomes).Whiletheaverageeffectoverallwasmodest(attributableriskdifferenceof0.05),projectiontoanationalscalecorrespondstoanacceptablylowcost-per-childforachievingunderlyingbehaviouralandattitudechangesthatmightwellbesustainable(duetopsychosocialbenefits).Althoughobviouslyaimedatchildren,anylongtermstrategytomodifyadultattitudesislikelytobemosteffectiveifitcanhaveanimpactontheformativeyears.

TheEnglishChange4Lifemarketingcampaign38,launchedinJanuary2009,hasbeencomparedtoVERBalthoughitsapproachextendsbeyondphysicalactivityanditsprincipleaudienceisintendedtobeyoungfamilies.Basedonareviewoftheeffectivenessofsocialmarketingtechniquestofacilitatehealthybehaviourchange,thecampaignfocusedonfourprioritypopulationsegmentstohelpovercomebarrierstoanimprovedlifestyle.Eachsegmentwascharacterisedwithparticularidentifiablebarriers(e.g.segment3wereoftenquiteaffluentfamilieswhotendedtotreattheirchildrenwithunhealthysnacks).Considerableattentionhasbeendevotedtothedevelopmentofamulti-componentevaluation,includingarandomisedstudywithacontrolgrouptoassesstheimpactoftheChange4Lifematerialsonfamilybehaviour.Earlyresultsaroundprocessandawarenessoutcomeshaveexceededsettargetsandhavebeenveryencouraging39.Thecampaignhasalsonowbeenextendedandtailoredforatriskadults(aged45to65years)40althoughtherecentchangeofgovernmentintheUKislikelytoleadtoalterationsinmanyprogrammes.

AswithChange4Life,notallmediacampaignstoincreasephysicalactivityareexclusivelyfocusedonchildrenandtherehavealsobeenanumberofwelldesignedstudiesinadults,the‘WheelingWalks’programmeinWestVirginiabeingoneexample[146].Thisquasi-experimentalmultimediaeducationalinterventiontargeted31,420adultsandmadeuseofthetheoryofplannedbehaviourchangetotargetthoselikelytobemostresponsiveorsusceptibletothecampaignmessages.Theresultswerealsopartlyverifiedbytheinclusionofa(relativelycrude)directobservationcomponentinadditiontotheself-reportmeasures.Althoughtheinterventiongroupdifferedfromthecomparisongroupononlyoneofthethreeactivityreportoutcomes(moderate-intensitywalking:seetable6.1),respondentsintheinterventioncommunityreportedwalkingmoreminutes(mean=122.9minutes/dayversus87.6minutes/day;P<0.003)thanthoseinthecomparisoncommunity.Directobservationdataalsoshowedasignificanteffect,witha23%increaseinwalkingobservationsintheinterventioncommunityversusa6%decreaseforthecomparisonarea(OR=1.31,95%;CI:1.14to1.50).

Table 6.1 Pre to post changes in self-reported physical activity (as recommended by Centre for Disease Control and US Surgeon General) among sedentary older adults

38 NHS Change4Life Campaign: http://www.nhs.uk/change4life/Pages/default.aspx39 www.obesitywm.org.uk/.../Change4Life_Evaluation_-_revised_16.11.09.doc40 http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/MediaCentre/Currentcampaigns/Change4Life/DH_112678

CRITERION[Telephonesurvey–selfreport]

Moderate–intensitywalkingfor30minormoreadayatleast5daysaweek

Moderate–intensityphysicalactivityfor30minormoreadayatleast5daysaweek

Vigorous–intensityphysicalactivityfor20minatleast3daysaweek

Interventioncommunitychanges

32.2%*#

22.9%

9.9%

Comparisoncommunitychanges

18.0%

19.6%

8.7%

70


Giventheestablishedimportanceofunderlyingattitudesindeterminingthetakeupandmaintenanceofchangedbehaviourshowever,perhapsnewthemostcompellingresultofRegeret al’sstudyistheparallelwiththeCDC’sVERBcampaign,inthatthereweremeasurable,statisticallysignificantchangesforthebetter,inboth‘intention’andin‘perceivedcontrol’.Suchanoutcomeisconsistentwithmeetingthepre-conditionsforasustainablechangeinusualhabits,withinthebasictrans-theoreticalmodelofbehaviourchange.Theauthorshadalsoundertookpre-testingresearchduringthedesignphaseoftheirstudyandfoundthatwhilesedentaryandirregularlyactivepeopleintheirtargetpopulationsharedsimilar‘attitudeandnormbeliefs’withregularexercisers,theydidshowstrongdifferencesinperceivedcontrol.Theeducationalmessageswerethentailoredtoinfluenceperceptionsofcontrolovertimeandscheduling,therebydirectlyaddressingthemainbarriertoincreasingactivitylevels.

Theimportanceofbeingabletotransformattitudeswaspreviouslyhighlightedinthediscussiononactivetravelandperceivedsafetyinchapter3(NewYorkcyclingexample).Masspublicparticipationeventsalsoofferahighlyvisibleandstrikingdemonstrationofwhatcanbepossiblewithlargescalecoordinatedeffortsacrossmajorcities.ThecityofBogotainColombiawasthefirsttoembracetheideaasameansofbeginningtocombatexcessivecongestionandpollution.NowtakingplaceeverySunday,70milesofcitystreetsareclosedtotrafficandresidentscomeoutintheirthousandsto‘walk,bike,run,skate,recreate,picnic,andtalkwithfamily,neighboursandstrangers’.41,42

Theeffectivenessofmasscommunitycyclingeventsinimprovingpublicself-perceptionsofcyclingabilitywasneatlyillustratedinanAustralianstudyin2006[147].WhileparticipantsintheSydneyeventwerepredominantlymaleandunder50yearsofage,therewereimpressivechangesinperceivedcyclingabilityandinratesofcyclingforparticipantsasawhole,afterthesingleevent‘intervention’.Specifically,halfofthesurveyrespondentsthatratedtheircyclingabilityaslowbeforetheevent,subsequentlyratedtheirabilityashighonemonthafterwards.Also,respondentswithlowpre-eventself-ratedcyclingabilityreportedanaverage4sessionsofbicycleridingthemonthbeforetheeventandanaverage6.8sessionsamonthaftertheevent,whichwasstronglystatisticallysignificant(p<0.0001).ThedemonstrationofsuchimmediatebenefitsandreturnsinpopulationattitudesandhabitshasinitiatedagrowinginternationalspreadofsuchorganisedeventswithonetakingplaceinIrelandinAugust201043.Thecloselyrelated‘criticalmass’cyclingevents,whichoriginatedinSanFrancisco,havealsobeenspreadinginternationallyandseveralhavetakenplaceinEdinburghinrecentyears.Notformerlyorganised,theseeventsdependontheorganisationofa‘criticalmass’ofcycliststoliterallytakecontroloftheroads44.

Figure 6.3 Ciclovia,Bogota,Columbia–thefirstandremainsthelargestofcitywideregularmasscyclingevents(seefootnoteforweblinktoshortfilmitem).

83

consistent with meeting the pre-conditions for a sustainable change in usual habits, within the basic

trans-theoretical model of behaviour change. The authors had also undertook pre-testing research

during the design phase of their study and found that while sedentary and irregularly active people

in their target population shared similar ‘attitude and norm beliefs’ with regular exercisers, they did

show strong differences in perceived control. The educational messages were then tailored to

influence perceptions of control over time and scheduling, thereby directly addressing the main

barrier to increasing activity levels.

The importance of being able to transform attitudes was previously highlighted in the discussion on

active travel and perceived safety in chapter 3 (New York cycling example). Mass public participation

events also offer a highly visible and striking demonstration of what can be possible with large scale

coordinated efforts across major cities. The city of Bogota in Colombia was the first to embrace the

idea as a means of beginning to combat excessive congestion and pollution. Now taking place every

Sunday, 70 miles of city streets are closed to traffic and residents come out in their thousands to

‘walk, bike, run, skate, recreate, picnic, and talk with family, neighbours and strangers’.39, 40

Figure 6.3 Ciclovia, Bogota, Columbia – the first and remains the largest of citywide regular mass cycling events (see footnote for weblink to short film item33).

The effectiveness of mass community cycling events in improving public self-perceptions of cycling

ability was neatly illustrated in an Australian study in 2006 [147]. While participants in the Sydney

event were predominantly male and under 50 years of age, there were impressive changes in

39 Ciclovia: Bogotá, Colombia. http://www.streetfilms.org/ciclovia/ 40 Streets as trails for life. http://www.americantrails.org/resources/health/streetspenalosa.html

41 Ciclovia: Bogotá, Colombia. http://www.streetfilms.org/ciclovia/42 Streets as trails for life. http://www.americantrails.org/resources/health/streetspenalosa.html43 International Cycling Event Launched in Ireland: www.bicycle.net/.../international-cycling-event-launched-in-ireland. 44 Critical Mass Edinburgh FAQ. http://www.edinburghguide.com/criticalmassedinburgh

(Source:LaVidaEsLocaWordpresspictures:lavidaesloca.wordpress.com)

71

Summary

Physicalactivityinterventions(macro-level)

• Althougheffectsizesinmassmediacampaignstoencouragehealthybehavioursaremodestatbest,theycan,becauseofscale,havethepotentialtoresultinsignificantpopulationhealthgainiftheycanhelpbringaboutsmallshiftsatthenationalorregionallevel.

• Largescalepublicparticipationeventsarebeingrecognisedasaneffectivemeansofbeginningtochangepopulationattitudesandbehaviours,aswellasindividualperceptionsofability.


Inlookingtoinfluenceprevailingattitudestophysicalactivity,itmightbeexpectedthatinterventionswhicharecarriedoutincloseproximitytotheirtargetpopulation,shouldbebetterabletotailortheirapproachappropriately.Micro-levelinterventionsaroundactivitycouldinprinciplebetargetedattheindividual,householdorinstitutional/workplacelevel,allthreeofwhichwillbeconsideredinthecurrentsection.Specifically,themeritsoftherespectivepublishedevidencewillbesummarisedfor:

i. Primarycareexercisereferral

ii. Householdtargetedactivetravel

iii. Workplaceactivetravel‘culture’.

i. Primary care exercise referral

Sincethisreportpurposelydoesnotaddressobesitytreatment,individuallevelinterventionswerenotoriginallyconsideredaspartofitsoriginalbrief.Exercisereferralhowever,isalsocommonlyusedforobesityprevention(principallyinprimarycare,forpatientsathighriskofdevelopingobesityanditscomplications).Socalled‘exerciseonprescriptionschemes’havebeenconsideredbytheNationalInstituteofClinicalExcellence(NICE)whichpublishedabestpracticeguidancesummaryin200645.MindfuloftheequivocalnatureoftheevidenceNICE,recommendedthatreferralsshouldbeissuedonlyaspartofaformalresearchstudies.SubsequentinterpretationoftheguidancebyNHSHealthScotlandendorsedthisopinionandconcludedthatnewschemesshouldonlybesetupaspartofadesignatedevaluationprogramme46.ThemostrecentlypublishedsystematicreviewofexercisereferralschemesbyWilliamset al(seetable6.2)concludedthattheymayhaveamarginalimpactinincreasingphysicalactivityinsedentarypeople,thoughproblemswithtakeupandadherencemeantthat17referralswerenecessaryforeveryonepatientwhosuccessfullytookup‘moderateactivity’[148].Onecomplicationwasthelevelofvariationinfollowup,andalthoughthemajorityofstudiesreportedat10to12weeks,thisisprobablytoosoontobeabletoevaluatesustainedeffectiveness.Exceptionswereonestudythatreportedatfourmonthsandanotherattwoyears.

45 Four Commonly Used Methods to Increase Physical Activity. NICE Public Health Intervention Guidance No 2; 2006. http://www.nice.org.uk/nicemedia/pdf/PH002_physical_activity.pdf

46 NHS Health Scotland Interpretation of NICE PG002: Four commonly used methods to increase physical activity.. http://www.healthscotland.com/uploads/documents/8449-NICEPHIG2HScommentarySummary10Aug06.pdf

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Table 6.2 Meta-analysis of exercise referral schemes compared with control according to the proportion of participants who took moderate exercise

(Source:Williamset al,2007[148])

86

ii. Household targeted active travel

Chapter 3 outlined the importance of structural interventions, particularly around safety, as a means

of overcoming barriers which discourage active travel. The long established priority given to

promoting sustainable transport in mainland Europe however, has also meant that public attitudes

and reasons behind travel mode choice have been the subject of considerable research since the

1970s. Research in Germany in particular revealed that for at least 25% of non public transport

journeys, the reasons underlying the choice were relatively trivial and were amenable to ‘voluntary

change’ with simple targeted information provision and discussion [149]. The use of such relatively

soft intervention measures aimed at voluntary travel behaviour change (VTBC), has now been

evaluated in many countries including parts of the UK. Beginning in Germany in the late 1980s,

individualised travel marketing (ITM), has been commercially implemented under the brand name

‘IndiMark’. Also referred to more generically as ‘personalised travel planning’ (PTP) programmes,

their evaluation can be methodologically challenging since the precise tools and techniques vary

between projects. The components for example typically include one or more of the following: (i)

one-to-one conversations with trained travel advisors; (ii) information provision on sustainable

travel (e.g. train and bus timetables, cycling and walking routes); and (iii) gifts and incentives to

encourage sustainable travel (e.g. pedometers, water bottles, bus passes etc).

An analysis which combines the results from three projects in Nürnberg [149], was able to

demonstrate an overall increase in public transport use of 13%, alongside a 3% reduction in trips as a

car driver and, less positively from an active living perspective, a 6% reduction in cycling. Consistent

with guidance from sustainable travel experts, that larger-scale trials are more effective, an

encouraging Australian study of the ‘Travelsmart’ programme reports a 14% reduction in car use in

South Perth [150], which appeared to have been ‘locked in’ and was sustained at 13%, four years

after the intervention. These evaluations are highly typical of almost all studies in this area, in that

ii. Household targeted active travel

Chapter3outlinedtheimportanceofstructuralinterventions,particularlyaroundsafety,asameansofovercomingbarrierswhichdiscourageactivetravel.ThelongestablishedprioritygiventopromotingsustainabletransportinmainlandEuropehowever,hasalsomeantthatpublicattitudesandreasonsbehindtravelmodechoicehavebeenthesubjectofconsiderableresearchsincethe1970s.ResearchinGermanyinparticularrevealedthatforatleast25%ofnonpublictransportjourneys,thereasonsunderlyingthechoicewererelativelytrivialandwereamenableto‘voluntarychange’withsimpletargetedinformationprovisionanddiscussion[149].Theuseofsuchrelativelysoftinterventionmeasuresaimedatvoluntarytravelbehaviourchange(VTBC),hasnowbeenevaluatedinmanycountriesincludingpartsoftheUK.BeginninginGermanyinthelate1980s,individualisedtravelmarketing(ITM),hasbeencommerciallyimplementedunderthebrandname‘IndiMark’.Alsoreferredtomoregenericallyas‘personalisedtravelplanning’(PTP)programmes,theirevaluationcanbemethodologicallychallengingsincetheprecisetoolsandtechniquesvarybetweenprojects.Thecomponentsforexampletypicallyincludeoneormoreofthefollowing:(i)one-to-oneconversationswithtrainedtraveladvisors;(ii)informationprovisiononsustainabletravel(e.g.trainandbustimetables,cyclingandwalkingroutes);and(iii)giftsandincentivestoencouragesustainabletravel(e.g.pedometers,waterbottles,buspassesetc).

AnanalysiswhichcombinestheresultsfromthreeprojectsinNürnberg[149],wasabletodemonstrateanoverallincreaseinpublictransportuseof13%,alongsidea3%reductionintripsasacardriverand,lesspositivelyfromanactivelivingperspective,a6%reductionincycling.Consistentwithguidancefromsustainabletravelexperts,thatlargerscaletrialsaremoreeffective,anencouragingAustralianstudyofthe‘Travelsmart’programmereportsa14%reductionincaruseinSouthPerth[150],whichappearedtohavebeen‘lockedin’andwassustainedat13%,fouryearsaftertheintervention.Theseevaluationsarehighlytypicalofalmostallstudiesinthisarea,inthattheypresentanumberofsignificantchallengestointerpretationwhichwerewelldescribedinameta-analysisbyMöserandBamberg[151].TheirmajorconcernsaboutPTPstudiesincludeweakstudydesignswithoutcontrols,nonrepresentative(often

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Chapter6

self-selected)populationsamplesandahighrelianceonselfreportingwiththeattendantriskof‘socialdesirability’bias.Consideringalsothatmostofthereportedstudiesarenotindependentevaluations,butinsteadoftenoriginatefromcommercialconsultanciessupplyingtheinterventions,thepotentialforpublicationbiaswasanadditionalcauseforconcern.

Havingdocumentedtheirreservationsabouttheavailableliterature,theauthorsofthereviewhadgatheredsufficientinformationtobeabletoderivepooledeffect-sizesfromatotalof141studies(seetable6.3).Althoughtherewasconsiderableheterogeneityamongtheincludedstudiesacrossthethreesettings(i.e.communitytravelplanning/awareness;worktravelplansandschooltravelplans),theincreasesinsustainabletravelchoiceswereallstronglysignificant(P<0.001)witheffectsizesoftheorderof0.10to0.15fortravel-planning,and0.24forworkplaceprogrammes.Translatingthesefindingsintomeaningfulimplicationsforplanningtravelprogrammes,theestimatedincreaseintheproportionoftripsoverallnottakenbycarwasfrom34%to39%47.Worktravelplansresultedinanestimatedincreasefrom35%to47%andforschoolstheoverallestimatedproportionnottravellingbycarincreasedfrom60%to64%.Althoughtheselikelybenefitsremainverymarginal,thereviewauthorsarestillcarefultocautionagainstthegeneralisabilityofthepooledresultsduetothestudydesignreservationshighlightedabove.

ArecentlypublishedevaluationofPTPprojectsineightareasofEngland[152],highlightedmanyofthesameconcernsoverstudydesignasMöserandBamberg.Theonereassuringaspectwasthattheresultsrange–a4%to13%reductionincardrivertrips–isinbroadagreementwiththelargerreviewandalsoconsistentwithresultsfromAustralianinvestigators[150].ThelargestincreasesintheEnglishstudieswerereportedforwalking,eventhoughmostinformationrequestswerearoundpublictransportandtherewerespecificcyclingpromotionsinseveralofthepilotsites.HavingbeeninvolvedinmanyPTPevaluationsintheUK,PeterBonsalloftheUniversityofLeedssharesfullythepreviouslycitedcriticismsaboutthestudyliterature[153]aswellasaddinghisownconcernsaroundthelackoflongtermfollowupandtheminimalconsiderationgiventolikelyeconomicimpact.Asawayforward,hesuggeststhatnewandongoingPTPschemessuchastheScottishGovernment’songoingSmarterChoices,SmarterPlacesinitiative48,oughttobemindfuloftheimportanceofcontinuingtoimprovetheevidencebaseandthatanysuchprojectsneedtosetasidesufficientresourcesforindependentevaluation(i.e.thatisnotundertakenin-housebythecontractedprovider(s)).Novelresearchstrategies,suchastravellersegmentationanalysis(whichlooksatthesocialdemographicsandlifestyleprofilesassociatedwithdifferentformsoftravel)[154]arealsolikelytobeofconsiderablebenefitinexpandingresearchers’understandingaroundthecomplexitiesoftravelchoice.

iii. Workplace active travel ‘culture’

Finally,giventheworkingagegroupfocusofthisreport,theresultsseenwithworkplacetravelplans(seetable6.3),areworthyofparticularmention.Ameanincreaseof12percentagepointsintheproportionofemployeesnotcomingtoworkbycar,incombinationwithreassuranceontheabsenceofbiasedreporting,isbyitselfanencouragingindicationofthepotentialforworkplacetravelplanstostimulatebehaviourchange[151].Oneparticularlysuccessfulcomponentofworktravelplanshasbeenthegovernment’sassistedbicyclepurchaseschemeinwhichemployeesreceiveassistancetobuyabiketaxfreeforthepurposesofcommuting.FortheUKasawholein2007,morethan10,000employeestookadvantageofthescheme49.Ofcoursetheextenttowhichbikepurchasestranslateintojourneyswillalsobeaffectedbymanyotherfactors,whichiswhyworkplaceactivetravelmeasuresneedtobemulti-componentandincorporateassistancewithinformationonroutes,dedicatedbikestoragefacilitiesandtheprovisionofshowersandchangingfacilities.

47 Translating effect sizes. The methodology is relatively complicated and outlined in the review. The author’s use the dimensionless Cohen’s h statistic to relate the effect size to the original proportion of the sample (between 0 and 1) whom were ‘not transformed’.

48 Smarter Choices, Smarter Places initiative: http://www.scotland.gov.uk/Topics/Transport/sustainable-transport/home-zones 49 Cycling To Work Saves 8,000 Tonnes Of Carbon Emissions http://www.planning-inspectorate.gov.uk/pins/publications/newsletter/issue_11/cycle_scheme.html

74


Table 6.3 The pooled mean effect sizes calculated under the fixed- and random-effects assumption# for the all studies and for studies evaluating the three soft policy measures separately

AspartofastudycommissionedbytheDepartmentofTransport,Cairnset allookedatworktravelplansinsevenUKtowns[155]andfoundthattheytypicallyreducedcommutercardrivingbybetween10%and30%.Thetypicalcosttothelocalauthorityforthepromotionoftheschemeswas£2to£4peraffectedemployee,peryear.City/urbanareaauthoritieswhoprioritisedworktravelplanswereabletoengagewitharound30%oftheareaworkforce,comparedwith10%inruralauthorities.Workplacetravelplanswerealsothemostcosteffectiveintermsofpricepervehicle-kmreduced.Theauthorsconcludethat‘smarterchoice’i.e.‘soft’travelmeasureshavethepotentialtoreducenationaltrafficlevelsbyabout11%,andbyupto21%atpeakperiods.Whilealloftheaboveuncertaintiesaroundtheevidencestillneedtobeborneinmind,theseestimatesareforsoftmeasuresaloneanddonottakeaccountofthelikelyenhancedeffectivenessofcombinationswithstructuralinterventions.

Allstudies(N=141)

Fixedeffects

Randomeffects

Fixedeffects

Randomeffects

Fixedeffects

Randomeffects

Fixedeffects

Randomeffects

0.12

0.15

0.10

0.11

0.24

0.24

−0.01

0.08

0.11

0.12

0.09

0.08

0.22

0.17

−0.03

0.02

0.13

0.19

0.11

0.13

0.25

0.31

0.01

0.14

0.01

0.02

0.01

0.01

0.01

0.04

0.01

0.03

26.53***

8.75***

14.01***

8.25***

30.61***

6.87***

−1.23

2.56**

140

71

43

24

1517.58***

122.72***

758.36***

205.55***

0.03

0.00

0.05

0.02

Model MeanES −95%CI

+95%CI

SE Z df Q V

Travelplanning/travelawarenesscampaign/PTmarketing(N=72)

Worktravelplans(N=44)

Schooltravelplans(N=25)

(Source:MöserandBamberg2008[151])

ES, effect size; CI, confidence interval; Q, homogeneity measure; V, random effects variance component.# A random effects model takes account of between study variability in the estimate of the overall effect size, whereas a fixed effects model does not; ***p<0.001; **p<0.01.

75

Chapter6

Summary

Physicalactivityinterventions(micro-level)

• Individuallyfocusedactivityincentives(suchasprimarycarebasedexercisereferral),havebeenshowntobemarginallyeffectiveforpromotingphysicalactivityinpeoplewhoarelargelyinactive.Althoughtooresourceintensivetobeausefulmeansofobesitypreventioninthegeneralpopulation,theirmediumtolongertermeffectivenessinhigherriskgroups,wouldbeworthyoffurtherevaluation.

• Personaltravelplanning(athouseholdlevel),hasbeenassociatedwithveryconsistentreductionsincardependenttravel,althoughtherearesignificantconcernswiththequalityoftheevidencebase.Furtherpublicinvestmentinsuchprogrammesshouldmakeprovisionforindependentrobustevaluation.

• WorkplacetravelplanshavebeenshowntobecosteffectiveandfeasibleinaUKsetting,asameansofreducingtheproportionofcardependentjourneys.

76


7

77

7 Chapter 7 – Current policy landscape in Scotland 7.1 Background and overview

TheForesightReport,TacklingObesities:FutureChoices[2],hasbeencitedanumberoftimesalreadyinthisreport.ForesightrepresentedthefirstcomprehensiverecognitionatUKGovernmentlevelthatmanyofthefeaturesofmodernliving,whichareattheheartoftheobesityepidemic,arebeyondthecontrolofindividuals.Theauthorsthereforeadvocatedtheneedforbroadreachingsocietalwidestrategiesiftherisingtrendsinthepopulationprevalenceofoverweightandobesityaretobestabilisedandeventuallyreversed.Asdescribedinchapter1,Foresightmadeuseofasystemsmappingapproachtoconceptualisethebiologicalandsocialcomplexityofobesity(seefigure7.1).Theoverallsystemsmapillustratesthecomplexityandinter-relationshipsbetweenthedifferentsocietaldriversofobesityandthatnosingledominantfactorisclearlyidentifiable.Inconsequence,ifrisingobesityistobeaddressedeffectively,thereisaneedfora‘whole-systems’approachwithacommitmenttolong-termsustainedinterventions.Additionally,becausemanyofthekeyleversofinfluencelieacrossandbeyondthejurisdictionofsinglegovernmentdepartments,theproblemcallsforcrossgovernmentsolutionsthatalsoengageotherkeystakeholdersfromindustry,tradeandagriculture.

Asisevidentfromthetitle,Foresightwaswrittenwithafutureorientationinmindandspecificallyadoptedanotional50yeartimescale.Sincemanyofthepossibilitiesforsocietalwideinterventionsarecriticallydependentontheprevailingpoliticalclimateandpublicattitudes,thelikelihoodofsuccessforashortlistedseriesofpolicyandenvironmentalmeasureswasconsideredagainstfourquitedifferentfuturescenarios.TheunderlyingtrendsandrationalebehindeachdevelopingscenarioaredescribedindetailinoneoftheForesightreportsaccompanyingpublications,VisualisingtheFuture:Scenariosto2050[156].Thefouralternativemajorsetsofdriversforfuturesocietalchangeare

i. Vocalconsumersdriveforbusinesstoleadchange

ii. Widersocialresponsibilitydriveslongtermpreparednessandadaptivebehaviouralchange

iii. Consensusandcollectiveactionsoughttodeliverflexibilityandreacttoissuesoftheday

iv. Shorttermvaluemaximisationandmarketslefttobalanceshiftsinresourcedistribution.

Chapter7

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Figure 7.1 Foresightsystemsmap[2]

92

Figure 7.1 Foresight systems map [2]

Seventeen short listed policy options, which were selected as examples of the range and depth of

responses that were generated from expert panels, were then imposed on each of the above

hypothetical future scenarios. Each intervention was assessed on the degree to which it might

impact on three aspects of the obesity epidemic: overall population prevalence of obesity;

socioeconomic differences in obesity prevalence and the prevalence of childhood obesity. Five of the

shortlisted actions were then deemed to be likely to have the ‘greatest average impact’ overall on

obesity across these three indicator areas:

• increasing walkability/cyclability of the built environment

• targeting health interventions for those at increased risk

• controlling the availability of/exposure to obesogenic foods and drinks

• increasing the responsibility of organisations for the health of their employees

• early life interventions at birth or in infancy

Crucially, the Foresight Report dismisses any suggestion of a magic bullet, either pharmaceutical or

policy led, to redress the obesity epidemic and also rejects options that focus on individual

behaviours (except for those that relate to early years intervention). Table 7.1 shows the

Formatted: Indent: Left: 0.75 cm,Hanging: 0.5 cm, Bulleted + Level: 1+ Aligned at: 1.27 cm + Indent at:1.9 cm

Seventeenshortlistedpolicyoptions,whichwereselectedasexamplesoftherangeanddepthofresponsesthatweregeneratedfromexpertpanels,werethenimposedoneachoftheabovehypotheticalfuturescenarios.Eachinterventionwasassessedonthedegreetowhichitmightimpactonthreeaspectsoftheobesityepidemic:overallpopulationprevalenceofobesity;socioeconomicdifferencesinobesityprevalenceandtheprevalenceofchildhoodobesity.Fiveoftheshortlistedactionswerethendeemedtobelikelytohavethe‘greatestaverageimpact’overallonobesityacrossthesethreeindicatorareas:

• increasingwalkability/cyclabilityofthebuiltenvironment

• targetinghealthinterventionsforthoseatincreasedrisk

• controllingtheavailabilityof/exposuretoobesogenicfoodsanddrinks

• increasingtheresponsibilityoforganisationsforthehealthoftheiremployees

• earlylifeinterventionsatbirthorininfancy.

Crucially,theForesightReportdismissesanysuggestionofamagicbullet,eitherpharmaceuticalorpolicyled,toredresstheobesityepidemicandalsorejectsoptionsthatfocusonindividualbehaviours(exceptforthosethatrelatetoearlyyearsintervention).Table7.1showsthecorrespondinggovernmentdepartmentswherethejurisdictionliesforeachofthesefiveinterventionareas.

Inrelationtothefiveidentifiedpriorityareasitisreassuringatleasttofindahighdegreeofconvergencewiththeinitialfindingsofthisreport.Withtheexceptionofearlylifeinterventions,whichwereoutsidethebriefofthecurrentreport,fourofthefiveoptionswouldclearlybeconsistentwiththerelativelyhighpromisepolicyandenvironmentalinterventionsidentifiedinthisdocument.Whilethe‘targetingofthoseatincreasedrisk’hastheleastobviouscorrespondingproposalwithintheprecedingchapters,thehigherpricesensitivityofthosemostatriskofobesitytoenergyrichfoodpurchases,representsagoodexampleofauniversallyappliedmeasurethattargetshigherriskgroupsbydefault(seesection4.2(ii)).

79

(i)Increasethe‘walkability’and‘cyclability’ofthebuiltenvironment.

Introducehealthasasignificantelementinallplanningprocedures50.

(ii)Targetinghealthinterventionsforthoseatincreasedrisk(dependentonabilitytoidentifythesegroupsandonlyifreinforcedbypublichealthinterventionsatthepopulationlevel).

(iii)Controllingtheavailabilityof/exposuretoobesogenicfoodsanddrinkse.g.foodlabellingstandards.

(iv)Increasingtheresponsibilityoforganisationsforthehealthoftheiremployees.

(iv)Earlylifeinterventionsatbirthorininfancy.

• Transport.

• Housingandregeneration.

• Builtenvironment.

Healthdirectoratesincluding:ChiefMedicalOfficerandPublicHealth;HealthcarePolicyandStrategy;PrimaryandCommunityCare;ChiefNursingOfficer.

Constitution,LawandCourts;RuralandEnvironment

DeptofWorkandPensions–thoughtrainingoftendelivered/organisedbyScottishagencies.

Children,youngpeopleandsocialcare.

Lifelonglearning.

Learning.

• DepartmentforTransport.

• Communitiesandlocalgovernment.

• DepartmentofHealth.

• DEFRA;DeptforConstitutionalAffairs(nowMinistryofJustice).

• FoodStandardsAgency

• LikelytorequireEUinvolvement(seenotebelow51)

• DepartmentofWorkandPensions.

• DepartmentforChildren,SchoolsandFamilies.

• DIUS(nowBIS):BusinessInnovationandSkills).

• FSA:FoodStandardsAgency.

Chapter7

Table 7.1 Foresight ‘highest likely impact options’ and the respective government departments/agencies in Scotland and the UK (adapted from Higgins 2010 [157])

[Shading denotes Scottish Government jurisdiction]

50 This option is not prioritised but in all bar scenario 4 is deemed to have a positive impact. It complements the walking and cycling proposal. 51 Food labelling overseen ultimately by EU Directive. http://www.reading.ac.uk/foodlaw/label.htm

Foresightpolicyrecommendations

Holyrooddirectorates Westminsterdepartments/governmentagencies

PerhapsthemostusefulanddirectlyrelevantaspectoftheForesightoutputswithrespecttothecurrentreporthowever,arethecharacteristicsthatdescribewhattheauthorsperceiveasanideal‘portfolioofinterventions’.Asoutlinedinchapter2,theultimateaimofthiscurrentreviewofevidencearoundobesitypreventionmeasuresistopresentamenuofoptionsthatwouldincludeabroadbalanceoflevelsofriskandlikelyreturns,justaswouldafinancialinvestmentportfolio[24].Anidealportfolioneedstobalancetheneedforshorttermactionagainstthedriveforlongertermsustainablechange.Toachievethisbalance,itisbesttoproceedwithamixofpopulationlevelandtargetedinterventionsandseekalignmentwithotherpolicyagendas,recognisingsynergiesandconflicts.Thepotentialforaligningobesitypreventionwithotherpublichealthandpoliticalpriorities,notablyclimatechangeandhealthinequalities,isdescribedinchapter8anddiscussedextensivelyintheForesightReportitself.

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7.2 Beyond Foresight in the UK and Scotlandi. NutritionThehugelychallengingagendasetoutbyForesight,todevelopgenuinelycrossgovernment,multi-levelresponsestotheobesityepidemic,hasgivenrisetoaseriesofkeypolicydocumentsfromboththeUKandthedevolvedScottishGovernment.Healthy Weight, Healthy Lives: A Cross-Government StrategyforEngland52,waspublishedin2008anddealtwithsomeofthespecificsofimplementinginterventionsinthefivepriorityareas.Thedocumenthadastrongfocusonearlychildhoodaswellastheprospectsforinvestmentinactivetravelprovisionandworkplacebasedinitiatives.Aoneyearpostlaunchevaluation53highlightedencouragingprogressinanumberofareas,particularlyinthecasestudyreportsofdemonstrationprojects,suchastheconveniencestorehealthyfoodavailabilityprogrammeinnortheastEngland(basedonamodeloriginallypilotedinScotland,whichisdescribedbelow).Theoneyearfollowupreportalsodescribedseveralexamplesofproductreformulationbymanufacturersandretailers,inwhichtherehavebeensubstantialreductionsinsugarlevelsandsaturatedfatinanumberofleadingbrands.Onphysicalactivitymeasures,earlyevaluationsofcyclingdemonstrationtowns(implementedaspartofHealthy Weight, Healthy Livespriorityactions),inEnglandandWaleshavebeenpromising(seesection5.4).

JustaswithHealthy Weight, Healthy LivestheequivalentobesitypreventionactionplanforScotland(Healthy Eating, Active Living)setoutanambitiouslife-coursebasedprogrammeofintendedactionsfor2008to2011.Manyoftheactionsoutlinedinthisplanarealreadyunderwayandhavebeenfavourablyevaluated.TheSchools(HealthPromotionandNutrition)(Scotland)Act200754forexample,buildsontheprogressofanearlierschoolsinitiative,HungryforSuccess,andseekstoimprovethestandardofschoolmealsaswellasincreasingtheiruptake.Localauthoritiesarealsoencouragedtoprovideschoolswithhealthysnacksanddrinks.Fortheadultpopulation,theScottishGrocersFederation’sHealthyLivingProgramme55hasdemonstratedthecapacityofimproved‘instorepresentation’toincreasethepurchasingoffruitandvegetablesinconveniencestores.Althoughthefindingshavenotyetbeensubjectedtoindependentpeerreview,preliminaryresultshavedemonstratedsignificantincreasesinthesalesoffreshfruitandvegetables,aswellasincreasesinself-reportedconsumption56.TheapparentsuccessoftheapproachhasledtotheadoptionofasimilarmodelinEngland(aspartoftheChange4Lifecampaign[seesection6.4]andanadditional£1.3millionfundingforexpansionfromtheScottishGovernment57.Theadditionalresourcesareintendedto:

• extendthecoverageoftheschemetoawiderrangeofretailers

• expandtherangeofproducebeyondfruitandvegetablestohealthieroptionssuchwholemealbreadandlowfatmilk

• createa‘goldstandard’forstoresalreadyparticipatingintheprogrammetoencouragethemtogofurtherinpromotinghealthierproduce.

Earlyin2010,theFoodsStandardsAgencyinScotlandissuedapolicyconsultationonmore‘upstream’interventionsthatwouldbealsobeconsistentwithForesight’sthirdrecommendationaroundrestrictingtheavailabilityofobesogenicfoodstuffs58.PartoftheAgency’sSaturatedFatandEnergyIntakeprogramme(SFEI),theconsultationrelatestothreespecificcomponents,advocatingvoluntarymeasuresbyfoodmanufacturersandretailersto:

• increaseaccessibilityofsmallerfoodportionsizes(see3.3(ii))

• encouragethepromotionandincreaseduptakeofhealthieroptions

• reducethesaturatedfatandenergycontentofpopularfoodsbyreformulationmeasures.

52 Healthy Weight, Healthy Lives. Dept of Health (Cross Government Obesity Unit); 2008. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_084024.pdf

53 Healthy Weight, Healthy Lives: One Year On. Dept of Health (Cross Government Obesity Unit); 2009. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_097623.pdf

54 Schools (Health Promotion and Nutrition) (Scotland) Act 2007http://www.ltscotland.org.uk/healthpromotingschools/practitioners/nationalguidance/scottishact2007.asp55 Scottish Grocers Healthy Living Plan: Evaluation http://www.communityfoodandhealth.org.uk/fileuploads/sgfhealthylivingevaluationreport-7313.pdf56 The Healthy Living Programme. Information leaflet. Scottish Grocers Federation; 2007 http://scottishshop.org.uk/wp-content/uploads/2009/09/Healthy-living-2leaflet.pdf57 Promoting Healthy Food Choices. News Release. The Scottish Government. http://www.scotland.gov.uk/News/Releases/2010/02/2617003058 Draft Recommendations on the Promotion of Lower Fat Products Including Dairy Products, Meat Products and Portion Size Availability. SFEI Programme: Consultation

Summary, launched Dec 2009. http://www.food.gov.uk/multimedia/pdfs/consultation/promolowfatprodssatfatreduct.pdf

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Theconsultationalsogoesasfarastostipulatelegallybindinglimitstothefatcontentofsausages(e.g.recommendation7stipulatesthatbytheendof2012,totalfatlevelsshouldbereducedby5%comparedtothelevelin2008).Suchmeasureshaveechoesofthemaximumfatcontentlimitsdiscussedinsection5.2(i),thatweresuccessfullyintroducedinGhana.CertainfoodstuffswhichaccountforsubstantialdietarycontributionsintheUK,alsocurrentlyhaveminimumfatthresholdsbydefinition,cheddarcheeseandicecreambeingthetwomostnotableexamples.Asaresult,thesecondpartoftheFSAconsultationfocusesonthelikelyimplications,includingdevelopmentcoststhatwouldbeassociatedwithamendingthecompositionallegislationforicecreamandcheddarcheese.UndercurrentfoodlabellingregulationsintheUK59forexample,productsdescribedasicecreamarerequiredtocontainatleast5%fatand2.5%milkprotein.Incontrast,theequivalentEuropeanregulations58havenominimumfatormilkproteincontent,whichhasledtocallsfrommanufacturersandsupplierstotheUKmarketfortheregulationtobebroughtintolinewiththerestofEurope61.Lowerfaticecreamproductscouldthenretaintheirproductdescriptionsandavoidconsumerconfusion.

Similar‘compositional’considerationscurrentlyapplytocheddarcheesewheretheamountofmilkfatexpressedasapercentageofthedrycheeseisstipulatedtobenotlessthan48%.TherealignmentofUKregulationswiththeinternationalCODEXstandardforcheddarwouldallowcheeseswithmilkfatcontentsfrom22%to47%toretainthe‘cheddar’productlabel,providinginformationwasincludedonthemodificationsmade.Whilethesemodificationstocompositionallegislationremainpending,theplanningprocessisobviouslyatanadvancedstageandtheFSA’scloseworkingwithmanufacturers,appearstofinallybepayingoffintheformofthedevelopmentofhealthieroptionsforconsumers.InanindependentreviewoftheScottishDietActionPlanin200662,effectiveengagementwiththefoodindustrywasidentifiedasproblematic.Theclosecollaborationwithmanufacturersinthereformulationofcompositionalstandardstherefore,canreasonablyberegardedasanindicatorofprogressinwhathasbeenadifficultarea.

ii. Physical activity/active travel

Unlikefoodlegislation,planningisoneofthepowersdevolvedfromtheUKParliamenttotheScottishGovernmentandanewScottishPlanningPolicy63waspublishedearlyin2010,whichreplaced17separateplanningpolicies.Atotalof37supplementaryPlanningAdviceNotes(PANs)werealsostillinplaceatthebeginningof2010,althoughsomerationalisationoftheseislikelyandongoing.Officialplanningpolicyguidanceiscriticalbecauseitsetstheparameterswithinwhichdecisionsaremadebylocalcouncilplanningofficersandplanningcommitteesacrossthecountry.AmongthefewreferencestohealthinthenewScottishPlanningPolicysetupareguidelineaspirationsaroundactivetravelnetworksandaccesstogreenspaces:

‘Developmentplansshouldpromoteapatternofdevelopmentwhichreducestheneedtotravelandencouragesactivetravelandtravelbypublictransport,takingintoaccountthelikelyavailabilityofpublictransportinruralareas...’(pp16)

‘Theplanningsystemhasaroleinhelpingtocreateanenvironmentwherephysicalwellbeingisimprovedandactivitymadeeasier...Accesstogoodqualityopenspacescanencouragepeopletobephysicallyactiveandaidhealthandwellbeing.’(pp30)

59 Food Labelling Regulations, 1996 (UK). http://www.opsi.gov.uk/si/si1996/uksi_19961499_en_1.htm 60 Euroglaces Code of Practice for Edible Ices. http://euroglaces.eu/en/upload/docs/Edible%20ices%20codes/English%20-%20Code%20for%20Edible%20

Ices%202006.pdf61 New Ice Cream Definition Would Boost Reformulation Work. Food Manufacturer.co.uk; March 2010 http://www.foodmanufacture.co.uk/Regulation/New-ice-

cream-definition-would-boost-reformulation-work62 Review of the Scottish Diet Action Plan Progress and Impacts 1996–2005 http://www.healthscotland.com/uploads/documents/3158-SDAP_Review_

Report_Full.pdf63 Scottish Planning Policy. The Scottish Government; February 2010 http://www.scotland.gov.uk/Resource/Doc/300760/0093908.pdf

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Thesectionontransportplanningalsonotesthatgreenhousegasemissionsneedtobereducedtomeetclimatechangetargetsandoneofthemeansbywhichthiscanbeachievedistoprioritiseotherformsoftravel(particularlyactivetravel),overmotorisedvehicles,forexample:

‘Theaimisforurbanareastobemademoreattractiveandsaferforpedestriansandcyclists,includingpeoplewithmobilitydifficulties.Cycleroutesand,whererelevant,cycleparkingandstorageshouldbesafeguardedandenhancedwhereverpossible...’(pp34)

AnumberofthesupplementaryPANsalsoreiterateacommitmenttoopenspaceprovisionandactivetravelconsiderations.PlanningforTransport(PAN75),forexamplehighlightsinfrastructureprovisionforprivatecaralternativesasakeycomponentofsustainabledesign.PAN65(PlanningandOpenSpaces)describesopenspaceprovisionasakeycriterionofneighbourhoodqualityandmeansofencouragingactivelifestyles.Othersupportivelegislationforactivetravelinvestmentincludesclimatechangetargetsforthereductionofgreenhousegasemissions64andstrategicenvironmentalassessment(SEA)65basedonanEUDirectiveandwithwhichallpublicsectorpoliciesneedtobecompliantwith.WhileSEAguidanceinprincipleimpliesthatthehumanhealthimpactsofallstatutorypoliciesneedtobeexplicitlyconsidered,theextenttowhichthisisadheredtoinpracticeremainsuncertain.Thismaybeduetoalackofconsensusonthedefinitionandscopeoftheterm‘humanhealthimpact’,whichcansometimesbeinterpretedquitenarrowlyaroundthebiomedical/traditionalhealthprotectionmodelofhealthhazards.

Giventhepotentialfora‘restrictedinterpretation’ofhealthcommitmentsoutlinedinplanninglegislationabove,itispossibletotakesomemeasureofreassurancefromthepublicationearlierthisyearoftheScottishGovernment’sCyclingActionPlanforScotland66.ThisplansetsoutanumberofstrongcommitmentsaroundprovisionforanimprovedcyclinginfrastructureinScotland.Theoverallstatedobjectiveoftheplanistoachieve10%ofalljourneysbybikeby2020,throughexpandingcyclenetworksacrossthecountryandenhancingdeliveryofcycletraininginschools.Theplanintendstodeliver:

• £2.5millioninvestmentincyclinginfrastructure,suchasnewpaths

• A£150,000trialloansupportschemein2010–11tohelpbusinessimproveworkplacecyclingfacilities

• £500,000toGlasgowCityCouncilforitsConnect2project,allowingcycliststotravelbetweenthecitycentre,theClyderiversidepromenades,KelvingroveParkandthewestendfreeoftraffic

• £300,000onchildcycletraining.

7.3 The route map for obesity prevention in Scotland

WhiletherehavebeenanumberofpolicyresponsesinScotlandthatareconsistentwithForesight’saspirationsfortacklingobesity,themostdirectlyinfluencedScottishGovernmentpublicationisclearlytheRoute Map Towards Healthy WeightpublishedinMarch201067.Thedocument’soverriding‘missionstatement’sumsuptheprincipleconclusionofForesight:

‘Whatisrequiredinthelongtermistransformationalchangeinsocietytoaddressthethreattoindividualandcollectivewellbeingposedbyweightgainandobesity.Thetypesofchangesweneedtomakeareanalogousintermsofscaleandcomplexity,tothoserequiredtomitigateandadapttoclimatechange.’

TheRouteMapalsodoesnotshirkfromambitiousobjectives,statingthefollowingaspirationatthebeginningofchapter3:‘forthemajorityofScotland’spopulationtobeinthenormalweightrange(i.e.BMI18.5to25)’.Notablyhowever,thereisnotimetablegivenwithinwhichthismightbeachieved.AlsoliketheForesightReport,theRouteMapisnotintendedtobeaprescriptivepolicydocumentbutinsteadit‘aimstosetoutthefuturedirectionofnationalandlocalgovernmentdecisionmaking’.RouteMapalsoeffectivelygoesonestagefurtherthanForesightinthatitattemptstotranslatefourofthefiveForesightpriorityareasintospecificideasforpolicymakers.Thefourcategoriesofpreventativeactiondescribedinsection6forinstanceareclearlyrecognisablefromtheForesightshortlistabove:

64 The Climate Change (Scotland) Act 2009 http://www.opsi.gov.uk/legislation/scotland/acts2009/pdf/asp_20090012_en.pdf65 The Environmental Assessment (Scotland) Act 2005 http://www.opsi.gov.uk/legislation/scotland/acts2005/pdf/asp_20050015_en.pdf66 Cycling Action Plan for Scotland. Scottish Government; 2010. http://www.cyclingactionplanforscotland.org/67 Preventing Overweight and Obesity in Scotland. A Route Map Towards Healthy Weight. Scottish Government; 2010. http://www.scotland.gov.uk/Publications/2010/02/17140721/19

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• Energyconsumption–controllingexposureto,demandforandconsumptionofexcessivequantitiesofhighcalorificfoodsanddrinks

• Energyexpenditure–increasingopportunitiesforanduptakeofwalking,cyclingandotherphysicalactivityinourdailylivesandminimisingsedentarybehaviour

• Earlyyears–establishinglifelonghabitsandskillsforpositivehealthbehaviourthroughearlylifeinterventions

• Workinglives–increasingtheresponsibilityoforganisationsforthehealthandwellbeingoftheiremployees.

Chapters4and5oftheRouteMaprespectivelysummarisethescaleofthechallengeaheadandthecurrentandongoingactionsthatarealreadyplannedorunderway.Thecombinationofactivitiescurrentlyinplaceservestodemonstratethatthereisnoover-relianceonanyoneparticularpolicyarea.Notablesuccessestodatehavebeenthe‘HungryforSuccess’schoolnutritioncampaign,whichsoughttoimprovenutritionalstandardsandincreasetheuptakeofschoolmealsbytacklingthesocialstigmaaroundreceiptoffreemeals68.

Intermsofintendedactions,theRouteMapdescribesafairlyextensiveportfolioofpossibleinterventionsthatarebeingconsidered,anumberofwhichcorrespondcloselytotheactionareasthatwouldbewellsupportedbytheevidencereviewthatmakesupthebulkofthisreport.Specific‘energyin’/nutritionrelatedexamplesinclude:

• Providingahigherproportionoflessenergydensefoodsaswellassmallerportionsizes(throughworkingwithmanufacturersandretailers)(pp17)

• Reservingtheoptionofstatutorymeasurestoimproveproductformulationsandportionsizesintheeventofunsatisfactoryprogresswithvoluntarymeasures(pp18)

• Supportmeasuresforcommunicatingthe‘energydensity’ofproductsinaneasilyintelligiblewayforconsumerswhomaybelesshealthliterate(pp19).

Onphysicalactivity/‘energyout’measures,thereisastatedundertakingtocreateenvironmentsthatmakewalkingandcycling‘partofeverydaylifeforeveryone’,throughaspectsofexistingtransportandplanningpolicies,forexample:

• DeliveringtheCyclingActionPlan(describedabove)withitsambitionthat10%ofalljourneysaremadebybikeby2020(pp20)

• WorkingwithArchitectureandDesignScotlandtoinvestigatethepotentialfor‘activetravel’featuresandfacilitiesinnewandrefurbishedbuildings(pp21)

• Reducingcommunitycrimeanddisordertoincreasesafetyandtheperceptionofsafetythathasbeenhighlightedasanimportantconsiderationintravelandrecreationchoices(seesection3.3(ii))(pp21).

TheserepresentonlyafewselectedexamplesofpossibleactionsthatarewithinthecurrentremitoftheScottishParliamentandthatcouldpotentiallycontributetoagenuinelycomprehensivecross-governmentapproachofthesortthathasbeenadvocatedintheUKGovernmentcommissionedForesightreportonobesity.TheRouteMapgivesmanyotherexamplesofinterventionsthatwouldbeconsistentwithoneofmoreofthefourForesight-derivedpriorityactionareasandthatcorrespondto‘moderatetohighpromise’categoriesofevidencepresentedhere.Itisintendedthatthecurrentreport’ssummaryoftheinternationalevidencebase,alongwiththepriorityrankingexercisedescribedinchapter8,willhelpinformtheeventualbalancedportfolioofproposedactionsthatwouldhavethebestprospectofmakingasustainableimpactontherisingprevalenceofoverweightandobesityinScotland.

68 Hungry for Success – A Whole School Approach to School Meals in Scotland: Final Report of the Expert Panel on School Meals. November 2002. http://www.scotland.gov.uk/Publications/2003/02/16273/17566

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8

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8 Chapter 8 – Prioritising the way forward 8.1 The portfolio matrix and evidence informed policy

Theportfoliomatrixforcategorisingobesitypreventionmeasures,introducedinsection2.6,presentedaframeworkfordecisionmakingthatshouldinprinciplehelppolicymakersdevelopabalancedprogrammeofinterventionproposalsacrossallfourANGELOdomains(i.e.physical,economic,legislativeandsocio-cultural).Althoughoriginallydevelopedasagenerichealthpromotiontemplate,theportfolioapproachisideallysuitedtoobesitybecauseofitsdiverseandrapidlyevolvingevidencebase,togetherwiththecapacityofthematrixframeworktoaccommodatescientificuncertainty.Theportfolioapproachalsoprovidesarationalefortakingarelativelybroadandinclusiveapproachtoevidencefindingandappraisalthatishighlyappropriateforcomplexembeddedpublichealthproblemssuchasobesity.Aswasalsohighlightedinchapter2,traditionalappraisalcriteriaforpublishedevidencetendtofocusonaspectsofstudydesignwhichcanbeverylimitingoutsideofanexperimentaltypesetting.Forthisreason,severalcommentatorshavehighlightedtheneedtoconsideranevidence-informedapproachtoobesitypreventionasopposedtoanevidence-basedapproachandarecentUSInstituteofMedicinepublicationondecisionmakinginobesitypreventionsetsoutadetailediterativeprocessforworkingwithadevelopingevidencebase(TheLEADFramework:Kumanyikaet al2010[158]).TheIOMframeworkemphasisesthevalueoflearningfromongoingpoliciesandpracticesandretainingtheflexibilitytoincorporateimprovementsbasedonanyinsightsgained.

Regardingtheuseoftheportfoliomatrixtocategoriseinterventionshighlightedinpreviouschapters,thefollowingassessmentcriteriafor‘levelofscientificcertainty’and‘potentialpopulationimpact’(tables8.1(a)and8.1(b)),werearrivedatusingthecombinedguidanceofseveralpublishedtemplatesfortranslatingevidenceaboutcomplexpublichealthinterventionsintopractice[24,158,159,160].Akeyprincipleinrelationtothistypeofappraisalistheneedtobeconsciousofthelimitationsofconventionalstudydesigncriteria,alongsidetheimportantcontributionthatobservationalandqualitativeworkcanbring,particularlywithregardtotransferabilityandcontext.

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Table 8.1(a) Portfolio criteria for evaluating level of certainty

Table 8.1(b) Portfolio criteria for evaluating likely population impact

Usingtheseguidancenotes,itispossibletoallocateamatrixpositionforanyproposedinterventiononthebasisoftheinformationavailable.InthefollowingexampletheeconomicandthelegislativedomainsoftheANGELOframeworkhavebeencombinedinonetable.Forconvenience,thecolourcodedtemplatefromchapter2isalsoreproducedbelow.InthiswayitispossibletoassembleacomprehensiveportfolioofinterventionsinthemanneradvocatedbytheForesightteam[2]andbytheWHO[1].



Low Moderate High

High

Moderate

Low

Promising

Lesspromising

Leastpromising

Verypromising

Promising

Lesspromising

Mostpromising

Verypromising

Promising

Table 2.4 Portfolio matrix for categorising potential interventions (reproduced as previous)

*Certaintyofeffectiveness–judgedbythequalityoftheevidence,thestrengthoftheprogrammelogicaswellasthesensitivityanduncertaintyparametersinthemodellingofthepopulationimpact(adaptedfromSwinburnet al,2005).

#Potentialpopulationimpacttakesintoaccountinterventionefficacy(impactunderidealconditions),combinedwith‘real-world’reachanduptakeandgenerallyreflectseffectivenessatthesocietallevel,weightedforrelativebaseline‘burdenofattributableillness’.

Levelofcertainty

High

Moderate

Low

Likelyimpact

High

Moderate

Low

Supportinglevelofevidence

Robustcredibleresearchevidence(e.g.:usingconventionalappraisalcriteriabasedonthequalityofstudies),combinedwithconvincingevidenceoftransferabilitytoaUKorScottishsetting(mostlikelytobederivedfromobservationalorqualitativestudies).

Consistentassociationscorroboratedbydifferenttypesofstudydesignalongwithestablishedplausibilityandlowriskofbiasedinterpretation.

Inconsistentreportsand/orquestionableobjectivitybasedonthetypeofinformationsourceorpoorstudyquality/highriskofbias

Supportinglevelofevidence

EvidenceofeffectivenessatpopulationlevelinUKorcomparablecountrywith“effectsize”>=0.05(atleast5%changeinaprimaryoutcomelinkedtohealthyweight).

Effectivenessdemonstratedincommunity/institutionalsettingsandlikelytobetransferabletotheUK/Scotland.

Inconsistentorcontradictoryevidenceofpopulationeffectivenesse.g.confinedtosmallnumbers/subgroupsorwherespecificpre-conditionsapply.

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Table 8.2(a) Portfolio matrix for categorising physical environment interventions

Table 8.2(b) Portfolio matrix for categorising economic and legislative interventions

Table 8.2(c) Portfolio matrix for categorising sociocultural interventions

Tables8.2(a)to8.2(c)showthematrixplacingformanyoftheinterventionscoveredinthisreportonthebasisoftheaboveguidancetablesandinformationfromtheirrespectivesourcereferences.Itisimportanttonotethatbecausethereisanelementofsubjectivityassociatedwitheachofthesematrixallocationsandtheevidencebaseiscontinuouslybeingdeveloped,therespectivepositionsarealsolikelytobesubjecttochangeovertime.







Low

Low

Low

Moderate

Moderate

Moderate

High

High

High

High

Moderate

Low

High

Moderate

Low

High

Moderate

Low

Pointofdecisionprompts(3.5i)

Workplacebuildingdesign(3.5i)

Proximitytohealthierfoodchoices(3.2)

Localpriceincentivesforhealthierdiet(4.3)

Financialincentivesforphysicalactivity(4.5)

Self-regulationbyfoodindustry(5.3)

Largescalepublicactivityevents(6.4)

Primarycareexercisereferral(weightmaintenance)(6.5i)

Multi-componentworkplaceprogrammes(3.3iii)

Activetravelincentives/facilities(3.4ii)

Portionsizeavailabilityrestrictions/widerchoices(3.3ii)

Traderestrictions/tariffs(5.2i)

MandatoryFoodlabeling(eg:trafficlightlabels)(5.2ii)

WorkplaceFoodPolicies(4.3)

Foodadvertrestrictions(6.2)

Personaltravelplans(6.5ii)

As yet no convincing measures score ‘High’ on both criteria

Builtenvironmentmodificationstoenhancesafety

Privatecarrestrictedareas(3.4ii)

Sugaredbeveragetax(4.2)

Agriculturalframeworks/CAPReform(5.2iii)

Area-widecyclingrouteinvestment(5.4)

Campaignsbackedwithsupportiveregulation(5.3)

Massmediaactivitycampaigns(6.4)

Targetededucationcampaignsforfoodawareness&cookingskills(6.3)

Comprehensiveworkplaceactivetravelprogrammes(e.g.includingonsitefacilitiesandassistedpurchaseschemes)(6.5iii)

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Selectingseveralexamplesthereforeasaguidetointerpretation,withinthetableforphysicalenvironment(8.2(a)),therewerenoidentifiableinterventionswhichfulfilledthehighestlevelofpromisebyscoringhighlyonbothpotentialimpactandlevelofcertainty.Workplacebuildingdesignalterations(suchas‘stairskip’(3.5ii))andPointofDecisionPrompts(PODPs(3.5i)),aresupportedbyahighlevelofcertaintyfromthepublishedevidence,buttheirlikelypopulationimpact,atleastintheUK,wouldbelowtomoderate.Thestateoftheevidenceidentifiedaroundeconomicinterventionsdoessuggestthatataxonsugaredbeveragescanbeaffordedthehighestlevelofpromisebyhavingastronglevelofcertaintyacrossmultiplesettingsandalikelyhighpopulationimpact,asaregionalstructuralmeasure(duetohighconsumptionlevelsandrelativelyhighpriceelasticity).Purelyinformationbasedcampaignsinisolationscorelowonbothlevelofcertaintyandlikelyimpact,sincetheyaregenerallynotwelltargetedandtheevaluationoftheireffectiveness,otherthanrecallandproblematicself-reporting,isnotoriouslydifficult.

8.2 Portfolio implementation

Whiletheportfoliomatrixasitstandsoffersausefulmeansofcategorisingpotentialinterventions,itdoesnotincorporatewhatisarguablythemostimportantstageintheprocessofnewpolicydevelopment,namelythatofplanningforimplementation.Asdescribedinthefinalsectionoftheirintroductorypaper[24],Swinburnandcolleaguessuggestthatmovingfrom‘coulddo’to‘shoulddo’bringsinanentirelynewsetofconsiderationsforstakeholdersanddecisionmakers.Althoughlargelyqualitativeinnature,thesejudgementsneverthelessneedtobearticulatedandtransparent,sincetheyarelikelytomateriallyinfluencethebalanceofproposalsinanyinterventionportfolio.Theirfiveadditionalproposed‘filtercriteria’(seetable8.3)of:practicality,sustainability,effectsonequity,potentialsideeffectsandacceptabilitytostakeholders,encompassthefinalstagesofthedecisionprocess.Inthisadaptedtable,theterm‘practicality’hasbeenusedinsteadof‘feasibility’(asinoriginaltable)becauseofitsgreaterspecificityofmeaning.Itwasfeltthattheterm‘feasibility’couldequallybeappliedtoanyofthefivefiltercriteria,eachofwhichcouldconceivablyimpactonthefeasibilityofagivenintervention.

Table 8.3 Suggested filter criteria for stakeholder judgements on implementation

Filtercriteria

Practicality

Sustainability

Effectsonequity

Potentialsideeffects

Acceptabilitytostakeholders

Description

Theeaseofimplementationconsideringsuchfactorsas:theavailabilityofatrained

workforce;thestrengthoftheorganisations,networks,systemsandleadershipinvolved;

existingpilotordemonstrationprogrammes.

Thedurabilityoftheinterventionconsideringsuchfactorsas:thedegreeofenvironmental

orstructuralchange;thelevelofpolicysupport;thelikelihoodofbehaviours,practices,

attitudes,etcbecomingnormalised;thelevelofongoingfundingsupportneeded.

Thelikelihoodthattheinterventionwillaffecttheinequalitiesinthedistributionofobesityin

relationto:socioeconomicstatus;ethnicity;locality;gender.

Thepotentialfortheinterventiontoresultinpositiveornegativesideeffectssuchas

on:otherhealthconsequences;stigmatization;theenvironment;socialcapital;traffic

congestion;householdcosts;othereconomicconsequences.

Thedegreeofacceptanceoftheinterventionbythevariousstakeholdersincluding:

parentsandcarers;teachers;healthcareprofessionals;thegeneralcommunity;policy

makers;theprivatesector;governmentandotherthirdpartyfunders.

(Source:AdaptedfromSwinburn,GillandKumanyika,2005[24])

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Crucially,theseadditionalfilterscouldserveasausefulbasisforconstructivediscussionsaroundthemeritsandfeasibilityofindividualproposals.Thesameapproachhasbeensuccessfullyemployedtocombinetechnical/researchoutputswithcontextual/realworldconsiderations,inthefieldsofmentalhealthandcancerprevention[24].TheyalsorepresentanimportantconceptuallinkwiththeANGELOframework,throughtheexplicitacknowledgementthatnocomplexpublichealthinterventioncanbeimplementedwithoutconsiderationofitswiderpolitical,economic,environmentalandsocialcontext.Thehighlycontextdependentnatureoftheseconsiderationshowever,meansthatthetransferabilityofeven‘wellevidenced’interventionsthathavenotyetbeentestedinaScotland/UKsettingcouldwellbelimited.Inpracticetherefore,assigningadefinitiveplacingtointerventionproposalswithinthegridbecomesarelativelycomplexundertaking.Thefactthatsuchataskisnolongermerelyaresearchbasedexercise,underlinesaneedforthewidestpossiblestakeholderinvolvementinworkingthroughthefivefiltercriteriaintable8.3,inordertoarriveataproperlyinformedassessmentofimplementationfeasibility.Suchabroad‘stakeholdergroup’wouldideallyincludefrontlinepractitionersandrepresentativesofthetargetpopulation,aswellaspolicymakers,withinputfrompublichealthprofessionalsandgovernment.Providedwithashortlistofrelativelyhighpromiseinterventions,discussiongroupscouldthenbeaskedtoallocate‘feasibilityscores’foreachofthefivecriteriaintable8.3,usinga5pointlikertscaleasfollows:

1. Notatallfeasibleinproposedsetting

2. Significantdoubtsaboutfeasibility

3. Feasibleandshouldbepossibletoimplementinproposedsetting

4. Feasibleandeasytoimplementinproposedsetting

5. Highlyfeasiblewithnopracticalproblemsinmostsettings.

Havingdiscussedandscoredeachofthefivecriteria,anoverallaverage‘easeofimplementation’score’couldbederivedforeachproposedintervention.Interventionswitharelativelyrobustevidencebaseandaclearfavourableconsensusoneaseofimplementationwouldrepresentstrongprospectsforinvestment.Therewillinevitablybesomeproposalswhich,despitemeetinganacceptableeffectivenessthreshold,aresimplynotfeasible(e.g.inScotland)atthepresenttime.Inordertofurtherillustratetheprocess,tables8.4aand8.4b,outlinehypotheticalstakeholdercommentsagainsteachofthefiltercriteriafortwointerventions:

• Transportinfrastructureinvestmentprogrammetoimproveactivetravelsafety(anactivityrelatedphysicalenvironmentmeasure:Section3.4)

• Astatutorilyimposedlimitonportionsizesinrestaurants(e.g.byweightortotalcaloriecontent:Section3.3)[Note:notdescribedinreviewasalegislativeinterventioninsection5,sincedealtwithonlyasan‘availability’issueandnostudieswereidentifiedthatmadeuseofstatutorylimits].

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Table 8.4(a) Hypothetical filter criteria results for transport infrastructure investment

Filtercriteria

Practicality

Sustainability

Effectsonequity



Description

Theverysubstantialcapitalinvestmentrequiredatatimeofconstrained

governmentspendingislikelytoreducefeasibilityintheabsenceofa

proactivefiscalstimuluspackage.

Criticalshiftsrequiredacrossgovernmentandinpublicconsciousness.

Transportinvestmentremainsheavilybiasedinfavourofprivatecar

transportandminor‘activetravel’projectsriskbeingunsustainableif

theyarerelativelyisolated.Intheabsenceofacomprehensiveapproach

therefore,sustainabilitylimited.

Undercurrentroadconditions,unlessactualsafety(andperceptionsof

safety)couldbeimproved,achievingwidertakeupwillbeproblematic

andthosewiththepotentialtobenefitthemostarenotlikelyto

participate.Genuineimprovementsinsafetywillhelpaddressthisissue

andhavebeenshowntoincreaseparticipation(eveninUS).

Adversesideeffectslikelytobeminimal.Bettertrafficsegregation

benefitsallroadusers.Largereductionsinrevenuereturnsfromfuel

dutyrevenuealsounlikelysincemostsubstitutedjourneysarelikelyto

beshortonesandmorethanoffsetbyreductionsinhealthcarecosts

(accidentsandprematurecardiovascularmortality).

ExperiencefromNewYork(section3.4)andLondon(reducedtrafficby

meansofcongestioncharge)suggeststhatinitiallevelsofresistanceare

likelytodeclineovertimeaspeoplerealisethebenefitsofimprovements.

Score#

2

2

3

5

4

#Score:1to5scale,where5isthemostfavourablefor‘easeofimplementation’and1theleastfavourable.

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Table 8.4(b) Hypothetical filter criteria results for restaurant portion size limit

Filtercriteria

Practicality

Sustainability

Effectsonequity



Description

Whilelegallybindinglimitswouldobviouslybethebestwayofensuring

compliance(inthelightofvoluntaryschemesbeinglargelyineffective,

demonstratedbytransfatsstoryinNewYork,section5.3),their

practicalfeasibilitywouldnotbestraightforward.Considerabledifficulty

inenforcementalsolikelytobecompoundedbycaterersfinding

‘creative’solutionse.g.twostartersforthepriceofoneetc.

Sustainabilitycouldbeunderminedbypracticaldifficultiesin

enforcementhighlightedaboveandhighlevelsofstakeholder(and

customer)resistance.

Thereisapossibilitythatthemorecompliantrestaurateursmightfind

theirprofitabilityaffectedintheshortterm.

Unlesscarefullythoughtthrough,thepotentialforthismeasureto

haveanadverseeffectonthemoreenlightenedcommercialcaterers

cannotbediscounted.Thisistheverygroupwhoarealreadylikelyto

beattemptingtoprovidefoodthatisatthemorenutritiousendofthe

spectrum.

Difficultyforeseeableinanenvironmentinwhich‘valueformoney’where

foodisconcernedisstillinterpretedintermsofquantity.Unlikelytofind

favourthereforewithrestaurateursorwiththeircustomers.Thereare

indicationshoweverthatthepublicwouldappreciateagreaterrangeof

choiceinportionsize(notthesameascompulsoryreductionsinportion

sizeofcourse).

Score#

2

2

3

3

3

#Score:1to5scale,where5isthemostfavourablefor‘easeofimplementation’and1theleastfavourable.

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Withoutanyclaimtobecomprehensive,Tables8.4(a)and8.4(b)atleastservetoillustratesomeofthecomplexitiesinvolvedinassessingtheeaseofimplementationacrossSwinburnandcolleagues’fivecriteria.Thedegreeofsubjectivityandscopeforinfluencebyindividualvalues,prioritiesandprejudicesisalsoreadilyapparentandunderlinesthechallengethatthemanagedconsensusprocesswillinvolve.Ifmanagedwell,however,theresultshouldbeawellbalancedportfolioofrealisticoptionswithclearindicationsonhowstraightforwardeachproposalwouldbetoimplementalongsideitslikelychancesofleadingtoadesirableoutcomeinScotlandatthepresenttime.

8.3 Obesity as a ‘complex adaptive system’

Asameansofaddressingthehighlevelofcomplexityandtheresultsofapplyingmultipleadditionalfiltercriteriaoutlinedintable8.1,themodernobesityepidemichasitselfbeendescribedasexhibitingallthefeaturesofa‘complexadaptivesystem’(CAS).ACASisdefinedasbeing‘composedofmanyheterogeneouspiecesinteractingwitheachotherinsubtleornon-linearwaysthatstronglyinfluencetheoverallbehaviourofthesystem’.ThethreecharacteristicsoftheobesityepidemicwhichmimicaCASare[14]:

• Avastrangeinthelevelsofscalethatisrelevant(e.g.rangingfrommolecular/genetictosocietalandglobal)

• Awidediversityof‘actors’rangingfromsmalllocalretailoutletstomultinationalcorporationsandworldtradeorganisations

• Themultiplicityofmechanismsandprocessesatwork(fromneuronalrewardpathwaysforsatietytothe‘spreading’ofbehavioursinsocialnetworks,andinfluencesfromthebuiltenvironment,aswellaseconomicfactors).

Furthermore,evenwheremechanismsofeffectareclear(e.g.theapparentassociationbetweenaccesstogreenspaceandpropensityforphysicalexercise,leadingtoeffectsonBMIasoutlinedinthePortland/Oregonstudiesreviewedinchapter3),thelinkagesandfeedbackbetweenthesemechanismsarenotnecessarilywellstudiedorwellunderstood.Hammond[14]eloquentlydescribesfivegeneralfeaturesofaCASwhichcouldhaveimportantimplicationsforanti-obesityinterventions,whichare(i)individualityof‘actors’(whichcanbepeople,largersocialunits,governmentsetc);(ii)‘actor’heterogeneityateachlevel(e.g.ingoals,rules,adaptiverepertoire,andconstraints);(iii)complexinterdependence;(iv)emergence:CASsareoftencharacterisedbyemergentunexpectedphenomena(e.g.patternsofcollectivebehaviourthatforminthesystemasawhole);and(v)tipping:CASscanalsoexhibitthephenomenonof‘tipping’inwhichintrinsicnon-linearitycanmeanthatsmallchangesresultinmassivelydisproportionatesystemoverhaul,orrecalibrationtoanew‘equilibrium’.

Consideringobesityasacomplexadaptivesystemhelpstounderlinetwobasicprinciplesaboutplanninginterventions,thesebeing:

• thatsinglecomponentinterventionsbythemselvesareunlikelytosucceed

• itisimportantnottooverlookthecumulativeeffectsofanumberofsmallchanges.

Singlecomponentinterventionsareunlikelytohaveameasurableimpact,particularlyonweightoutcomes,firstlybecauseofthealmostuniversallysmalleffectsizesseenthroughoutthisreport,andsecondly,fromthetendencyofcomplexsystemstopreserve‘equilibrium’(individualsforexamplemaycompensateformorephysicalactivitybyincreasingtheirfoodintake[161]).Withregardto‘smallchanges’,ajointtaskforcereportledbytheAmericanSocietyforNutrition,advocatedasocietalapproachtotacklingobesitybasedonincrementalsmallchangesinbothdietandphysicalactivity.FirstproposedbyHillandcolleagues[20],the‘smallchanges’approachisbasedontheprinciplethatsmallchangesinhabitarelikelytobemoresustainablethanmajorlifestylechanges.Italsoarisesfromthe

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observationthatweightgainthroughouttheadultlife-courseismediatedbyverymarginalimbalancesinenergyintakeandexpenditure.Thespecialtaskforcereportcitesanumberofexampleswheresmallchangeinterventionshaveproventobesuccessfulinchangingweightoutcomesandinalteringenvironmentaldeterminants.Theexamplescoverseveralinterventionsalreadydiscussedindetailinthisreport,includingreductionsinportionsizes(section3.3),replacinghelpingsofsugarsweetenedbeverageswithsugarfreealternatives(section4.2)andsimplepointofdecisionprompts(PODPs)forincreasingstairuse(section3.5).

Amultiplesmallchangesprogrammethereforeadherestobothoftheaboveprinciplesindealingwithacomplexadaptivesystem.Theobjectivesofsuchaprogrammewouldbefirsttostabiliseobesityratesbyreducingorhaltingtheriseinprevalencebeforefocusinginturnonreducingtheabsoluteprevalenceofobesity.Thebasicunderlyinglogicissimplythatiftheobesityepidemichasbeencausedbythegradualconcurrenceofmanydifferentdriversateveryscaleinthemodernworldbeing‘ratcheted’inonedirection[16,26],thenitshouldbepossibletounpicktheprocessbymultiplesmallratchetsintheoppositedirection.Giventheproblemsthatcanarisefromtryingtoengagedifferentstakeholderswhocanbefarapartintheirimmediateobjectives,Hills’sreportfortheUSNutritionTaskForceenvisagesthatthesmallchangesapproachcouldprovideacommonfocusforallstakeholderstobothcoordinatetheiractions,whilstmakingtheirowndistinctcontribution[20].Thefactthatbydefinitionthechangesdonotneedtobemassive,shouldalsohelpmitigateresistancefromvestedinterests,whichcanbeamajorstumblingblockasillustratedbytheeffortsaroundtradetariffsandfoodlabellinginsection5.2.Inthemostoptimisticscenariooutlinedinthereport,theauthorsuggeststhattheeffectofmultiplecoordinatedsmallchangesoperatingintherightdirection,mightbesufficienttopushmodernsocietiestoanew‘tippingpoint’wherethepossibilityofreversingobesitytrendscouldfinallybearealprospect.Thiswouldofcourseonlyberealisticwhenamajorityofthesubtleobesogenicpolicyandenvironmentaldrivershaveswitchedinasufficientlycomplimentaryandconvergentmannerthattheyeffectivelyre-inforceeachotherandbringaboutaseismicshiftintheoveralldirectionoftravel.

8.4 Combining public health and economic perspectives

Whilethehealthbenefitsfromtacklingobesityshouldmakeasufficientcaseintheirownrighttopersuadepolicymakersthatpreventionmeasureswouldmakeworthwhileinvestments,itshouldalsobeborneinmindthatallgovernmentscontinuallyfaceawidevarietyofdemandsandproposalsthatcallupontheirattentionandresourcesatanyonetime.Withchapter4ofthisreportalreadydevotedtotheeconomicenvironmentandalmosteverypotentialinterventionhavingsomecostimplicationsfromsomestakeholder’sperspective,itisclearthattheeconomiccaseforobesitypreventionmustbeset alongsidethepublichealthrationale,especiallyundertheconditionstimesofconstrainedpublicexpenditure,whichboththegovernmentsofScotland67andtheUKarelikelytobeoperatingunderfortheforeseeablefuture.Onehighlyarticulateaccountofdrawingtogetherpublichealthandeconomicperspectives,wasarecentdiscursivereviewbyBleichandSturmonpolicysolutionstoincreasephysicalactivityintheUS[162].Inclassicaleconomicsforinstance,neitherhealthcompromisingbehavioursnortheiradverseoutcomeslikeobesity,arethemselvesajustificationforgovernmentintervention.Similarly,anyhealthriskbyitselfisnotviewedbyeconomicsasaproblem,unlessithasarisenasaconsequenceofmarketfailuretooptimisetheallocationofresources.Generallyspeaking,therearethreebroadtypesofsituationwheremarketsfailtooptimallyallocateresources:publicgoods(oncetheyarefreelyavailable,nobodyhasanincentivetopayforthem),externalities(sideeffectsarisingfromproductionorconsumptionofagood,butnotincludeintheprice)andinformationasymmetry(whereonepartyisnotfullyawareofthelikelybenefitsorrisks).

67 Scotland’ Public Finances: Preparing for the Future. Audit Scotland; November 2009. http://www.audit-scotland.gov.uk/docs/central/2009/nr_091105_scottish_public_finances.pdf

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Marketfailuresarisingfrompublicgoodsandexternalitiesaremoreapplicabletophysicalactivity,whilethosearisingfrominformationimbalancearemorelikelytoberelatedtofood[162].Theeconomiccaseforinterventionisusuallyapparentfromanexaminationofwheremarketfailurearises.Examplescoveredinthisreportinclude:

• Thesupplementarytaxonsugaredbeveragesinchapter4(tocountertheinformationimbalanceforconsumersregardingtherisk)

• Measurestoincreasepedestriansafetytoreducetheexternalitiesofdriving(section3.4)

• Increasedavailabilityofsaferecreationspace(increasingthesupplyofpublicgoods)(section3.4).

Inthisway,instancesofmarketfailureapplytoalmostallenvironmentaldriversforobesity,sincepeopleareoftennotfullyinformedaboutlongtermrisksoralternatives,andtheobesogenicbehaviourbecomeseffectivelythelineofleastresistance.Theeconomiccasetherefore,isusuallycomplementarytotraditionalpublichealthevidenceofeffectiveness,particularlywhenactualchoicesandbehavioursaremorecloselyalignedwithanindividual’sownpreferredoutcomes(e.g.goodhealthandhealthyweight).

8.5 Historical public health parallels

Thesearchforhistoricalparallelscanoftenbeausefulsourceoffreshinsightsintocurrentproblemsthathavesimilaritieswiththe‘insurmountable’issuesofthepast.Victorianpublichealthmeasures(i.e.hygiene)forexample,althoughbasedonanincompletebiologicalunderstandingoftheinfectiousaetiologyofmuchprevalentdiseaseatthattime,amountedtoacombinationofsubstantialinfrastructuralinvestmentstodevelopgoodsanitation,aswellaslargescaleinformationcampaignstochangepersonalhabits,evenincludingproscribingofsomeofthosehabits(e.g.spittinginthestreet)[163].ThiswasatimebeforemodernpublichealthdivergedintowhatRaynerlabelsasitstwoconstituent‘rulingorthodoxies’,namelythebiomedicalmodelversusthehealthychoicesmodel.Manynowconsiderthis‘split’tohavebeenadetrimentalstepandtherehasbeenastrongcasemadeforareturntoamore‘ecological’orwholesystemperspective,whichgenuinelyreflectsthedegreeofcomplexityassociatedwithmulti-factorialpublichealthissueslikeobesity[163].Inresponse,thereisnowavarietyofpublishedecological/wholesystemsmodelsdealingspecificallywiththeobesogenicenvironment,themostcomprehensiveofwhichisthatproducedaspartoftheUKGovernment’scommissionedForesightReportdiscussedinchapter7.

Aboveall,ecologicalmodelsemphasisethecomplicatedinterplaybetweendifferentdriversacrossallofthefourmajordomainsoftheANGELOframework.TheymayalsohelptofacilitateareturntothepracticalsolutionorientatedmeasuresthatcharacterisedtheVictorianapproach.Inspiteofanincompleteunderstandingofcontemporarycommondiseasesandthemassivescaleofthechallenge,theydevotedverysignificanteffortsandresourcestowardscombatingwhatwasinmanyrespectsa‘toxicenvironment’withregardtoinfectiouspathogens.Theoneadvantagethattheydidhavewhencomparedtothecurrentobesityepidemic,waswidespreadpublicconcerndrivenbytherapiditywithwhichcholera,typhoidandsimilarepidemicsdeveloped,combinedwithastrongenoughpoliticalwilltoimplementstructuralinterventions.Thepoliticalpressure,incontrast,forgovernmentstoactonobesitypreventionislargelyprofessionallyled[164],eventhoughmainstreammediamaintainsarelativelyhighprofileforthecrisis.Victorianinfectiousdiseaseoutbreaksexertedavisiblylethalandrapideffectonmortality,asopposedtothe‘slowburn’25-yeartimeframeofexcessmortalityattributabletoobesity.Ironically,forbothmodernchronicobesity-relateddiseaseandtheVictorianinfectiousdiseaseepidemics,nosectorofsocietywasimmune.Amoreappropriatepublichealthanalogytherefore,isprobablytobaccosmoking,whereincreasinglycompellingscientificevidencepromptedaprofessionallyledcampaignthateventuallychangedpublicattitudesenoughtosupportmeasures,suchasbansonpublicareasmokingwhichwouldhaveseemeddraconian,eventenyearspreviously.Althoughtobaccoiscertainlydifferent,insofarasthereisnosuchthingasa‘healthysmoke’,andinvoluntaryexposure(i.e.forcedconsumption)ofobesogenicfoodisrare,therearestrongsimilaritiesinthecurrentattitudeanddefencesofthefoodindustrytocallsforstructuralcontrols[165,166].

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8.6 Integration with other political and health priorities

Advocatesforpublichealthactiononobesitypreventioncancertainlytakesomeencouragementfromthe‘tobaccojourney’,inthatprofessionallyledattemptstoaltertheculturearoundsmokingeventuallydeliveredontheirpromise,intheformofeffectivetaxesandagreatlydiminishedsocialacceptabilityofsmoking.Makingthecase,however,thatsomedietaryconstituentsareintrinsicallybad,orthatcertainseeminglyharmlessleisuretimepursuits(suchasintensiveTVwatching)shouldbeavoidedorminimised,ismuchlesslikelytobegratefullyreceivedandactedupon.Takingaccountofsuchconsiderations,combinedwithanestablishedreluctanceofthegeneralpublictobetoldwhattodobyhealthservicesandgovernment,itishardlysurprisingthatcallsforlargescaleactionstotackleobesitydriversarelargelyrestrictedtohealthandotherprofessionals,whoarecontinuallyconfrontedwiththeconsequences[164].Inlobbyingtermsfromapolitician’spointofview,thismakesforarelativelysmallconstituencyandonethatisunlikelytoreceiveagreatdealofattentioninthefaceofsomanyotherpressingprioritiesandresponsibilities.Giventheverybroadscopeofobesitydriversandtheirhighdegreeof‘sharedpathology’orcommonunderlyingcauses(e.g.over-consumption)withseveralothermajorpublichealthproblems,thereisplentyofscopeforcombiningactionstomitigateobesitywithotherhighprofilecampaignsinthepolitical/publicarena.Themostnotableofthesetwotargetsarehealthinequalities[167]andclimatechange[168].

i. Health inequalities

Forawidevarietyofreasons,sectionsofthepopulationwhoexperiencerelativelyhigherlevelsofsocioeconomicdeprivationarenotaswellequippedtodealwiththenegativepressuresonhealthstatusexertedbymanyobesitydrivers.FromEnglishpopulationdataatleast,thesteepincreasesinchildobesitythroughtheearly2000s(whichwerealsoseeninScotland),wereclearlymoremarkedinchildrenfromlowerincomefamilies.Interestinglyinoneparticularlywellpoweredstudybasedontwonationalsurveysources[169],therewasastrongerassociationforincomethanforsocialclassitself,leadingtheauthorstospeculateonthelikelyimportanceofbudgetaryconstraintsasabarriertoahealthyhouseholddiet.Amajorinternationalsystematicreviewpublishedin1999,basedpurelyonlongitudinalstudies,alsofoundastrongandconsistentassociationbetweenchildhoodsocioeconomicstatusandincreasedobesityinadulthood[170].TherelativeabsenceofanysocialgradientforadultobesityinScotland(exceptforthemarginallyincreasedriskforwomeninlowersocialclassesandaslightinverseriskformen[seesection2.3]),maysuggestthatthereachoftheepidemicissouniversalthatallgroupsaresimilarlyaffectedbyadulthood.AlthoughtheepidemiologyofobesityinScotland(chapter2)isnotprofoundlysociallypatterned,itonlyrequiresacursoryconsiderationofthefourANGELOdomainstobegintoappreciatetheincreasedchallengesthatarelikelytoariseinassociationwithsocialdeprivation.Table8.3summarisestheselikelyadditionalbarriersand,aswithpreviousillustrativetablesinthischapter,itdoesnotsetouttobeexhaustive.Mitigationstrategiesthathavealreadybeendiscussedarealsoincludedforeachexample.Althoughthesocietywideprevalenceofobesitymayrenderasociallytargetedpreventionprogrammeineffective,therearestrongsocioeconomicexacerbatingfactorsacrossallfourANGELOinterventiondomainsthatcouldconceivablybeaddressedbywellevidencedinterventionsdiscussedpreviouslyinthisreport.

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Table 8.5 Obesogenic drivers associated with deprivation by ANGELO framework domain

Socialinequalityandpovertythereforedonotfulfilthedefinitioncriteriaforclassicalepidemiologicalriskfactorsinthecaseofobesityandoverweight.Incomplexsystemsthinkingdiscussedabove,theyareriskregulatorsinthebroadestsenseandcanmostusefullybeviewedasdynamiccomponentsgoverninginteractionswiththeobesogenicenvironment,influencingobesityrelatedbehavioursatthepersonalandsocietallevel[15].Sincetheseinteractionscanbestbemoderatedbystructuralandpolicyinterventionsdiscussedinthisreport,themajormeansofamelioratingtheirimpactshouldbeexternalandnotrelyonpersonalchoicesinthesocialgroupswherethisismostrestricted.

ii. Climate change

Thenowoverwhelmingscientificconsensus,thatmeanglobaltemperaturerisesof1.4oCto5.8oC68canbeexpectedbytheturnofthenextcentury,havefocusedmindsonthelikelyimplicationsofthisincreaseforhumanhealth[168].AllgovernmentsarenowwellawareoftheneedtobeseentobeactingresponsiblyinrelationtoclimatechangemitigationandtherehavebeenencouragingsignsfromtheObamaadministrationintheUS,althoughitisunlikelytobeplainsailing69.Sincehealthconsequencesaremostfrequentlydiscussedintermsofpopulationshiftsofinfectiousdiseasevectors,andclimatemediatedchangestothefoodsupply,directlinkstotheobesitypandemicarenotoftenselfevident.Also,incontrasttoadvocacyforobesityprevention,climatechangeactivismisverywellestablished,aswellasbeingmainstreamandworldwide.Itisfortunatetherefore,inonesense,thatmanyoftheactionsneededtodealwiththethreatofclimatechangehaveasubstantialandreadilyapparentoverlapwithmeasuresneededtotackleobesity[164,174].Fromtheneedtowalkandcyclemore,andreducedependenceonprivatemotorisedtransport,allthewayuptoformulatingnewinternationaltradeagreementsforamoresustainableandecologicallysoundfoodsupply,therearemajorcrossoversbetweentheobjectives

68 Climate Change 2007: The Scientific Basis. Intergovernmental Panel on Climate Change IPCC: http://www.ipcc.ch/publications_and_data/ar4/wg1/en/spmsspm-projections-of.htm

69 Obama's Climate-Change Bill Stymied by Bipartisan Quarrel. The Independent; 26 April 2010. http://www.independent.co.uk/news/world/americas/obamas-climatechange-bill-stymied-by-bipartisan-quarrel-1954231.html

DOMAIN

Factor/driver

Leadsto...

Effectofdeprivationreobesity

Counteractwith...

Potentialmitigation

Relevantsection(s)

References

Physical

Highneighbourhooddisorder.

Reducedopportunity/inclinationforactivity.

Improvedsafe/greenspaceprovision.

3.4

[66,81,171]

Economic

Tendencytooptforlowestcostpercalorie.

Increasedconsumptionofenergydensefoods.

Subsidisedhealthierfoods;restrictbulkpromotionsofHFHSfoods.

4.2;5.2

[103,104]and[172]

Legislative

Lowersocialgroupslessabletocampaignfortheirinterests.

Tendencytowardsmakingdowithpooroptions/localfacilities.

Facilitatedcommunitydevelopment/activityevents.

3.4;6.4

[66],[143,146]

Sociocultural

Immediategratificationoftenacopingstrategy.

Longertermconsequencesofbehaviournotconsidered.

Improvementstocircumstances=Reducedcomfortseekingbehaviours

6.5

[1,148,173]

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ofbothmajoragendas.Interventionswhichpromotehealthyeatingorphysicalactivity,butwhichareenactedforotherreasons,couldbeconsidered‘stealthinterventions’.

Environmentalsustainability,liketheobesityepidemic,hasallthefeaturesofacomplexsystemsproblem,althoughpublicappreciationofcomplexityinthecaseofthelatterremainsrelativelylimited[172].Sincemanyofthesocietalchangesforbothproblemshavesubstantialoverlaps,itshouldbefeasibletodovetailobesitypreventioneffortsintotheenvironmentalsustainabilityagenda,wherethereisalreadywidespreadpublicengagement.Huangelegantlydescribesasix-phasestrategyforconvergingeffortsinthesethetwoareas[15,174]:

i. Framingobesityasacomplexsystemsissueinboththescientificandpublicspheres

ii. Emphasisingcrosslevelandcrossdisciplinaryhypothesesattheoutsetofresearch

iii. Investinginthetestingandevaluationofupstreaminterventions

iv. Increasingthecapacitytoconductmulti-levelresearchandpolicytranslation,bybuildingcoalitionsandtraininganewgenerationofmultilevelscientistsandpractitioners

v. Developingandapplyingsystems-sciencemethodologiestotheobesityproblem

vi. Cultivatingaglobalperspective.

Thecalltoincreasecapacityforresearchinmulti-levelinterventions,isareflectiononthecurrentabsenceofanyrealevidencebaseintheeffectiveuseofthistypeofmodellingforobesityorpublichealthproblemsingeneral.Forwardlookingdocuments,suchastheForesightReportandtheScottishGovernment’srecentlypublishedRouteMapforObesityPrevention70haveclearlygraspedtheneedforawholesystemsapproach.Itishopedthatthisdocument,incombinationwiththeambitiousscopeoftheRouteMap,canbethebeginningofagenuinelybalancedprogrammeofinterventionsthatareabletotarget alltherelevantdomainsandmajordriversatthecoreoftheobesityepidemic.

8.7 Recommendations for next steps

Baseduponthediscussionframeworksandadditionalbroaderrangingconsiderationssetoutinthischapter,itisclearthatanymanagedconsensusprocessneedstobeabletodrawuponabroadandwiderangingmixofexpertiseandexperiencetoderiveapracticableportfolioofpotentialpolicyinterventionstotackleobesity.Inorderforanysuchdiscussionstobemaximallyproductive,thepanelorgroupswouldbenefitfromhavingreadyaccessto:

• AsummaryportfoliomatrixwitheachrecommendationcategorisedbyANGELOdomainanditsrespectivelevelofevidence(followingtheformatoutlinedforcomplexpublichealthinterventionsbySIGN/NICE)

• Anestimateofthepotentialpopulationimpact(e.g.inScotland)ofeachproposedintervention

• Briefguidancenotesforeachstakeholdertoassignfeasibilityscoresaccordingtothe‘thirdaxis’filtercriteriaofpracticality,sustainability,effectsonequity,potentialsideeffectsandacceptabilitytostakeholders.

8.8 Limitations of this review

Sincethereareveryfewaspectsofmodernlivingthatarenotrelatedinsomewaytorisingobesityprevalence,itisvirtuallyimpossibletopresentacomprehensivelistofcontributoryfactorsorpotentialtargetsforintervention.Whilethepublishedscientificliteraturearoundobesityisalsovastandvoluminous,thedifficultiesassociatedwithinvestigatingobesitymeanthatprogressisatdifferentstagesindifferentareasandthequalityofstudiescanbehighlyvariable.Thisreviewsetsouttocategoriseenvironmentalandpolicyinterventionsinsuchawaythattakesaccountoftheirrelativestrengthofevidenceandpotentialpopulationimpact.Itdoessobymakinguseoftwopreviouslyvalidated

70 Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight. The Scottish Government; 2010. http://openscotland.net/Publications/2010/02/17140721/0

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frameworks,namelytheANGELOsystem(analysisgridforenvironmentslinkedtoobesity)andtheportfoliomatrixforcomplexpublichealthinterventions.Noclassificationsystemwilleverprovideaperfectfitforamulti-dimesionalproblemsuchasobesityandthereareinevitableareasofoverlapanduncertaintywithintheapproachaspresentedinthisreview.Thecapacityofthesystemtoaccommodateuncertaintyandrevisionswhereappropriatehowever,meansthatitcanprovidetherawmaterialforbuildingacomprehensiveinterventionstrategybasedonthecurrentstateoftheevidencebase.Thecriticalphaseofanysetofproposedinterventionsisofcourse‘real-world’implementationandjudgementsaroundpracticality,sustainability,effectsonequity,potentialsideeffectsandtheacceptabilitytostakeholderscanonlybemadewiththeinputfromabroadrangeofrelevantexperienceandexpertise.Thetemplatescoringsystemforthesemoresubjectivediscussionsdoesnotsetouttobeadefinitivequantitativetool,butratherservesasafocusfordecidingontheimplementationfeasibilityofanyspecifiedintervention.

8.9 Overall conclusion

ForthereasonsgivenintheabovechapteritwouldbeinappropriatetoattempttodescribeadefinitivelistofpolicyoptionsthatshouldbeimplementedinordertotacklerisingobesityprevalenceinScotland.Drawingonthefullreporthowever,anumberofgeneralisationscanclearlybederivedthatcouldbeusedtoinformthenextstageintheprocess:

1. Policyoptionstotackletheobesogenicenvironmentarecharacterisedbyanenormousdiversityofapproachesanddrawuponahighlyvariableevidencebasefromobservationalassociationstorandomisedtrials

2. Conventionalcategoriesofevidenceforhealth-careinterventions,basedonhierachicalclassificationsofstudydesign(withrandomisedtrialsbeingthegoldstandard),areofteninsufficienttoaccommodatecomplexembeddedpublichealthissueslikeobesity,wherequestionsoftransferabilityandcontextarecriticalcomponentstothefeasibilityofanyintervention

3. TheavailabilityofvalidatedpolicyframeworkssuchasANGELOandSwinburnandcolleagues’portfoiliomatrix,offersdecisionmakersasystematicmeansofsummarisingpolicyandenvironmentaloptionsalongsideadecisionmakingframeworkthattakesaccountofscientificuncertainty

4. A‘portfolioapproach’alsohelpspromotetheconceptthatanyseriousattempttotackleobesitywillneedtobebasedonamulti-componentapproachthatcanaddressthepowerfulsocial,economicandenvironmentaldriverswhichsustaintheepidemic.Thesuccessofmulti-componenentworkplaceinterventionsprovidesencouragingevidencethatconcertedprogrammesofactioncanresultinrealbenefits

5. Inspiteoftheenormityofthechallengethatobesitypresents,itsharessubstantialcommonalitywithothermajorpublichealthproblemsofourtimesuchasclimatechangeandhealthandsocialinequalities.Implementingevidenceinformedsolutionstorisingobesityisthereforeaquestionofintegratingthetaskcloselywiththeothersubstantialchallengesfacingmodernsociety

6. Ultimatelytherefore,thedecisionsabouthowbesttoprioritisepolicyinterventionoptionstotackleobesitywillneedtobecarefullyappraisedfortheirfeasibilityatalocalandregionallevelalongsidetheircapacitytoachieve‘win-wins’forsocietiesothermajorchallenges.Thepotentialforhighlevelgainsshouldhaveastrongappealforstakeholdersatthenationallevelaswellasenhancingsustainabilitywithminimaladverseimpactsontargetpopulations.

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