by Peter Walker
But perhaps the greatest issue is stigma. Obesity is a hugely complicated issue, as much so as inactivity, and is shaped by all sorts of factors which are beyond the control of any individual, especially someone living in more deprived circumstances. This is another hugely broad and complex subject, going into psychology as well as the lived environment, and also beyond the scope of this book. But the general principle must be noted. To take one key example, we live in an era in which an increasing amount of the foodstuffs on offer are highly processed and often laden with ingredients like high-fructose corn syrup. They are made by corporate giants who ensure the products are prominently displayed on supermarket shelves and heavily marketed to households.
Tom Watson says he was formerly a ‘sugar addict’, and is scathing about the malign power of the food industry in shaping what people eat: ‘I now go into supermarkets and there are whole aisles of just zero-nutrition, highly calorific, highly industrialised, processed foods. Whereas before I would literally salivate looking at the packets, now they’re just lost to me. You really realise the very deeply ingrained axiomatic responses we have to certain foods.’
Watson’s book describes how, as a politician, he experienced the influence of ‘Big Sugar’ in shaping government decisions. This resonated with me – even as a journalist I’ve seen how this can work. A couple of years ago, while researching a news story connected to lobbying efforts by food corporations, I received a letter from the very expensive lawyers representing one of the companies, warning of dire consequences should we publish the piece. I’m lucky enough to work for a newspaper with very good lawyers of our own, who could quickly see the threat was baseless. But as a vignette it demonstrates the forces at work.
Scientists have examined other impacts of this obesogenic foodscape, as they describe it, on people’s diets. One alarming study of an area of Cambridgeshire in the UK measured the number of takeaway outlets within a mile radius of people’s homes and workplaces, and on their commutes. Aside from the sheer amount – the average person was exposed to just over nine outlets at home and on their commute, and almost fourteen at work – it found that of the 5,000-plus people surveyed, those in the top 25 per cent group whose environment was most saturated with takeaway outlets were more than twice as likely to be obese compared to those in the bottom 25 per cent.3 That research was from 2014, before the era of ubiquitous, app-based food ordering services. Now, you don’t even need to leave the house to face this obesogenic world; it’s right there in your pocket.
And yet societal prejudice towards excess weight is rife, prompting feelings of shame and humiliation which can become particularly intense when physical exertion is involved. A US study about overweight people who went to gyms found those who were obese in particular felt particular stigma, which affected their motivation. ‘Worrying that other people will laugh at me or judge me,’ one person wrote when asked to explain why they were wary about going. ‘Fearing that I will break or damage equipment because of my weight,’ said another.4
Tom Watson recalls how he would habitually stigmatise himself for three decades: ‘I used to describe myself as the hardest-working laziest person I knew. I self-identified as overweight and lazy and slothful because of all the caricatures, but there was the contradiction of working eighteen hours a day, seven days a week. I couldn’t work it out. There’s this sort of binary idea about health and weight loss and wellbeing, that it’s down to the individual. And yes, it is ultimately about very deeply personal decisions about what you put in yourself and how you expend energy, but the system is stacked against you.’
Given the overwhelmingly strong evidence that increased activity helps someone’s health more or less whatever their weight, such attitudes are deeply alarming. Dr Robert Ross, from Queen’s University in Ontario, Canada, is one of the world’s leading researchers on the interaction between excess weight and activity. While Ross stresses his job does not officially cover behavioural science, he recognises the attitudes many overweight and obese people face, particularly when they begin to become active. ‘Sometimes, obesity in some people’s eyes is the last justifiable prejudice,’ Ross tells me. ‘People look at someone who is overweight or obese and automatically assume “lazy”, “inconsiderate” and things like that. And for many if not most, nothing could be farther from the truth. If we want people that are overweight and obese to engage in physical activity and to consume a balanced, healthful diet, we have to make those healthy choices easier choices. It’s not a question of being lazy, it’s a question of just how difficult it is in today’s environment to do it.’
It is, Ross says, a prejudice which is particularly directed at women: ‘This is my opinion, but I do believe there’s a gender difference. For a male to have a little bit of an expanded waistline, if he has grey hair and smoked a cigar, you could be a CEO of a company. But when a woman has the expanded waistline we say things like “lazy”, and we say things like “not pretty”, and this is such a shame. We’ve seen that in our own research programmes.’5
More than one metric
It’s worth mentioning what is meant by BMI, the standard measure for excess weight. It is your weight in kilograms divided by the square of your height in metres, and there are numerous websites which calculate this for you, as well as converting non-metric measurements. There is a much-used guide for BMI which states that if yours is below 18.5 you are classed as underweight, with anything from 18.5 to 25 seen as healthy. From 25 and above, we are in the realm of excess weight, but this is divided into four sections, with varying health risks for each. At 25 to 30 people are classified as overweight, or ‘pre-obese’. There are then three levels of obesity: BMIs of 30 to 35, 35 to 40, and 40 and above, with the last one sometimes labelled ‘extreme’ or ‘severe’ obesity.
An important point must be stressed here: while this is seen as the ‘standard’ set of measures, it is based on white European ethnicity, and the danger levels can vary for people of other heritage. The biggest potential impact is for people from an Asian background, whether South Asian or East Asian, where health concerns appear to set in at slightly lower BMIs. For example, one huge long-term US study into women and the prevalence of type 2 diabetes found that at the same BMI levels, women from Asian backgrounds had more than twice the risk of developing diabetes over the twenty-year course than their white peers. Hispanic and African-American women also had a slightly higher risk, though not to the same extent.6 The reasons for this difference are not fully understood, although one factor is believed to be that Asian people, particularly those of South Asian descent, can have up to 5 per cent more body fat than someone of the same BMI from a European background.7 The World Health Organization (WHO) thus now recommends that for Asian people, the threshold for being overweight should be a BMI of 23 rather than 25, with obesity starting at 27.5, and not 30.8
Another caveat to mention here is that the theories about any benefits of activity potentially exceeding the perils of weight are only really argued in the lower categories. If your BMI is 40, that means even an average-height UK man would weigh something over 120kg, or nearly 19 stone. That is not a healthy weight in the long term. For any long-term benefit someone of this BMI would need to lose weight as well as become more active.
What is clear is that excess weight is an increasingly significant, worldwide problem, with an extent that is almost shocking to comprehend. In England, just under two thirds of adults have an excessively high BMI. Of these, an estimated 35 per cent are overweight (a BMI between 25 and 30) and another 28 per cent are classified as obese.9 Statistics are collected separately by each UK nation, and England is not the worst – in Scotland the figures are 40 per cent of people overweight and 29 per cent obese.10
This situation varies by age and is more common in men. Of English men aged between fifty-five and sixty-four, more than 80 per cent are overweight or obese.11 There is also a significant correlation with economic and social hardship, particularly for women. In the English dist
ricts classified as being in the most deprived fifth of the total, 35 per cent of men and 37 per cent of women are obese. In the best-off category, the figures fall to 20 per cent and 21 per cent.12 Excess weight might not be explicitly a disease of poverty, as with the rheumatic heart disease seen by Jerry Morris in Chapter 3, but the evidence is very clear that to characterise it as a condition dictated by willpower, let alone greed or indolence, is utterly mistaken, and does nothing to make the situation any better.
It is also increasingly a condition of childhood. Currently, 28 per cent of English children (those aged two to fifteen) are overweight or obese, of whom 15 per cent are classified as obese.13 Worldwide, things are generally no better, although the extent of excess weight does still vary massively between nations. The most recent estimates by WHO, for 2016, say that globally, 39 per cent of adults are overweight or obese, with about 13 per cent classified as obese. The prevalence of obesity around the world nearly tripled between 1975 and 2016, the organisation says. The rise in excess weight for children and adolescents has been even more dramatic. While in 1975, just 4 per cent of those aged five to nineteen had excess weight, with 1 per cent obese, the equivalent 2016 figures were 18 per cent and 7 per cent.14
In a 2016 speech on the crisis, the WHO’s then-director general, Dr Margaret Chan, noted that in just a few decades the world had ‘moved from a nutrition profile in which the prevalence of underweight was more than double that of obesity, to the current situation in which more people worldwide are obese than underweight’. The shift towards what she termed population-wide obesity was, Chan said, ‘a slow-motion disaster’.15
One study illustrates the still considerable differences in obesity between different parts of the world. The research, published in 2014 in The Lancet, showed that at least 50 per cent of men were now classified as obese – not just overweight – in Tonga, with the same for women in Kuwait, Kiribati, Micronesia, Libya, Qatar, Tonga and Samoa. For children and teenagers, obesity levels varied from over 30 per cent for girls in Kiribati, Samoa and Micronesia to less than 2 per cent in countries like Bangladesh, Cambodia and Laos. The vast, 140-strong authorial team noted gloomily that they had ‘found no countries where there have been significant declines over the last 33 years’.
They said: ‘This raises the question as to whether many or most countries are on a trajectory to reach the high levels of obesity observed in countries such as Tonga or Kuwait.’ The one slightly hopeful note they added was the observation that, given rates of increase seem to be slowing in some developed countries, especially among younger people, the epidemic might have peaked in a few places.16
Excess weight is a particular worry in countries which have seen rapid economic development in recent decades, notably China. The most recent estimates say 46 per cent of Chinese adults and 15 per cent of children are overweight or obese.17 China might have the greatest absolute number of overweight people, but India is not so far behind, with one 2019 study finding that suddenly inactive lifestyles and the arrival of high-calorie foods meant anything up to a third of Indian adults were classified as obese.18
All of this does, of course, come at a significant economic cost, both to health systems and more widely. NHS figures say that in England alone, 710,000 people every year are admitted to hospital with obesity cited as a primary or secondary cause.19 This is connected to dozens of medical problems, ranging from arthritis to heart disease or pneumonia, as well as the effects of excess weight on pregnant women and foetal health. Calculating an overall economic cost is hugely difficult, but one study by the London-based World Obesity Forum, which gathers scientific expertise on the subject, estimated that by 2025 the total global bill connected to obesity would be around £950 billion.20
The association of excess weight with generally poorer health outcomes has been highlighted anew by the coronavirus pandemic. To reiterate, this book is being written during the period of its peak in the UK, and many of the public health lessons are only emerging. But one repeated feature of studies both in China and Europe has been the greater probability of obese patients to require hospital treatment for the Covid-19 virus, and also to die.
The energy balance
How did the world get to this point? The answer in its broadest terms was expressed with great eloquence more than sixty years ago by one of the first experts to warn about the then-nascent obesity crisis. Jean Mayer, a French-American nutritionist who advised three US presidents on the subject, is yet another of the extraordinary but now virtually forgotten figures to crop up in this book. Mayer was a genuine pioneer in research on nutrition, encompassing an era of transition in which he could simultaneously warn about the need for extra food assistance for America’s poor, and about the consequences for others who were well fed but increasingly inactive.
Like Jerry Morris, Mayer’s life story was astounding enough on its own. Born in Paris in 1920, he was captured by the invading Germans in 1940 while fighting as an artillery lieutenant, later escaping from a prisoner of war camp. Over the rest of the war Mayer worked for the French underground and then as a British agent, fought with Free French and then Allied forces in North Africa and Europe, and served on General Charles de Gaulle’s staff in London, eventually receiving fourteen decorations, including the Croix de Guerre and the Resistance Medal.
After the war he married an American woman and took a postgraduate course at Yale, becoming a nutritionist, then a noted expert on how to tackle famines overseas. But he also researched the importance of balancing food intake with activity levels as a way to prevent obesity, a particularly far-sighted approach in a time when, as one of Mayer’s colleagues later put it, ‘obesity in humans was seen as the result of some sort of character defect’.21 His research discovered that while people tend to compensate for increased exertion by eating more food, the converse is not true: when someone becomes less active, their appetite does not normally diminish to match it. This creates what is technically known as a ‘continued positive energy balance’ – consistently eating more calories than you expend – and thus excess weight.
Noting the fact that even 1950s Americans were moving far less than those a generation before, Mayer warned in 1955 that many of them faced a dilemma, given that their bodies were seemingly not able to adjust to being satiated with less food.
‘In many cases, adaptation to modern conditions without development of obesity implies that the person will have to either step up his activity or endure mild or acute hunger all his life,’ he wrote in The Physiological Basis of Obesity and Leanness. ‘If the first alternative, stepping up activity, is difficult, it is well remembered that the second alternative, lifetime hunger, is so much more difficult that to rely on it for weight control in cases of sedentary overweight can only continue the fiascos of the past.’22
The subsequent decades have proved Mayer correct. While eating a relatively moderate, balanced diet is of course essential for maintaining a healthy weight, simply imploring people to eat a bit less doesn’t really solve anything. Their activity levels also need to step up. And as we have seen, even if a minority of people are throwing themselves into regular, vigorous, organised exercise, the everyday world has changed so much that overall activity has, on average, diminished.
This is perhaps the one certainty of the intake/output debate when it comes to excess weight at population-wide levels. Curiously, while it is often assumed that people today eat consistently more calories than earlier generations, this is up for some debate, and in part depends on who you ask. One study based on US census data calculated that the average American in 2010 consumed 2,481 calories per day, 20 per cent more than their peers in 1970, with the make-up of food also considerably changed, including less sugar but considerably more high-fructose corn syrup.23 In contrast, a study of food consumption in England between 1980 and 2013 calculated that total intake had actually fallen, despite a shift from calories from home-cooked meals towards those in restaurant food, takeaways, drinks and snacks. The research
ers suggested that the increase in spending on food caused by more eating out had led in part to an assumption that more was being eaten.24
Yet another complication is that basing any assessment on how much people say they eat is a perilous business. One UK government statistical study from 2018, which surveyed what people said they ate and then accurately measured the actual calories consumed, found that people tended to wildly underestimate. Men declared an average daily intake of 2,033 calories, and women 1,584 calories, both well under the recommended intake of 2,500 and 2,000 calories. But the researchers found the actual average was 3,119 calories a day for men, and 2,393 for women.25
To an extent, such debates are beside the point. For as long as so many people are living less actively, unless their food intake is reduced to compensate, over time their weight will increase. Time is a key factor here. A continued positive energy balance does not need to be very great at all to prompt a significant difference in weight, if maintained over the months and years. According to calculations in a book chapter on obesity co-authored by Robert Ross, someone who is just ten calories a day above what is termed their ‘weight maintenance energy requirement’ will gain about half a kilo a year, which is in fact the current average increase for middle-aged Americans.26
Ten calories, as you can imagine, is very, very little food, perhaps a bite of a chocolate bar, or a part-teaspoon of mayonnaise. More positively, to burn up those ten calories in activity is a matter of just a very brief walk. And as Jean Mayer pointed out at the beginning of the obesity crisis, as a way of reorganising one’s life, being more active can often be more straightforward than eating less.
