Writing for the Fuse Blog, Naomi Griffin, Fuse/NIHR SPHR Post Doctoral Research Associate, looks at how UK policy defines ‘obesity’ and its approach to ‘choice’ & ‘stigma’ in relation to health inequalities.
‘Childhood obesity’ has been a key public health priority area for those with an interest in challenging health inequalities among children and young people. This is because we can see, at a population level, that children living in the most deprived areas in England are twice as likely to measure as ‘obese’ than children in the most affluent groups (as measured by Body Mass Index*). The gap between the most and least deprived is growing.
Logic may suggest that if certain children are more likely to be categorised as ‘obese’, we should focus on ‘childhood obesity’. However, when exploring wider evidence, it is clear that this approach misses out important pieces of the puzzle. Our research used an approach to policy analysis developed by Professor Carol Bacchi called ‘What’s the problem represented to be?’, whereby the researcher infers what the policy makers are implying the ‘problem’ to be addressed is by looking at what is proposed. For example, if a policy calls for teacher training, the problem is represented to be: teachers lack training. We used this approach to investigate the way UK government ‘childhood obesity’ policy (which I will call ‘The Policy’ from this point) frames the ‘problem’ of ‘childhood obesity’ in relation to health inequalities.
Firstly, we looked at the way ‘obesity’ is defined in the policy. The Policy’s definition of ‘obesity’ focuses on child weight status, rather than presence of health problems, where the determinants of change are calories consumed vs energy expended: ‘at its root obesity is caused by an energy imbalance: taking in more energy through food than we use through activity’ (Chapter 1, p.3). However, the causes of ‘obesity’ (as defined by BMI) are embedded in an extremely complex biological system that interact with cultural, structural and economic contextual factors, none of which exist in isolation. In truth, BMI is a rather crude measure of height versus weight. BMI data can tell us about population level trends in BMI, but it is not complex enough to tell us about individual health status. It is also not a particularly appropriate measure for children as it was designed for use in adults.
Secondly, The Policy proposes ideas around ‘choice’ and ‘informed decisions’, implying the ‘problem’ is a lack of information or poor choices. For example:
‘I want to see parents empowered to make informed decisions about the food they are buying for their families when eating out.’ (Chapter 2, p.5).
However, it lacks consideration of the accessibility of a balanced diet due to: affordability of food, practical considerations on physical cooking equipment and energy costs of preparing and cooking food, skipping meals, needing to use food banks, or varied availability of healthy food options.
Thirdly, in The Policy, ‘stigma’ was given as a reason for the need for a childhood obesity policy, as children deemed ‘obese’ are likely to experience ‘bullying, stigmatization and low self-esteem’ (Chapter 1, p6). However, there was no targeted response to stigma itself. The attention paid to stigma is necessary. The physical and psychological harms caused by stigma, and the negative impact that stigma can have on the quality of healthcare has been evidenced. Not only is stigma and misinformation about ‘obesity’ likely to impact an individual’s health and wellbeing, it also causes barriers to appropriate and timely treatment of many health concerns, not just those that have been linked to weight status. By framing stigma as the result of ‘obesity’, rather than a problem to challenge head-on, The Policy supports individual behaviour change and responsibility, rather than addressing the wider determinants that are necessary to understand these social trends and the negative impacts of weight stigma.
So, is ‘childhood obesity’ really the policy ‘problem’ we should be addressing in order to challenge health inequalities? I don’t think so. We propose that inequality itself is the ‘problem’ we need to challenge. For example, the unequal distribution of wealth that leaves millions of children in poverty, increasing food insecurity, unequal access to healthy food and green spaces, and unequal opportunities for physical activity. Policy decisions that have drained public services and policy approaches that unfairly tip the scales of responsibility for addressing the effects structural inequalities onto individuals must be challenged.
The proposals in The Policy, and the evidence bases drawn on (and those absent), reflect a broader ideological trend in government policy on health to move from addressing social/structural dynamics to focussing on individual responsibility. The Policy reflects ideological decisions which are difficult to challenge. The notable absence of the impact of austerity on health budgets and spending on child health inequalities in The Policy is evidence of this.
With Chapter 3 of The Policy potentially delayed due to COVID-19, I hope that government will revisit and review the aims of The Policy with a focus on structural dynamics like health inequality and poverty. At the very least, the government must work to remove barriers to healthy eating and physical activity, regardless of socioeconomic or weight status, for healthier outcomes for all young people.
Failing this, the government’s messaging about ‘obesity’ directly impacts the wider conversation and so I feel that it is the duty of those of us working in public health to challenge the ineffective proposals and damaging narratives that have been put forward in these policies, especially where we cannot change the policies themselves. I hope that our review can be used to challenge and strengthen future policy development, pushing for effective action against health inequalities and policy/intervention-generated inequalities in child health.
An open access research article detailing the project which informed this blog post is available via BMC Public Health here: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-12364-6
*Body Mass Index (BMI) is a calculation of body mass based on dividing a person’s weight by the square of their height.
For further information on this research project, please visit the NIHR School for Public Health Research website here.
This blog was originally published on the Fuse Blog here.
This project is funded by the National Institute for Health Research (NIHR) School for Public Health Research (Grant Reference Number PD-SPH-2015-10025). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.