Successive governments' approach to obesity policies has destined them to fail

Government obesity policies in England over the past three decades have largely failed because of problems with implementation, lack of learning from past successes or failures, and a reliance on trying to persuade individuals to change their behaviour rather than tackling unhealthy environments. This is the conclusion of new research by a team at the University of Cambridge funded by the NIHR School for Public Health Research.

The researchers say their findings may help to explain why, after nearly thirty years of government obesity policies, obesity prevalence in England has not fallen and substantial inequalities persist. According to a report by NHS Digital in May 2020, 67% of men and 60% of women live with overweight or obesity, including 26% of men and 29% of women who suffer clinical obesity. More than a quarter of children aged two to 15 years live with obesity or overweight and the gap between the least and most deprived children is growing.

Successive governments have tried to tackle the obesity problem: in research published today in The Milbank Quarterly, Dolly Theis and Martin White in the Centre for Diet and Activity Research (CEDAR) at the University of Cambridge identified 14 government-led obesity strategies in England from 1992-2020. They analysed these strategies -- which contained 689 wide-ranging policies -- to determine whether they have been fit for purpose in terms of their strategic focus, content, basis in theory and evidence, and implementation viability.

Seven of the strategies were broad public health strategies containing obesity as well as non-obesity policies such as on tobacco smoking and food safety. The other seven contained only obesity-related policies, such as on diet and/or physical activity. Twelve of the fourteen strategies contained obesity reduction targets. However, only five of these were specific, numerical targets rather than statements such as 'aim to reduce obesity'.

Theis said: "In almost 30 years, successive UK governments have proposed hundreds of wide-ranging policies to tackle obesity in England, but these are yet to have an impact on levels of obesity or reduce inequality. Many of these policies have largely been flawed from the outset and proposed in ways that make them difficult to implement. What's more, there's been a fairly consistent failure to learn from past mistakes. Governments appear more likely to publish another strategy containing the same, recycled policies than to implement policies already proposed.

"If we were to produce a report card, overall we might only give them 4 out of 10: could do much better."

Theis and White identified seven criteria necessary for effective implementation, but found that only 8% of policies fulfilled all seven criteria, while the largest proportion of policies (29%) did not fulfil a single one of the criteria. Fewer than a quarter (24%) included a monitoring or evaluation plan, just 19% cited any supporting scientific evidence, and less than one in ten (9%) included details of likely costs or an allocated budget.

The lack of such basic information as the cost of implementing policies was highlighted in a recent National Audit Office report on the UK Government's approach to tackling childhood obesity in England, which found that the Department of Health and Social Care did not know how much central government spent tackling childhood obesity.

"No matter how well-intended and evidence-informed a policy, if it is nebulously proposed without a clear plan or targets it makes implementation difficult and it is unlikely the policy will be deemed successful," added Theis. "One might legitimately ask, what is the purpose of proposing policies at all if they are unlikely to be implemented?"

Thirteen of the 14 strategies explicitly recognised the need to reduce health inequality, including one strategy that was fully focused on reducing inequality in health. Yet the researchers say that only 19% of policies proposed were likely to be effective in reducing inequalities because of the measures proposed.

UK governments have to date largely favoured a less interventionist approach to reducing obesity, regardless of political party, prioritising provision of information to the public in their obesity strategies, rather than more directly shaping the choices available to individuals in their living environments through regulation or taxes. The researchers say that governments may have avoided a more deterrence-based, interventionist approach for fear of being perceived as 'nannying' -- or because they lacked knowledge about what more interventionist measures are likely to be effective.

There is, however, evidence to suggest that policymaking is changing. Even though the current UK government still favours a less interventionist approach, more recent strategies have contained some fiscal and regulatory policies, such as banning price promotions of unhealthy products, banning unhealthy food advertisements and the Soft Drinks Industry Levy. This may be because the government has come under increasing pressure and recognises that previous approaches have not been effective, that more interventionist approaches are increasingly acceptable to the public, and because evidence to support regulatory approaches is mounting.

The researchers found little attempt to evaluate the strategies and build on their successes and failures. As a result, many policies proposed were similar or identical over multiple years, often with no reference to their presence in a previous strategy. Only one strategy (Saving Lives, published in 1999) commissioned a formal independent evaluation of the previous government's strategy.

"Until recently, there seems to have been an aversion to conducting high quality, independent evaluations, perhaps because they risk demonstrating failure as well as success," added White. "But this limits a government's ability to learn lessons from past policies. This may be potentially compounded by the often relatively short timescales for putting together a strategy or implementing policies.

"Governments need to accompany policy proposals with information that ensures they can be successfully implemented, and with built-in evaluation plans and time frames. Important progress has been made with commissioning evaluations in the last three years. But, we also need to see policies framed in ways that make them readily implementable. We also need to see a continued move away from interventions that rely on individual's changing their diet and activity, and towards policies that change the environments that encourage people to overeat and to be sedentary in the first place."

Living with obesity or excess weight is associated with long-term physical, psychological and social problems. Related health problems, such as type-2 diabetes, cardiovascular disease and cancers, are estimated to cost NHS England at least £6.1 billion per year and the overall cost of obesity to wider society in England is estimated to be £27 billion per year. The COVID-19 pandemic has brought to light additional risks for people living with obesity, such as an increased risk of hospitalisation and more serious disease.

The research was funded by the NIHR School for Public Health Research, with additional support by the British Heart Foundation, Cancer Research UK, Economic & Social Research Council, Medical Research Council, and Wellcome Trust.