Public health strategies

Farihah Choudhury ANutr

Farihah is a Public Health Nutritionist within Hampshire County Council. She is particularly interested in food policy, noncommunicable diseases as a result of changing food environments, sustainable diets and food culture, and anthropology.

www. easypeasysustainability nutrition.co.uk

easypeasy sustainability

farihahchdhry

REFERENCES Please visit: nhdmag.com/ references.html

PUBLIC HEALTH STRATEGIES: DO THEY WORK?

In the UK, we have had 30 years of public health strategies on obesity, the latest being the Government’s ‘Better Health’ campaign. This article hones in on the last 30 years of public health strategies targeting obesity, in response to some newly published research from the Centre for Diet and Activity Research and MRC Epidemiology Unit at the University of Cambridge.3

Public health strategies can take many forms. Usually, they are an ongoing response to long-term population health issues, or a reactive response to emerging issues. From a historical perspective, public health campaigns tell an illuminating tale.

WHEN DO WE NEED PUBLIC HEALTH STRATEGIES? As we have witnessed with the COVID-19 pandemic, public health campaigns as part of a strategy response, traverse all of the undulating motions, from beginning to end (which may be decades later). The motions of population panic, rapid response scientific and healthcare innovation, misinformation, mixed messaging, interventions with various degrees of success, dissenters and the residual ebb and flow of the responsible agent as part of ‘business-as-usual’ society – whether that is tobacco or an airborne virus – are etched into public health history for the rest of time.

Devastating and global reaching public health disruptors requiring quick and reactive responses tend to take the form of viruses, causing some scale of epidemic. Public health strategies to contain viral agents usually take the same trajectory, ending in containment and then eventual vaccination, with a view to achieving complete eradication when enough of the population are vaccinated, imbuing herd immunity and hence minimising transmission to almost zero. In August 2020, in the midst of the COVID-19 pandemic, for example, Africa declared they were polio-free after over a century in response.1

Communicable diseases understandably take the spotlight when talking about public health strategies, due to how they are transmitted. Other major public health problems we have experienced of the non-communicable type are tobacco smoking, alcohol consumption and high prevalence of obesity. The UK Government has a list on its website of all the issues they currently consider as requiring an ongoing public health response.2 Over the last 50 or so years (depending on the part of the world in question), we have seen a steady rise in prevalence of obesity as a consequence of a rapidly changing global food environment. An issue is considered a public health problem when it is causing significant morbidity or mortality in the population, and consequently puts a strain on health services, both operationally and fiscally.

By pure happy coincidence for this feature, very recently, academics Dolly Theis and Martin White of the Centre for Diet and Activity Research and MRC Epidemiology Unit, University of

Cambridge, published a research analysis of just shy of 700 UK obesity policies from over the last 30 or so years, assessing their effectiveness.3 This feature will explore the findings of this paper, tied in with the wider picture.

WHY IS OBESITY A PUBLIC HEALTH PROBLEM? The first time obesity was formally recognised as a public health problem was in 1991.4 The changing food environment, alongside societal shifts in how we work, study and relax, have engendered what some describe as an obesogenic environment. The current architecture of living in a technology-powered world is such that it allows for many citizens to participate in virtually all aspects of their life through a screen. Entire degrees and school lessons can be completed online (whether voluntarily or virusinduced) and there are even remote-controlled vacuum cleaners.

Perhaps more insidiously, the globalisation of the food industry has shifted food habits to convenience meals, cheap snacks and drivethroughs aplenty – not to mention the targeting of low-income neighbourhoods with fast food outlets, encouraging stark health disparities. Whilst technological and food-related innovation is perhaps a strategy in itself to increase convenience in a busy world, it has given rise to a now not so new public health problem, which is requiring stringent and effective strategising (see Table 1 overleaf). But how well are these strategies working?

The majority of adults and over a quarter of children aged 2-15 in England are either overweight or obese.5 Although we sometimes see a plateau in prevalence, between 1992 and 2020, despite government putting forward 14 strategies for reducing obesity, the prevalence remains vastly unchanged.

EFFECTIVENESS OF OBESITY STRATEGIES Theis and White3 outline a clear timeline of overarching obesity policies since 1992 (see Figure 1), using Health Survey for England data. We can see that this was pioneered with the 1992 ‘Health of the Nation’ strategy, feeding through to ‘Tackling Obesity’ in 2020, which forms Boris Johnson’s ‘Better Health’ campaign.

The target of the very first strategy was to reduce the proportion of obese men to 6% and obese women to 8%, by 2005. Given that obesity prevalence today sits at 26.2% for men, and 29.2% for women,5 the goalposts have now drastically

Table 1: Steps to successful strategising

Clear, measurable targets.

Including and honouring the most recent and relevant evidence at all stages: pre- and post-delivery.

Shifting the onus from policies focusing on individual agency to structural policies targeting food industries, retailers and, above all, food environments.

Robust monitoring and evaluation procedures.

Ensuring policies are equipped to reduce health inequalities as a first priority.

moved. Interestingly, the very first target did not include one for children or for overweight, decoupled with obesity. Without specifying the exact wording for each of the subsequent 11 strategies from 1999 to 2018, no single strategy specified a clear target for reduction, other than vague targets relating to decreasing prevalence of obesity and overweight. This begs the question whether these strategies were set up to fail. Is it possible to achieve an outcome when there is no clear goal from the outset?

Encouragingly, however, since 2018, there have been clear timeframes and percentage reductions set. June 2018’s ‘Childhood Obesity: a plan for action, Chapter 2’ sets a goal: ‘By 2030, halve childhood obesity rates and significantly reduce the health inequalities that persist.’ This recognises both the extent of childhood obesity and, importantly too, the role of health inequalities.

The subsequent strategies published in 2019 and 2020 echo the same targets and timeframes, packaged in slightly different methods. The authors highlight the issue of strategies not referring back to previous strategies, or creating a cohesive narrative to outline progress made since previous manifestations. This exposes the vulnerability of the strategies put forward since 1992, insofar as confirming that none have made the appropriate progress to be able to be a point of reference for subsequent strategies. The lack of measurable targets has been pointed out previously by food policy experts.6 Instead, it appears that each strategy ‘refresh’ is an attempt to start from scratch and fix the growing problems that are not being tackled. Theis and White also note that despite beginning with a blank slate with each new strategy, the policies proposed were similar or exactly the same as prior proposed policies.3

TYPES OF POLICIES PROPOSED The authors note3 that the biggest proportion of policies (20%) fell under the umbrella of ‘Enable’ policies. An example of this is the Healthy Start Voucher scheme. Sixteen percent of policies were also ‘Guidance-’ or ‘Standards-’ related, aimed at the public sector, educational settings and the NHS. The ‘5-A-Day’ campaign falls under the ‘Inform’ category, under which 12% of policies fell.

Very few policies were ‘Fiscal disincentive’, ‘Nonfiscal-disincentive’, ‘Fiscal incentive’ or ‘Eliminate’ and ‘Restrict’ choice-based. Extensive research, including a review of the evidence by Public Health England, suggests it is these genres of policies that have the greatest benefit in reducing poor health,7 yet these are the policies least frequently adapted by the UK Government. Furthermore, only 24% of the policies enclosed details of plans for monitoring and evaluation; only 19% cited evidence to support the policies being proposed; and a meagre 9% offered information regarding the financial cost of the strategy. The failure to detail robust methods of monitoring and evaluation alongside expected costs, suggests that these strategies were ill-prepared from their inception.

‘Implementation viability’ is a measure of how well a policy can be taken up in the population – this metric is measured with seven variables, including having a timeframe, a cost or budget and evidence. Only 8% (59) of policies across the 30 years have fulfilled all seven variables. From this analysis then, it is clear to see these strategies were not adequately planned, leading to their subsequent failure, signalling a need for subsequent strategy refreshing.

Moreover, we must constantly consider the battle, or maybe the delicate balance, between public health strategies that place burden upon the individual’s agency, and strategies that are more upstream and structural, directly affecting