Bernardette McInally reflects on this public health challenge and why we need to focus on a whole systems approach.
Obesity in Scotland is one of the highest among OECD countries. The risk of obesity is double for adults and children living in the most deprived areas.[ 1] The prevalence has not reduced in over a decade and the gap in inequalities continues to widen. Current approaches are clearly not working. We urgently need to shift mindsets, redesign the system, build partnerships, actively involve, and empower communities to reduce health inequalities and address obesity.
So what’s going on?
Obesity is not just caused by an unhealthy diet and lack of exercise. It is driven by obesogenic environments. It is more difficult for the most disadvantaged to eat healthily and exercise. These inequalities have continued to widen even though this inequality has been widely understood and recognised for a long time  and have been exacerbated by the pandemic.
Despite this recognition, health promotion initiatives continue to focus on getting people to change their behaviour. Just last summer, the UK Government announced the ‘Better Health’ campaign to motivate people to lose weight and the announcement of a new office for Health Promotion still seems to focus on behaviour change campaigns.
What needs to change?
The narrative needs to change, moving away from the rhetoric that obesity is a lifestyle choice and the individual’s responsibility and ignoring the other drivers of obesity. It’s not that these initiatives have no impact but if the environment is not conducive to a healthier lifestyle than the effects are very limited, if not negligible.
Obesity is a complex web of social, cultural, environmental, biological and psychological influences. This needs a collaborative and a systematic change including the government, local health services, environment, and the food industry. It is the government not individuals that change the food environment, the infrastructure and built environment, legislation and taxes, and control availability, accessibility, and affordability.
A whole systems approach (WSA) is the way forward, or the obesity prevalence is unlikely to reduce
A WSA responds to complexity through an ongoing, dynamic and flexible way of working. It brings together stakeholders and communities to work together in recognising the opportunities for change. It draws on the local strengths, supports communities to create initiatives that are better and more effective by using their local assets. It engages stakeholders to develop a shared vision and actions to address obesity outside the ‘usual’ spheres of public health. Responsibility for action lies with everyone in the system working together in an integrated way to bring about long-term change.
How do we get there?
This is not an overnight change but the longer we leave it the harder it becomes. PHE have talked about the importance of a WSA and have published guidance for local authorities to implement this approach. While the latest UK Government’s obesity strategy did not go further into taking this approach itself, there are some welcoming measures targeting the obesogenic environment such as regulating food advertising and food promotions, and mandatory food labelling and calories displayed on menus.
WSA is not just about prevention. Two thirds of the adult population is already affected by overweight or obesity. Obesity treatment needs to be part of the strategy. This is often missing with emphasis still placed on individual change and prevention, promoting stigma and discrimination against people living with obesity. More needs to be done in increasing access to weight management services across the country and mental health support and involving people living with obesity in the discussion.
WSA needs to be community centred – actively involving community members in the design, delivery, and evaluation, use and build on community assets, focus on changing the wider determinants of poor health and develop collaborations with those most at risk.
One interesting example of change is the Scottish Government who have adopted a WSA to diet and weight. Work is under way with seven areas selected as ‘early adopters’ who are developing a local plan and activities for testing a WSA to diet and healthy weight.
Rocket Science has experience in community-centred approaches which is central to WSA. We undertake research with communities to gain insight of their lives, needs and priorities. We are helping our clients to consider the social determinants of health and use a WSA to set their vision, develop organisational strategies and develop plans for change. This includes helping organisations and partnerships to be responsive, manage change and transform their services through a flexible range of support.
 Scottish Government (2020) The Scottish Health Survey. 2019 edition. Volume 1.
 Tackling Obesities: Future Choices. Government Office for Science 2007 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf
 Marmot, Michael. (2020). Health equity in England: The Marmot review 10 years on. BMJ. 368. m693. 10.1136/bmj.m693.