Q How did you come to focus on nutrition and obesity?
When I started, I was just interested in writing. At the time I had young children, so childhood nutrition was very relevant. As I read more about it, I found there was an information gap: there was some lovely research, but it didn’t seem to be translating into mainstream messages.
I wanted to find ways to broadcast those messages, so I wrote Weight Matters for Children, which looked at eating behaviour – both under-eating and overeating. We have to understand how a behaviour develops in the first place, otherwise we’ll struggle to influence that behaviour. Specifically it looked at people’s understanding of food hierarchy and how we use foods in our daily lives.
Q What do you mean by food hierarchy?
With the advent of mechanised food production, the cost and ease of preparation are no longer limiting our access to very rich foods. They’ve just become everyday things. People no longer recognise what a ‘celebration food’ is, nor is there a clear idea of what the staple diet is in the UK – what constitutes an ordinary meal.
Q The national media focuses a lot more on health now – is this helping educate people?
Not always. Often we find the academic bullet points are delivered in the opposite way from what was intended, and somehow the message ends up being used as a weapon rather than a motivator. People start beating themselves up: “I’m supposed to eat five a day, or is it seven or nine a day – but I just feel a failure because I’m not even managing three.”
The recent debate on sugar is another example, making people feel as though there’s a massive threat to the point where they feel overwhelmed with food advice and like they aren’t allowed to eat anything any more. I think we have to take a lot more care in how our academic research findings are conveyed to the public, so the messages aren’t twisted into headline grabbers rather than constructive messages.
Q So should people turn to their GPs for advice instead?
Nutrition isn’t something most GPs know a huge amount about. It’s never been part of our training, although we’ve made big steps over the last few years to try and address that. Because of that, GPs have always been very wary of getting involved.
However, nutrition is so fundamental to health that we want to move the agenda forward. The quality of the consultations needs to mature, factoring in more subtle motivational and behaviour change messages.
The RCGP has set up a nutrition group to develop resources and to challenge any old-fashioned, slightly dismissive or judgemental attitudes GPs might have had in the past.
We’ve also set out to show that it’s not a case of taking on additional work – it’s simply fundamental knowledge that will help GPs do their job. GPs are very nervous that, by showing enthusiasm for weight management, they’ll be landed with responsibility that isn’t supported by good evidence and that they’re not trained to offer. There are more appropriately suited and qualified people who already run weight management services, and GPs should therefore focus on their signposting role. GPs should also undertake tasks those people can’t provide, such as assessing and treating the health risks arising from obesity, and helping patients deal with low self-esteem and depression, so they’re in the right emotional state to begin helping themselves.
I can see many barriers preventing GPs from engaging more in this area, so I’m aiming to break each barrier down one by one and see what happens.
Q Where does physical activity come into all this?
It’s an equal half of the story and tremendously important to health in general, not just for weight. But once again, the level of confidence among many doctors is very low when it comes to talking about exercise.
There’s also a perception that it’s somebody else’s job. One of the things I’ve become increasingly interested in is how we divide up these complex agendas that actually relate to lots of different health professionals. If you had a heart problem, it’s very obvious you would be under a heart specialist. But it isn’t clear who things like weight and fitness sit under, so health professionals try and wiggle out of them and pass the buck to somebody else.
Q What can be done about that?
I think sharing the agenda is our real next step forward, and that’s one of the reasons why I recently called for the formation of a Child Obesity Action Group (COAG). There are a huge number of health professionals who interact with children in all sorts of ways, and they’re all relevant and all do a little bit. Rather than hoping somebody will take responsibility for child obesity in its entirety, we all need to join forces and recognise how we link together.
We need to recognise if somebody else might already be doing a bit of our work, for example, but unless we convene and discuss these things, we’re not going to know.
For instance, dentists do a huge amount of health messaging about sugar and not eating between meals, which is hugely relevant to childhood obesity. And what about midwives? They have that important window when parents can’t wait to get more information on how to do things well. So we have this wonderful shared agenda. Why aren’t we sitting around the table together and making sure it’s all joined-up?
Q What is COAG hoping to achieve?
One big ambition, aside from getting the collaborative group working together in the first place, is to explore how services can be developed to support the national child measuring programme. It’s currently just about measurement, and it’s a postcode lottery as to what child obesity services will be available in your area, if any. Since the Health and Social Care Act devolved responsibility to different localities, nobody has a handle on the national picture of child obesity services up and down the country, so it’s very difficult to co-ordinate approaches or establish a minimum standard of care.
Q Shouldn’t physical activity providers be involved in COAG?
They probably should be, yes, but I think that has to come from Public Health England (PHE). Not everyone can afford to join a health club, so PHE needs look at how much we involve commercial activity groups, how much funding could be made available through the NHS and so on. There are some difficult topics to explore there.
There’s also the big issue of how we measure what public health might have funded. With physical activity, we don’t have any good way of demonstrating what the health service got out of it. We could say getting fitter is going to reduce your risk of a heart attack – which it may well do, but are we going to wait 15 years to see what happens to the heart disease rate?
We don’t have any easy measures, and that’s one of the areas I think the fitness industry could explore much more: finding different, really simple tools that show what people have gained in the short term.
But overall I’m a huge fan of people being in charge of their lives. Losing weight and getting into shape is so empowering, so I do believe health clubs have a big part to play.
Q What can gyms do better?
There’s too much focus on weight, which is the hardest indicator to change from a lifestyle approach: BMI is very tough to alter. In the meantime there are other health gains that people do achieve, but they usually go unnoticed and unmeasured.
We see a rapid drop-off in gym attendances between January and February because gyms use the wrong measure – indeed, a commonly unhelpful measure – which is BMI change. People think they’ve achieved nothing so they stop going. Gyms should encourage more specific measures to track progress and show the real health gains people are achieving, such as improved stamina, muscle strength and sense of wellbeing.
They could also better manage expectations. Ensure people have realistic goals. Give them an understanding of the timescale over which they may get benefits. Help people understand what to expect from activity – that they will ache, feel breathless and so on.
The really important thing is to make sure they’re giving comprehensive advice – not getting embroiled in the very specific health messages but just teaching basic principles. For example, there are plenty of people who do one thing to compensate for another – who starve themselves because they don’t exercise, or who exercise and then stuff their faces – and health clubs could help them understand and change these behaviours. They could teach people to eat to appetite, to respect their sense of fullness. They could help parents understand how to get variety into their children’s diets, which basically starts with eating that same variety yourself and looking like you’re enjoying it.
It’s about helping people create simple structures for healthier living, and health clubs are in a great position to do this.
