Mental health services for marginalised women
By Geraldine Esdaille,
The UK is the third fattest nation in Europe, according to a World Health Organization study of 53 nations published in 2018. Almost two-thirds of adults in the UK are overweight or obese, and 20% of children are affected by overweight and obesity. This summer the UK government has recognised the problem by launching a major campaign on obesity - but what should they include in their approach?
"The link between obesity and an increased risk of death from Covid-19 has suddenly catapulted obesity to the forefront." - Mars Skae, Fellow
Obesity is a complex disease with many causes which include socio-economic, genetic and lifestyle factors. Nevertheless, what is striking is its direct link with multiple health-related problems, with its latest partner being a global pandemic. Obesity is the speedy bowling ball that has the momentum to topple a whole host of pins and wipe them out.
Tragically the childhood obesity agenda appears to be largely dependent on political trends. I think it is fair to say that the agenda for change has been approached with lukewarm interest by the UK government in the last decade. However, the link between obesity and an increased risk of death from Covid-19 has suddenly catapulted obesity to the forefront once again.
The first part of the government’s childhood obesity plan, Childhood Obesity: a Plan for Action, was published in August 2016. At the time, it was estimated that in England the NHS had spent £5.1 billion on overweight and obesity-related ill-health in 2014/15, which was more than the sum spent on the fire service, police and judiciary put together. This plan set into motion a number of initiatives, such as the sugary-drink levy and a food industry programme to reduce sugar in food products by 20% by the year 2020.
In July 2020, Public Health England published a report which indicated that being obese or excessively overweight increased the risk of severe illness and death from Covid-19. One adult study found that people with a body mass index (BMI) of 35 to 40 had a 40% increased risk of death from Covid-19, and closer to 90% for those with a BMI over 40, when compared to non-obese individuals. As a result, tackling obesity was made a priority once again.
In early childhood, overweight children are more likely to suffer from respiratory conditions such as asthma and sleep apnoea. The latter in particular can impair sleep quality, rest, and consequently daytime concentration and learning capacity. In the medium term, children can suffer from poor quality of life. Stigmatisation and mental health issues such as reduced self-esteem and depression can occur, as obese children are more likely to be bullied when compared to their normal weight peers. This can also have longer term consequences through its impact on reducing educational and lifetime achievement. Lastly, for those in whom childhood obesity persists into adult life (which occurs in over half of those affected), the condition is linked to more serious health conditions. These include an increased risk of cardiovascular problems, such as ischaemic heart disease, high blood pressure and stroke and other conditions with multiple long-term complications, such as type 2 diabetes and certain cancers.
Lockdown, shielding and school closures have been a particular concern for the last six months, because they have hampered effective monitoring of those children who are worst affected by obesity. The lockdown has also reduced the provision of healthy meals to those children from more deprived backgrounds, and significantly reduced activity levels of children, resulting in worsening obesity in these children.
My 2019 Fellowship focussed on identifying gaps in obesity-related services in the UK, whilst seeking solutions to stem the tide of rising childhood obesity. Spending time with other experts and analysing similarities and differences in practice helped me develop a more evidence-based and scientifically informed approach to addressing the condition with affected individuals and their families. It also shifted my focus to empowering individuals to seek out self-help solutions that could be individualised and tailored to their preferences, abilities and needs.
I currently work at the Royal Manchester Children’s Hospital, a regional centre of excellence in the Northwest, as a child specialist hormone and diabetes doctor where I lead the strategy for tackling childhood obesity.
Below are my recommendations for tackling childhood obesity in the UK:
Talk the talk: Healthcare providers, teachers, social workers, parents and families need to overcome their fears of addressing conversations around obesity, by using non-stigmatising terminology that promotes health-related concern and positive encouragement to achieve a healthy weight. Individuals must be informed regarding the significant adverse physical and mental health outcomes that arise from obesity. The media and public health promotion are key to this effort.
Empower individuals so they walk the walk: Information and self-help tools, to encourage autonomy amongst those affected, should be used to ensure that the decision-making process for lifestyle changes is owned by the individual and their family. Changes must be individualised, actively chosen, and agreed in a manner that encourages accountability within the home and immediate community.
Ensure targets are easy to measure: Targets for change should be set in a measurable format so that individuals can easily understand what they are aiming to do. One such format is calorie counting. Using calorie counting provides a single measure for both ‘energy intake’ through counting total calories consumed in food eaten to ‘energy output’ in the form of calories burned through exercise. Focussing on what a person needs for both allows them to set clear targets for achieving a healthy weight. In addition, these targets can be individualised and tailored in children according to age and can be altered according to results seen to improve outcomes. Information regarding calories is also now more easily accessible, through food labelling on products (even in fast food restaurants), available calorie-counted recipes, and the use of caloric counting applications and technologies on devices, which make this easier to track.
Choose dietary interventions that are scientifically shown to reduce obesity-related health problems: Obesity-related lifestyle changes should not just be about achieving a set weight, but about improving health as a whole. Therefore, adopting dietary principles that are sustainable, achievable, affordable and are shown to improve health-related outcomes such as diabetes and cardiovascular disease are important. This is preferable to choosing an extreme diet that might be the latest trend and will help weight loss but is not sustainable as a longer term lifestyle change. Adopting dietary principles such as eating low glycaemic index (GI) foods (which include foods that release sugar more slowly, wholegrain-containing foods and fibre) is easy to do, and even education on how to do so can easily be accessed via the internet. This also encourages more fruit and vegetable consumption.
The Sister Sledge hammer to obesity - ‘we are family’: Any intervention to tackle childhood obesity should adopt a family-based treatment or strategy. This ensures that the individual concerned is not isolated, penalised or marginalised in tackling their unhealthy weight, and encourages a responsibility from every member of the household to contribute to the wellbeing of that individual. It also ensures sustainable change, by altering habits for the whole family, which is especially useful in 80% of those households where other family members are likely to be affected with the condition.
Exercise – reduce the pain and increase the gain: To make exercise meaningful to individuals, it needs to be measureable. Healthcare professionals need to prescribe exercise with clear targets in terms of a ‘caloric expenditure prescription’ to make it measurable and relational to food consumed. The key to promoting engagement and success is in making recommendations to increase physical activity that are enjoyable at an individualised level. This can be achieved through choosing music-related activities, competitive activities, group activities or personal sessions. Therefore, signposting individuals to the use of technologies such as free YouTube videos, exercise apps, and local amenities such as gyms and communal park runs, is essential. Any solution proposed should be cost-effective and readily available, to encourage regular engagement.
Healthcare T.E.A.M – together, everyone achieves more: To develop successful health services that create healthy lifestyle changes in families and their children, we require a concerted effort within our healthcare system in the UK. These services should seamlessly run across public health and primary care into specialist multidisciplinary secondary teams that provide a whole-person approach to bringing about healthy weight and wellness. These services should run across all life stages, to tackle the various obesity-related complications that are experienced by those who are of an unhealthy weight. In addition, partnership between healthcare providers and community stakeholders is needed to provide effective lifestyle-change packages and prescriptions that are readily accessible for people involved.
It takes a village to raise a child: Obesity and its health implications include socio-economic, lifestyle, genetic and ethnicity-related diseases. Obesity can increase the risk of entire populations to unexpected conditions such as the Covid-19 pandemic, as we have just discovered. Therefore, city-wide and community-based approaches are required using a ‘whole-systems approach’ to influence change within entire communities. There is a role for councils, educational authorities, healthcare providers, community services, supermarkets, town planning and transport agencies, and numerous other stakeholders, to all play an integral part in an effort to stem the rise of obesity.
In addition, involvement of governmental bodies at the highest level to bring legislative changes to nudge the UK population toward healthy lifestyles is necessary for change. This will require investment, forethought and intentional decision making by councils and government to bring about gains not just for us but for future generations.
The views and opinions expressed by any Fellow are those of the Fellow and not of the Churchill Fellowship or its partners, which have no responsibility or liability for any part of them.
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