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We need a more independent public health system to beat obesity

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Diabetes and obesity, linked to excess sugar consumption, is generating much avoidable illness.

One in 10 adults in deprived parts of Britain has diabetes and one-third of the population may now be pre-diabetic. A recent Scientific Advisory Committee on Nutrition report recommended halving the amount of sugar people consume daily.

Since 1990 consumption of sugar in Britain has increased by a third. The commercial industries responsible for this say they are just meeting consumer demand. We are hardwired to like fat, sugar and salt, but the problem is that governments have failed to stem the amount of sugar hidden in our food by food companies and have refused to stop them actively promoting high-sugar foods to children.

This health governance failure is killing us on a scale far larger than any clinical governance failures outlined in the Francis Report into Mid Staffordshire. A key issue there was that many professionals knew what risks were emerging but few spoke out in time. Sugar consumption is a variation of the same problem.

Last week, I bought a healthy looking breakfast cereal. The next day I read the ingredients list. Its prime contents were 55% wholegrain oat flakes but the second biggest ingredient was raw cane sugar. The cereal was ctually a sugar-bomb disguised as a healthy option.

When so many of the causes of avoidable illnesses are hidden in this way, why haven’t we taken action already?

One reason is that the public health system, which has brought us the longest life expectancy in recorded history, is now at risk of decline. It is experiencing a slow dispossession of its powers. The system has been fractured and spread across many organisations; it has experienced significant disinvestment but, most importantly, it seems to be losing its appetite and capacity to voice public dissent.

It would be politically unpopular with governments reluctant to constrain markets, but the measures below would have an immediate, sustainable and beneficial effect on health:

  • A statutory reformulation of all processed foods to reduce sugar
  • A ban on marketing and promotions of high-sugar food and drink to children
  • Raised taxes on sugar

Such measures would immediately reverse many of the principal causes of avoidable health and care demand. Yet in the absence of a strong, independent public health voice it has been too easy to let the problem drift.

The National Instittue for Health and Care Excellence is charged with providing evidence of effective public health interventions. It has never recommended these actions for government. NICE argues that it is not its job to review the effectiveness of, or recommend public policy options for, national government. Its role is “to develop guidance on public health topics for practitioners in the field, primarily those working in local government”.

This may be part of the problem. NICE’s role excludes reviews of evidence of national health policy or legislative interventions. This limits the scope of actions that might be taken to address public health challenges at national level. It limits the capacity of local communities to hold national government to account for failures in national disease prevention plans. It limits democratic public policy debate for health improvement.

Most effective public health behaviour change interventions have been whole-population interventions established through national legislation (eg seat belts, safe clean water, banning sales of cigarettes to children).

These have generally been implemented following a technical analysis of intervention options at all levels of governance followed by a presentation in the public domain of their likely effectiveness. Such interventions have led to political debate – and ultimately legislative enablement.

If NICE is ‘framing out’ evidence reviews and subsequent recommendations for government, then its guidance and standards on public health risk being ideologically driven. National public policy options that may have been the most effective will be systematically excluded from any guidance produced.  

Looking at sugar consumption from the perspective of local communities, the problem is obvious. Most health professionals and parents find themselves unable to fight the tide of added or promoted sugar their children are encouraged to consume. Individual behaviour change interventions will not be able to counter the insidious architecture that the food production, retail and media industries have constructed to shape these choices.

The systematic lack of rigorous challenge to central government on national prevention policy is a system failure for public health. If we are going to continue the public health successes of the past, we need a renewed, empowered and more rigorously independent public health system.

Dominic Harrison, director of public health, Blackburn with Darwen BC

 

 

 

 

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