SERIES: Part 5 – Conclusions on Causes and Consequences of Rising Obesity Levels in the UK

I’m back!

And this is the fifth and final edition of my ‘Obesity in the UK‘ series: Conclusions on Causes and Consequences of Rising Obesity Levels in the United Kingdom. Throughout this series, we have explored causes and consequences; physiological, behavioral, economic and social. All references are available upon request.

So, here’s my sum up:

A response to the question of the causes of rising obesity incidence in the United Kingdom principally focuses on the drivers this incidence.

Whilst sometimes framed as a debate on genetics versus environment, the causes are most broadly attributed to these: behavioral and environmental factors, and psychosocial factors.


A growing body of evidence shows that behavioral factors outweigh genetic factors. This is an important finding for intervention studies and policy. This series has argued that rising incidence in the UK has been fuelled by multiple, interconnecting causes. Early intervention by government, the World Health Organization and citizens can begin to alter these trends.

However, many studies suggesting that individuals can halt or reverse progression to obesity by food and diet control follow the cognitive model of eating behavior. This model assumes that intentions are a weaker predictor of behavior than attitudes, social norms and even perceived behavioral control.

At an individual level, studies have shown that obesity is associated with low self-esteem and body dissatisfaction in children and adults, affecting work and performance; and in some cases leading to depression, anxiety and other negative psychological consequences. The bias and discrimination reported by overweight and obese individuals has also been explored.

A very important limitation to discuss is the use of BMI. Most of the literature reviewed in this series, and indeed around this subject area, uses BMI to classify overweight or obese status. However, BMI as a classification is occasionally met with criticism. It is not always an accurate measure of risk. It does not account for muscle density, fat distribution or ethnic variations in risk thresholds. The National Institute for Health and Care Excellence (NICE) recommends that in obesity management, BMI is used in combination with waist circumference as centripetal adiposity is often considered a risk factor for a number of cardiovascular diseases.

Furthermore, in many instances, self-reported data was used. It is not uncommon for these to be inaccurate: overestimated height in men and underestimated weight in women.

Individual-level factors can no doubt contribute to consequences on a larger societal level as a greater proportion of the population falls into obesity. The economic costs to individuals can be high; and may be related to prevention, treatment and social adjustments

However, the cost at a national level, in the United Kingdom, may be even greater as obesity and its associated comorbidities incur greater costs to NHS health, support and emergency services.

Although the rising incidence of obesity in the UK and globally is alarming, the phenomenon has precipitated a greater awareness of obesity as a public health problem in the principal global policy formulating body, the World Health Organization and also by the UK government.  The UK has introduced important policy options and strategies.

The rise in obesity has been shown to be multifaceted. The significant contribution of behavioral factors to the rising incidence of obesity suggests an important role for well-defined interventions to manage and reduce obesity levels.

Further research may be needed to better understand the most effective interventions that should be applied. Despite the concern of rising obesity, UK data is promising as it has already been shown that increasing obesity levels in children in particular are responding to the intervention measures.

Let’s see what the future holds!

Mini Hiatus

I don’t like to say it. But I will be taking a tiny hiatus from writing. I am, as ever, dedicated to contributing to this discourse with well researched pieces. Thank you very much to all who read – my readership has grown so much recently and I am grateful to you all.

I am currently doing some exciting work on Antimicrobial Resistance and the Pharma Industry. In due time, you will hear more about it.

Please feel free to e-mail me any time. I would love to hear from you.


See you in November!



The “Thinker’s” Guide to becoming a useful citizen of the world.

So this is going to be a very different kind of post. (New month, new me! Right?) I’m going to share some of my ideas about global citizenship; and how I feel about navigating life in both a sensory, intentional and intellectual way. Let’s hope I don’t ruffle too many feathers. But then again, that may or may not be my objective. It’s all light hearted, but in the spirit of (not) striving to create ‘evergreen’ content, I dare say that it is apt. Politically. And indeed, I mean what I say.


Global citizenship is not a term that I have ever particularly loved.

Rather, it is one that has, perhaps, been thrust upon me. And that I have not felt a specific reason to resist. Conceptually, however, it is important. We live in a world in which hate has no place, but persists. And many of us have the desire to DO something to make it better. “Making an impact” is a vague term.

In my opinion, the first step to becoming part of the solution is extracting oneself from being part of the problem (well-meaning as one may be).


So here are my ‘thinker’s’ first steps to becoming a useful citizen of the world:

  1. Question everything you know about the world.

Knowledge is an asset. Misinformation is a liability. It’s easy to take certain information for granted that may not necessarily be grounded in contemporary, statistical or empirical evidence or proof.


  1. Challenge knowledge you have through your own personal experiences.

How representative are the perceptions you hold based on experience? Seeing may be believing; but remember that the worlds that you have experienced; be it the neighbourhood you grew up in, or stories from major metropoles you have heard, or the village in a country that is low-income by classification, may not be representative.


  1. Realise that the world is constantly changing: and in many instances, that change is incredibly rapid.


Some of our facts may be outdated. And that’s okay. Clinging to them as contemporary truth, however, is not.


  1. Accept that the everything in the world is incredibly nuanced.


There is rarely right and wrong, black and white. Most situations are remarkably complex: inherently so and additionally by virtue of the multiple external factors that influence and manipulate them. As a rule of thumb, if anything – an epidemiological trend, a political action or the funding of drug development seems easy to understand – you may have an accurate conceptual understanding but you almost certainly have not yet had the opportunity to understand the full picture.

Challenges arise when we, or those we elect, do not have a broad and comprehensive understanding of a situation. Sometimes, it is not necessarily in their interest to do so. (It is important to recognise all the stakeholders and attempt to understand the factors that inform their agenda.) But a genuine lack of understanding can result in poorly designed, imprecise solutions that do not prove effective; or misallocation of resources.

My hope is that this will be food for thought.

It’s a foggy Wednesday in London, from whence I write. So it is surely an act of true altruism for me to end this blog post, as always, by wishing you a stellar day!

– Christiana

SERIES: Part 4 – Consequences of Rising Incidence of Obesity in the United Kingdom

In my opinion, the consequences of increasing incidence of obesity fall into four key dimensions: individual, societal, structural and economic.


This is Part 4 of my Obesity in the UK series. If you missed Parts 1, 2, or 3 – mainly dealing with the causal factors of obesity – you can find them by following the links. 🙂 This part addresses consequences of rising obesity in the UK. And it is the penultimate article in this series.

I try to keep this blog relatively positive (despite the subject matter). Thus, the final article will deal with ‘solutions’ and a bit of a discussion about the previous articles. So, here goes.


  1. Individual Consequences of Rising obesity

The consequences of obesity as they affect individuals in the UK are primarily health related. In the United Kingdom, the National Health Service (NHS) means that government funded free healthcare is available to all – alongside a far smaller private sector. The consequences I discuss here are largely those that affect the quality of life of obese individuals.

Of particular concern is the number of disability adjusted life years (DALYs) that obese individuals face as opposed to normal weight individuals.

Obese individuals with a co-morbid condition also incur a greater cost both to health services and the individual in terms of time. Furthermore, T2DM, for example can reduce life expectancy by up to 10 years.


Amongst other major risk factors are an array of Cardiovascular diseases including stroke, arthritis, gallbladder disease, OSAS (Obstructive Sleep Apnoea) and infertility.

Despite lower levels of overall obesity, women were found to have significantly higher levels of “very high waist circumference”; 44% compared with 34% in men, suggesting a risk that members of this group may progress towards obesity or the development of a comorbid condition.

Encouragingly, even modest weight loss, has been shown to have an effect on improving other co-morbid conditions associated with obesity, including diabetes.


Nonetheless, some of these conditions are fatal. Thus, many obese patients face the risk of a shorter, lower quality life than the general population as a result of their obese status.

Moreover, childhood obesity is of particular concern as it has been shown to have immediate and long-term detrimental effects to health.

A societal effect of increased incidence of obesity is the potential for further increased incidence of obesity. People evaluate themselves compared to those around them. One study found that even having obese friends increases an individual’s likelihood of progression to obesity. This causes a shift in societal perception of normal: thus a vicious cycle of increased obesity.


2. Structural Factors – Industry and marketing

A consequence of rising obesity is the potential for more stringent measures on the food and beverage industry. In 2014, New York mayor, Bill De Blasio proposed a portion cap on sugary beverages. In the UK, lawmakers have proposed various reforms and restrictions on the food industry, such as taxes on certain foods.

Some argue that introducing a tax on typically unhealthy foods, may cause some groups, particularly teenagers, to reduce their consumption. Nonetheless, it may also have an unintended detrimental effect on the lowest income individuals, making food too expensive.


3. Economic Cost to Health Services


The economic burden of disease of overweight and obesity is huge. It is estimated that the direct cost to the National Health Service (NHS) in 2007 was £3.2 billion. This is an almost three-fold increase from £1.1bn in 2004, which was already more than twice the £480 million in 1998.

Unsurprisingly, if the growing proportion of healthcare spending on obesity follows this trend it may soon be unaffordable, resulting in an insurmountable burden on national health services.


4. Cost to Society

More easily overlooked is the cost of productivity lost by individuals who can no longer work due to their obese status and associated conditions.

This could have a massive impact on the economic climate in the UK as it can severely augment the number of tax payers in years to come whilst incurring greater cost to health and social services.

The consequences on the British economy could be profound, particularly due to the nation’s ageing, and comparatively older population. Furthermore, fiscal interventions to increase government spending on health and social services by increasing taxes could lead to a slowdown in consumer spending and a ripple effect on the broader economy.


In my opinion, the burden and cost of the consequences of obesity justify the need for the United Kingdom to aspire to meet its own targets and those set by the World Health Assembly. But further investigation may aid a better understanding – from a behavioural economics and behavioural medicine perspective of the kind of interventions that might prove beneficial. 


Learning from Macron : Why simplified and antiquated assumptions about the world are a direct threat to public health

I went back and watched the French president’s full speech at this month’s G20 meeting in Hamburg, in the original language, in an attempt to gain an understanding of the point he was trying to make. Aware that the noise of the ‘soundbite’ media can often drown a well-intentioned message. I also listened to the original question posed that incited his response. For those of you who don’t know what was said, here is an English translation of the major points raised in the particular answer that caused the contention taken from The Independent.

“The problems Africa face today are completely different … and are ‘civilizational’…. What are the problems? Failed states, complex democratic transitions and extremely difficult demographic transitions

He also referred to the continent as “a land of opportunity”.

It’s by a more rigorous governance, a fight against corruption, a fight for good governance, a successful demographic transition when countries today have seven or eight children per woman…At the moment, spending billions of euros outright would stabilize nothing. So the transformation plan that we have to conduct together must be developed according to African interests by and with African leaders.

Emmanuel Macron / Ed Alcock / M.Y.O.P.

Let’s deal with this in parts.

  1. The Role of Opinion

In my opinion the problem here is exactly that. His statement is based largely on opinion and possibly also some outdated world views. But not on fact.

He was factually wrong. Completely wrong. There are no such states in Africa – where 7 – 8 children are born per woman.


  1. The Numbers

I sat down, created a spreadsheet; and using world bank data, carefully compiled a list of all 54 African states (excluding South Sudan, for which there is not yet data) and crunched the numbers.

The average number of babies per woman on the African continent is 4.32.

In terms of countries today that have seven or eight children per woman. There is only one such country in the world today. Incidentally, that nation is Niger: 7.51 children per woman. This is the only nation with an average of 7 or above in the continent. At 1.55 babies per woman, Mauritius has the lowest number followed by Tunisia – 1.97.

Presenting a skewed view of the world is dangerous. Without accurate information, we cannot effectively address REAL problems that exist in the world today; nor fully understand their causal factors. This is not just a development issue: it is a public health issue.

The number of babies per woman, globally, is (unsurprisingly) inversely proportional to infant and child mortality rates. It is therefore, no surprise that Niger, with the highest number of babies per woman, also has one of the continent’s highest child mortality rates at 95.5 per 1000 live births. Compared with Tunisia at 14 per 1000 live births.

This is a vital concept. Parents will have fewer children when their likelihood of survival to adulthood increases. And to frame this issue any other way would be a mistake. When child mortality falls, babies per woman fall too.


  1. The Point of Demographic Transition

I have yet to fully understand the demographic changes the French president is referring to. (Maybe someone will explain this to me.)

I cannot say I understand the elusion to ‘demographic transition’; outside of my assumption that he is making reference to the tensions created at the Berlin conference of 1884 – 1885, better known as the Scramble for Africa, when European leaders divided the continent between themselves with arbitrary borders, many drawn quite simply with a ruler, with no regard for the ethnic and religious groups living in those areas.

Or perhaps how many of these states were subsequently administrated in a way that was to the complete exclusion of African interests, creating areas of wealth and poverty, new forms of discrimination between ethnic groups, such as in Sudan (now Sudan and South Sudan) or Rwanda, and centres of commerce. Many of these centres placed particularly at ports ultimately leading to the creation of land locked developing countries, today some of the continents’ poorest, with little access to these newly formed trade routes, as opposed to the forms of trade that had existed for centuries.


  1. Spending Billions of Euros on…. ?

Just to clarify: ‘Western’ nations do not bail out ‘failing’ African economies as they do their own. Furthermore, to speak of ‘challenges facing African economies’ is to speak of nothing at all.

Africa is the most genetically diverse continent on the earth. A continent of 54 states. The majority of which were colonised; as were India, Bangladesh and what are now the independent states of Peru and Bolivia, respectively. Today, when European nations intervene in African politics these actions are almost exclusively to the benefit of their own interests. Not for the development of African states purely for the benefit of these states. (See: France Operation Serval in Mali 2013)

Nonetheless, I don’t think any of us Africans believe that billions of Euros were to be donated/invested in our economies had the president been aware of our “demographic” profile according to fact, versus fiction. Being a bit of a pet peeve, I have deliberately elected not to address the use of the term ‘civilizational’. The problems with this kind of phraseology are numerous and based on multiple assumptions. Nonetheless, we understand the sentiment being expressed here, so dissecting its misuse would be redundant given the subject matter.

‘Africa today’; to use the same language of the French president, and to acknowledge the validity of his closing remark in this question; will and must develop according to African interests (finally). And in my opinion this will take the continued cohesion within this highly heterogenous continent. And if nations such as France and other members of the G20, all foreign states with the exception of South Africa, wish to be part of accelerating Africa’s continued development, the participation of African leaders who hold the interests of their populations at heart is indeed vital.

True progress requires the involvement of all stakeholders and a comprehensive, representative, contemporary understanding of both the developmental and healthcare landscapes, by all parties. And a poor grasp of these can lead to ill-informed, unpointed, one-size fits all interventions that, despite best intentions, are functionally ineffective.



SERIES: Part 3 – Even more causes of rising obesity incidence in the United Kingdom

This is Part 3 of my Obesity in the UK series. If you missed Part 1, or Part 2, you can find them by following the links. 🙂 Like part two, this part addresses causal factors but with a greater emphasis on some indirect causes.

Beliefs, Perceptions and Stigmatisation

There is evidence to support that a potential driver of obesity is the failure of obese persons, or parents of obese children, to recognize themselves or their child as obese. In short, weight perceptions among obese adults in Britain do not match clinical definitions of obesity. Most obese adults do not describe themselves as obese. Another study of 2976 English children found that a third of parents underestimate their child’s BMI.

As more people in the community grow into the category of obesity, perceptions of “normal” for everyday Britons may be increasingly swayed. Even teenagers, were not immune to this warped self-perception in terms of weight: 39% of overweight teenagers described themselves as “normal”.

At first glance, these findings seem almost counterintuitive. However, in a society that stigmatizes obesity, it is no surprise that many do not wish to recognize themselves as “obese”.

Moreover, overweight and obese individuals who reported experiencing fat stigmatization gained 0.95kg over a year. In an image-obsessed world, many people are experiencing stigmatization due to their weight. Thus, paradoxically, this cruel, “skinny-culture” may be a factor driving more overweight individuals towards obesity.



Socioeconomic status

At first glance, higher levels of obesity among low-income groups may too seem counter-intuitive. However, in the UK, as in many other high and middle-income countries, this is the case.

There is an existing or emerging inverse relationship between income and obesity. Attempts to explain these trends follow the assumption that in high and middle- income nations, the vast majority of the population is able to afford to be adequately fed. Thus, a very negligible proportion of the population will be underweight due to an economic inability to access food. What may be significant in understanding this is how socioeconomic factors drive the types of food that individuals and families consume on a regular basis.

Whilst the prevalence of childhood obesity and overweight in the UK has stabilized in recent years, children from the lowest socioeconomic groups have continued to exhibit increased levels of overweight and obesity in comparison to their counterparts from other socioeconomic strata. The outlook is similarly bleak for low-income adults. This points to the importance of appropriate education on diet. According to the HSE, lower income women exhibited a higher proportion of obesity: 26% – 31%, as opposed to 15% – 18% in the highest income quintiles. Men in the lowest income groups were also more likely to be obese: 29% – 30% were classified as obese, versus 23% –

Urbanization is shown to have an effect on diet. In a study examining obesogenic environments, it was found that individuals in the most deprived areas consumed significantly fewer portions of fruit daily; as did those living in densely populated environments. According to the World Bank, in 1985, 78% of people in the UK lived in urban areas, versus 82% today, a percentage that is expected to increase.

Furthermore, energy-rich, processed foods are cheaper to produce and thus cheaper to purchase. Many are increasingly marketed towards children from a young age. These subtle lifestyle changes may be driving many Britons transition into overweight and obesity, resulting in continued increased incidence.

Slightly distinct from the factor of income is that of income inequality. Studies show that national income inequality is associated with higher BMIs within obese populations, lower life expectancy and other negative health and psychosocial outcomes. It is theorized that life near the bottom of more hierarchical societies, such as the USA, results in higher levels of psychosocial stress than in more equal nations, such as Sweden.

Compared to many other high-income countries, the United Kingdom has a very high level of income and wealth inequality. Moreover, the gap growing: between 1985 and 2010 inequality rose by almost 25%, making the UK the most unequal country in Europe.

Thus, growing inequality may be one of the primary factors driving growing waistbands.

The Basics: A beginners guide to acronyms and jargon

It’s been a while since I have published a “Basics” series article.

I am grateful for the interest I have received on this humble blog of my musings in areas from economic development to novel treatment modes and health policy. Some of the feedback I have received has been concerning my occasionally excessive use of jargon and acronyms. My intention with this blog was to provide accessible insights that are both relevant and beneficial to peers within this interest and subject area as well as others who are simply interested in discussion about statistical trends in healthcare or the role of pharma in public health. Some of these terms are explained further in other articles within “the basics” section of this blog – I have linked those articles where relevant. 🙂


So here’s my growing list of acronyms and jargon for clarification:

AIDS: Acquired Immunodeficiency syndrome

ARVs: Antiretrovial drugs for the treatment of HIV

BMI: Body mass index – (Healthy BMI is generally accepted to be 18.5 – 24.9)

BRICS: Brazil, Russia, India, China, South Africa – large, growing middle-income nations

CDC: Centers for Disease Control and Prevention

CDs: Communicable Diseases

COPD: Chronic Obstructive Pulmonary Disease

DALY: Disability Adjusted Life Year

FDA: United States Food and Drug Administration

GWAS: Genome Wide Association Study

HIV: Human Immunodeficiency Virus

MAb: Monoclonal Antibody

MDG: Millennium Development Goals

NCDs: Non-communicable Diseases

NGO: Non-governmental Organization

NTDs: Neglected Tropical Diseases

OECD: Organisation for Economic Co-operation and Development

PEP: Post-exposure Prophylaxis

SDG: Sustainable Development Goal (based on the United Nations 2030 Agenda for Sustainable Development)

T2DM: Type II Diabetes Mellitus

TB: Tuberculosis

WHO: World Health Organization



SERIES: Part 2 – Causes of Rising Incidence of Obesity in the United Kingdom

This is Part 2 of my Obesity in the UK series. If you missed Part 1, you can find it here.

So back to Causes.

Among other factors, rising incidence of obesity in the UK can be explained by behavioral theories relating to changes in physical activity and eating behavior.

Basic weight gain is most commonly caused by excess energy consumption for expenditure. Rising incidence of overweight and obesity on a population level, however, is more complex. Whilst there are individual physiological and genetic factors resulting in obesity, one may infer that obesity trends are a result of multiple direct and indirect factors including social, political and economic factors affecting our behaviour. Some of them are introduced here.

Environmental Obesogenicity

Environmental factors of societal and market forces driving eating behavior within the population are an area of increasing interest. An obesogenic environment is one where the food and activity environment may drive individuals towards obesity progression. Plenty can be said about obseogenic environments and I will write about this particular aspect more pointedly in future.

Physical Activity and Inactivity

Similarly, It is well understood that appropriate physical activity is a means of effective weight management. It has been argued that the cause of weight gain pertaining to physical exercise is not only low levels of physical activity, but also by high levels of physical inactivity. Sedentary behaviour in itself is linked to co-morbidities.

One theory for increased incidence of obesity considers decreased levels of energy expenditure. An example of this is a change in shopping behavior. Greater accessibility and affordability of services such as online grocery shopping and delivery positively impact the lives of many people, e.g. disabled and elderly, but many modern conveniences have come at a social cost to health.

A greater proportion of the working population in the UK is employed in occupations conducive to levels of relative inactivity. Improved transport services, urbanization, affordability of vehicles and even mobile internet access have made life more convenient, de-necessitating much of our passive physical activity. As early as 1984, a US telephone company estimated that an additional phone extension in the household saves approximately 1.6km of walking annually.

It has been found that children were more likely to be obese for each additional hour of sedentary time. Low levels of activity have been shown to be the most prominent risk factor for weight gain. This trend of increased sedentary behavior may form part of the forces driving obesity incidence in the UK.

Eating Behaviour

Genetics & Physiology

A number of studies have explored the genetic bases of obesity. In particular, twin studies and Genome-wide association studies (GWAS). Results of the Twins Early Development Study (TEDS) show a strong heritability of adiposity and waist circumference as do GWAS. However, these explain less than 3% of BMI variation in children and adults.

Furthermore, it is unlikely that genetic factors are central to rising obesity incidence, as these have not changed substantially, relative to the short time frame of rising prevalence discussed earlier.



There is no doubt that the causes of rising obesity are complex, multiple and multifactorial. Thus, this article has a Part 2: More Causes of Rising Incidence of Obesity in the United Kingdom

Today’s Agenda: World Health Assembly General Elections

Today I report to you from the Palais du Nations in Geneva where a secret ballot is currently being held for the new Director General of the World Health Organisation.

who Flag

Margaret Chan’s decade tenure has drawn to an end. Dr Chan will leave a strong legacy without a doubt, as did many before her. And today’s events and outcomes may have a profound role in defining the next 10 years in global health and indeed, the direct of leadership for the bulk of the SDG era.

World Health Organisation (WHO) Director

Who will it be?