In 2020 Prime Minister Boris Johnson launched a series of policy initiatives as part of his government's new obesity strategy. The prime minster himself was admitted to an intensive care unit after being infected with the SARS-CoV-2 coronavirus and succumbing to COVID-19. Following his successful treatment and discharge from hospital he acknowledged that his deterioration was probably linked to his own excess body weight. When instigating the 2020 policy Boris Johnson was well aware of the causal link between obesity and deaths from COVID-19 (Glasper, 2020).
Ryan and Caplice (2020) have suggested that adipose tissue may act as a reservoir for more extensive viral spread, with increased shedding, immune activation, and with the potential of cytokine storm amplification. Hence the connection between severity of illness in COVID-19 and obesity is now firmly established and nearly a year after the launch of the 2020 obesity strategy, it has been recognised that even more needs to be done to tackle excessive weight gain within the population. The latest obesity initiative augments the 2020 policy with a more focused aim of promoting healthier lifestyles. Confidence that tackling obesity as a way of mitigating the effects of the virus is growing, and to this end the new government plan will invest £100 million to support children, adults and families to achieve and maintain a healthier weight (Department of Health and Social Care (DHSC), 2021).
Underpinning the association between obesity and morbidity from COVID-19 is a 2020 Public Health England (PHE) report entitled ‘Excess Weight and COVID-19: Insights from new evidence’. In this report (PHE, 2020), the researchers provide evidence that suggests excess weight is associated with an increased risk of a range of factors that may occur in obese people following a positive ‘COVID test’. These include hospitalisation, advanced levels of treatment (including mechanical ventilation or admission to an intensive or critical care unit) and death. These risks appear to increase progressively with increasing body mass index (BMI) above the healthy weight range. The report shows that differences in excess weight may explain some of the observed discrepancies in clinical outcomes linked to COVID-19 for older adults and some black, Asian and minority ethnic (BAME) groups. PHE has estimated that having a BMI of 35 to 40 kg/m2 could increase a person's chances of dying from COVID-19 by 40%, while a BMI greater than 40 kg/m2 could increase the risk by 90%.
Background
Rates of obesity in the western world have been steadily increasing since the 1980s. In the UK, as elsewhere, this rise is projected to continue (Agha and Agha, 2017). Obesity is now one of the biggest health crises the UK is encountering with almost two-thirds (63%) of adults in England being overweight or living with obesity and 1 in 3 children leaving primary school already overweight or obese (DHSC, 2021).
COVID-19 is not the only pandemic facing the world—obesity is now a new pandemic that is the cause of many facets of ill health and additional morbidities. Previously, it was malnutrition caused by a lack of food that was of concern in many parts of the world—and there are still some 690 million people in the world who do not have enough to eat (Action Against Hunger, 2021). Nonetheless, it is childhood obesity that is becoming a growing problem of the twenty-first century and requires urgent preventive actions to promote healthy lifestyles. A failure to aggressively address rising levels of obesity in childhood will create a ticking time bomb for tomorrow's adults where morbid obesity is linked with a whole range of severe comorbidities including hypertension, type 2 diabetes, coronary heart disease, osteoarthritis and now higher death rates from COVID-19 (Malecka-Tendera and Mazur, 2006). Although focusing attention on adult obesity levels is laudable and necessary, failing to address excessive weight gain in childhood is akin to leaving the stable door wide open for the horse to bolt.
It should be stressed that obesity is not a lifestyle choice that a person consciously makes. Weight gain is the result of many compounding factors including biological, psychological, sociological and environmental influences. A draft report from the British Psychological Society (2019) entitled ‘Understanding Obesity’ outlined some of the issues involved in this complex disease of the 21st century. In particular it pointed out that despite a plethora of polices and strategies over the last three decades—including the establishment of nutritional standards in schools, programmes aimed at boosting physical activity, and weight management services—some of which have been successful, there has been little overall impact on the national rise in obesity rates.
Although there are genetic tendencies involved with obesity it is people who live in deprived areas and who experience high levels of stress, including major life challenges and trauma, who are most susceptible to weight gain. Such deprived neighbourhoods offer few opportunities and incentives for physical activity and options for accessing affordable healthy food are limited. Crucially this report showed that nearly 50% of adults attending specialist obesity services have experienced childhood adversity.
I recently listened to Professor Dame Theresa Marteau from the University of Cambridge discussing how interventions are formulated to help people change their behaviour (The Life Scientific, 2021). As director of the university's Behaviour and Health Research Unit she has been involved in research on behaviour change around food and alcohol consumption. However, she acknowledged that health promotion and health education has had limited success in changing people's lifestyles.
The World Obesity Federation (2021) highlights that studies overwhelmingly show that obesity is associated both with a higher risk of intensive care unit admission and less optimum outcomes. In the UK, for example, the latest Intensive Care National Audit and Research Centre (2021) report shows that out of 34 174 patients admitted to critical care with confirmed COVID-19 (where BMI was recorded), 77.9% were living with overweight or obesity.
Senthilingam (2021) cited data from the USA that show that having a BMI over 30 kg/m2 (the threshold that defines obesity) increases the risk of being admitted to hospital with COVID-19 by 113%, of being admitted to an intensive care unit by 74%, and of dying by 48%. Being overweight or obese is also associated with worse outcomes in younger populations. Worryingly, Senthilingam (2021) also cited a report from Italy in February 2021 that suggested that obesity might correlate with a lower immune response to the Pfizer-BioNtech COVID-19 vaccine (Pellini et al, 2021). This research, which has not yet been peer reviewed, was also discussed in The Guardian (Geddes, 2021).
What does the new obesity initiative envisage?
Perhaps the most important aspect of this latest obesity strategy is that the government intends to spend a further £100 million to help support children and adults to achieve and maintain a healthy weight (DHSC, 2021).
The first £70 million is scheduled to be spent on developing weight management services, which are intended to be made available through the NHS and local councils. It is envisaged that up to 700 000 adults will be able to access support that can help them to lose weight, such as specialised digital apps, weight management groups or individual coaches and specialist clinical support. The government plans to spend the remaining £30 million on funding strategies to assist people in maintaining healthy weights including free access to the NHS 12-week weight loss plan app. This plan (also available as printable PDFs https://tinyurl.com/92j6nhuu) promotes safe and sustainable weight loss strategies, which help a person lose weight at a rate of one to two pounds a week through adherence to a daily calorie allowance.
Another part of the funding from this £30 million will go towards upskilling health professionals to support those in early years and childhood with intervention and enhanced training packages aspiring to help up to 6000 children and families to lead healthier lives. This funding will support GPs and other health professionals to help make weight management an integral part of routine care delivery. Furthermore, clinicians will be encouraged to initiate dialogue with patients about weight and to encourage them to refer patients to the new envisaged weight loss services.
The government has appointed Sir Keith Mills to lead this initiative. He is the man credited with the development of reward programmes through Airmiles and Nectar points. He plans to introduce a new similar ‘fit miles’ approach to tackling obesity, which will use incentives and rewards to support people to eat better and move more. One component of this approach will examine schemes from around the world that have been successful in getting people fit and eating better. One such scheme being considered by Sir Keith is ‘the step challenge in Singapore’, which is a nationwide physical activity programme aimed at encouraging people to do more physical activity with financial incentives (Roach, 2021).
Conclusion
Living with excess weight puts people at greater risk of serious illness or death from COVID-19. The pandemic has illuminated the impact that living with obesity can have on people's health when they contract the disease. Obesity is costing the NHS an unsustainable £6 billion a year and urgent action now needs to be taken to alleviate the toll on the nation's health. The determination of the government to tackle obesity is evident in the prominence given to the subject in the Queen's speech to parliament (Prime Minister's Office, 2021).
KEY POINTS
- The government has launched a package of additional measures designed to help people lose weight and reduce morbidity from COVID-19
- The connection between severity of illness from the SARS-CoV-2 virus and obesity is now firmly established and confidence is growing that tackling obesity is a way of mitigating the effects of the virus
- Public Health England has estimated that having a BMI of 35–40 could increase a person's chances of dying from COVID-19 by 40%, while a BMI greater than 40 could increase the risk by 90%
- Obesity is now one of the biggest health crises in the UK with almost two-thirds of adults in England being overweight or living with obesity and 1 in 3 children leaving primary school already overweight or obese