By Nicholas F Rowe (Chair of OSS Research Advisory Group)
Published 28 April 2020
It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way.
Charles Dickens, ‘A Tale of Two Cities’ 1859
THE CORONAVIRUS epidemic will change everything, and sport is not immune. Obesity is also an epidemic and one that we have been living with for decades. It has directly or indirectly been responsible for over 300,000 deaths in the UK over the last 10 to 15 years and over 30,000 deaths in Scotland. Scotland has one of the worst obesity records amongst OECD countries. What makes these two epidemics different and what do they have in common? And what fundamental questions does the ‘coronavirus experience’ raise for the government response to obesity, its prioritisation of community sport and the relationship between sport development and health promotion and prevention?
Sport, obesity and the coronavirus – what have these three apparently disparate topics got to do with each other? This article suggests quite a lot and in ways that might not at first be obvious.
Let’s start with the easy bit. The link between sport and obesity is perhaps the most obvious one to make. Sport in its widest sense of the word i.e. not just including competitive sport but extending to informal recreation and fitness activities, involves physical activity. Increased physical activity is one of the key ingredients for reducing overweight and obesity. But even this link is not as clear cut as many might think and brings with it contentious issues which I return to later.
Sport and its link to the coronavirus epidemic is more complex and to use mixed sporting metaphors introduces ‘a whole new ball game’ where we are ‘making up the rules’ as we go along. The strong suspicion is that we are dealing with a ‘game changer’ for sport just as we are in many if not most aspects of our broader social, cultural and economic lives.
But perhaps the most interesting connection to be made, and the one that is the focus of this article, is that between the coronavirus epidemic and the obesity epidemic. Accepting that they are both ‘epidemics’ what do they have in common and what differentiates them? How has public policy response differed for each and why? And does this raise fundamental questions about the equivalence and appropriateness of the response for one epidemic compared with another?
Let’s start with the most pressing issue of the day, of perhaps any day, certainly in living memory. The coronavirus global epidemic has brought a shock to the economic and social systems of most if not all countries around the world. There have been prior warnings and even precedents – but it appears to be part of the human condition to put such thoughts to the back of our minds and to park them in the it will never happen to us box. The minority in the know about the risk that a viral threat posed found their protestations generally falling, if not on deaf ears, certainly on complacent ones. And now it has happened. Epidemiologists have become famous and their lexicon of R values, transmission rates, viral load and ‘flattening the curve’ have become the topics of everyday conversation, embedded into the public consciousness.
In the UK alone the death toll at the time of writing has reached over 10,000. The ultimate number of deaths has been projected at 20,000 although there is considerable uncertainty around this figure as a ‘best-case’ scenario dependent upon social distancing behaviours being complied with and maintained. The government response to the viral threat has been unprecedented involving ‘lockdown’ of our normal lives through a ‘social contract’ of limited interaction with our fellow human beings. The economic consequence in the UK is again uncertain but is now realistically being considered as comparable to the 1930’s great depression. The medium to long term economic hardship will itself impact on public health and wellbeing in ways that are difficult to predict or quantify.
This is not the time for retribution or blame. Inquiries will be held after we emerge from this real and present threat to our lives, our communities and our society and lessons must be learned. It is a time for immediate crisis management and action. But it is also a time to start thinking about ‘re-evaluation and rebuilding’. The focus of this article is unashamedly on the latter. Painful and tragic as this pandemic is proving to be, in a strange kind of way it also offers up hope for renewal. It has led us to fundamentally question our taken for granted world order, the ways of organising our societies and how we assign value and priorities to our workforce and to the choices we make in our everyday lives (McKinsey and Company, March 2020).
It is my contention that the coronavirus epidemic has raised fundamental and challenging questions for how historically we have viewed the other major epidemic of our time, obesity. My analysis suggests an inconsistency and jarring dislocation of response with reasons that may be understandable, at times may be fully justified, but in many respects do not ‘add up’ or make rational sense. My attention here is on the link to sports policy and practice but my analysis raises legitimate questions and implications for the wider integrated approach to addressing the obesity challenge. The same argument could be applied, for example, to public policy and intervention on nutrition, on environmental planning and on preventative health care. My focus here is on Scotland, but the principles are applicable across most if not all developed nations.
So, let’s spend a little time examining what we know about the obesity epidemic. What exactly is the obesity challenge? Worldwide obesity has nearly tripled since 1975 (Scottish Health Survey 2017). According to World Health Organisation (WHO) data, globally more than 1·9 billion adults are overweight and of these over 650 million are obese. Forty-one million children under the age of 5 years and 340 million children and adolescents aged 5–19 years are overweight or obese worldwide. In 2016, 39% of adults aged 18 and over across the world were overweight, with 13% considered obese (World Health Organisation, March 2020).
Scotland has one of the worst obesity records amongst OECD countries (Scottish Health Survey 2017). In 2017 the Health Survey for Scotland reported that 29% of adults in Scotland were obese (BMI of 30 kg/m² or greater) and that around two thirds (65%) of adults were overweight or obese (BMI of 25 kg/m² or greater). Prevalence of children at risk of obesity in Scotland in 2017 was 13%. The shocking thing about these figures is that they are no longer shocking.
Perhaps slightly less familiar are the financial impacts of obesity. It is estimated that the National Health Service (NHS) spent £6.1 billion on overweight and obesity-related ill-health in 2014 to 2015. The UK-wide NHS costs attributable to overweight and obesity are projected to reach £9.7 billion by 2050, with wider costs to society estimated to reach £49.9 billion per year. Annual spend on the treatment of obesity and diabetes is greater than the amount spent on the police, the fire service and the judicial system combined (Public Health England, 2017).
The impact of obesity is not confined to economic consequences but also has human ones. Obesity is a major risk factor for non-communicable diseases, such as cardiovascular disease, diabetes, and several cancers. It is estimated that obesity is responsible for more than 30,000 deaths each year in England and by inference an estimated 3,000 in Scotland (Public Health England, 2017). On average, obesity deprives an individual of an extra 9 years of life, preventing many individuals from reaching retirement age. In the future, obesity could overtake tobacco smoking as the biggest cause of preventable death. It is not unreasonable to suggest that obesity has directly or indirectly been responsible for over 300,000 deaths in the UK over the last 10 to 15 years and over 30,000 deaths in Scotland.
Although no one is immune to obesity, some people are more likely to become overweight or obese than others. The Marmot reviews (Institute of Health Equity, 2010 and Institute of Health Equity, 2020) highlights that income, social deprivation and ethnicity have an important impact on the likelihood of becoming obese. Obesity in Scotland shows a strong link with inequalities. Lower socio-economic status is associated with higher levels of obesity. Risk of obesity in children is lowest for those living in more affluent areas. Around 32% of adults living in the most deprived areas are obese, compared with 20% of those living in the least deprived areas. Women and children in the most deprived areas are particularly affected by more extreme obesity.
These statistics, when combined with the language associated with obesity, make interesting comparison with the coronavirus. Like the coronavirus, obesity is described by scientific experts and social commentators alike as a global epidemic (pandemic). Writing in 2008 the World Health organisation referred to “an escalating global epidemic of overweight and obesity – “globesity” – (that is) taking over many parts of the world”. It went on to say that, “If immediate action is not taken, millions will suffer from an array of serious health disorders” (World Health Organisation, undated). The evidence presented above shows that in aggregate the human and economic cost of obesity almost certainly outstrips that of the coronavirus. And yet the public policy response has shown no equivalence. Why is this and what does it tell us about obesity, our response to date and what perhaps we should do different in the future? An exploration of the similarities and the differences between the two epidemics might explain this disparity in public policy response:
- Although the coronavirus and obesity may both be classified as epidemics the former is infectious, you can catch the coronavirus and it is highly contagious, while the latter is not. However, even this distinction is not a simple one. There is a growing body of theory and empirical support for the idea of “social or behavioural contagion” (Christakis and Fowler, 2012). In the context of obesity this is reflected in, for example, young people growing up in obesogenic environments making them more predisposed to put on weight and to become obese in adulthood (Ashlesha and Nicosia, 2018). People do not catch obesity like they catch the coronavirus, but they do acquire the habits and behaviours associated with obesity from the behavioural norms displayed by their family, friends and the communities and culture within which they live (Powell et al., 2015).
- The coronavirus has what is called an R-0 value which is the transmission rate from one individual to another. The value of R-0 is crucial to the rate of spread of the epidemic across the population. A relatively small increase in R-0 can very quickly increase the rate of infection from a linear one to an exponential one. Clearly, obesity does not have a simple equivalence to R-0 in that it does not involve a process of contagion between one individual and another individual by way of contact or proximity alone. But the measure does have relevance if we think about prevalence of obesity in the population as a whole and the potential for obesogenic behaviour to spread through ‘social contagion’ dependent upon its normalisation in social networks.
- Covid-19 is a novel virus with no immunity in the population. Consequently, when combined with its high transmission rate it has the certainty of rapid infection across the population with inevitable consequences for high rates of morbidity and mortality, with the latter currently estimated at around 1% of those infected. This impact is dramatic, intense and frightening. It has the potential to overwhelm our National Health Service and to create public panic and instability. The obesity epidemic is very different in the way it manifests itself. Growth in obesity across the world population has been by comparison, slow, insidious, less simple in its cause and effect on illness and death and by implication less dramatic and frightening. Put succinctly, obesity has crept up on us while coronavirus has slapped us in the face.
- Covid-19 has one clear cause, an invisible virus that we can rally around and seek to address. Obesity has a more complex aetiology with no one causal factor but a combination of social, cultural, environmental, behavioural, and biological factors that interact in ways that are difficult if not impossible to disentangle. As challenging as covid-19 is, it’s more simply attributed cause makes it easier, in principle at least, to address than obesity. It is possible, and very likely, that we will develop a vaccine to protect us from covid-19. Even without a vaccine it is possible to envisage a route map of actions that will mitigate, if not fully eradicate the impact of the coronavirus on the population over time. A route map of actions to mitigate obesity may also be possible, but it seems more complex, multifaceted and uncertain in its outcome. A vaccination against obesity is a much less likely prospect and even if possible, brings with it many challenging ethical questions. The coronavirus has the potential for a ‘silver bullet’ solution while the obesity epidemic does not.
- It has long been known that the impact of obesity and associated morbidity and mortality is not evenly distributed in the population falling disproportionately on those from lower socio-economic circumstances and living in areas of multiple deprivation. When the coronavirus first appeared and started to spread it was generally thought to represent an indiscriminate threat with everybody equally at risk. As patterns of disease have emerged it has become clear, however, that just like obesity the incidence of infection and its impact is higher amongst the more deprived sections of our communities. It has also become clear that the two epidemics are not mutually exclusive (Huang, 2020). Coronavirus and obesity are linked in a deadly combination with obesity presenting as an underlying health condition, a co-morbidity, that increases the probability of complications and mortality from infection.
- Finally, the coronavirus for all its horrors does have a theoretical end date with quantifiable trajectories. This end date may come relatively quickly as we develop a new vaccination. But even without vaccination the virus will take its course attenuated by social distancing, isolation of the most vulnerable, widespread testing and targeted contact tracing. Over a number of years as immunity builds in the population the incidence will diminish if not completely go away. The obesity epidemic is, however, quite a different beast with no theoretical or foreseeable end date and no predictable peak. This uncertain future should in theory at least heighten political and public concern about the obesity epidemic although its insidious nature seems to dampen any sense of urgency.
The above analysis in part explains why government response to the coronavirus has been unprecedented and many orders of magnitude beyond any that we have seen to address the obesity epidemic. This despite the fact it could be argued that in aggregate, spread over time, the obesity epidemic has had a greater quantifiable impact on morbidity and mortality, and substantial if not comparable impact on the economy and National Health Service.
It is important to be clear. I am not in this article suggesting that the government response to the coronavirus epidemic has not been justified or proportionate. What I am suggesting is that for reasons associated with its insidious nature, its slow but apparently inexorable growth, its more complex aetiology and associated need for more complex multifaceted ‘solutions’ we have been prepared to live with and tolerate the obesity epidemic, addressing it at the margins, rather than find it intolerable and tackling it head on. I am also asking the question that given the scale of its impact and the direction of travel is this a rational, acceptable or sustainable position to take? As we emerge from the coronavirus epidemic should we turn our attention in a much more focused and concerted way to address the other epidemic in our midst?
Sport will not feature at the top of the list of governments, societies or most individuals concerns as we re-evaluate and rebuild. However, sport in all its manifestations has in many ways come to represent the cultural impact that the coronavirus has had on our lives. Closing or postponing sports events has had, if not a visceral, certainly a symbolic impact on all of us, sports fan or sport agnostic alike. Less visible, but perhaps felt more strongly by millions, is the shutdown of the places and social networks that support their participation in sport and exercise activity – the strangely silent sports clubs, gyms, football pitches, golf courses, leisure centres and swimming pools.
Although lower down the pecking order than say employment, housing and education and associated issues of social inequality and poverty the ‘coronavirus experience’ has shown that we should not underestimate the place and importance of sport in society. The social isolation and distancing that has been a crucial part of the crisis response has also served to illustrate the loss felt by taking sport out of our lives. There is a realisation that rather than sport being ‘the icing on the cake of life’ it is a crucial part of the cake itself. The impact of the enforced withdrawal of sport from society is being felt tangibly with consequences for both mental and physical health. Many are adapting their exercise behaviours, and for some this may be a positive change, but sport ‘as we knew it’ faces an uncertain future as we emerge from this crisis – a crisis that will have longstanding social and economic consequences.
A new focus on and prioritisation for addressing the obesity epidemic would have important implications for community sport as it faces new challenges and perhaps opportunities. Many health professionals have been lukewarm advocates for sport preferring an ‘everyday physical activity’ response to tackle increasing BMI in the population. Community sport advocates have enthusiastically extolled the fun benefits of sport that distinguish it from the functional and instrumental nature of the ‘everyday’ and emphasised its wider social and mental health benefits. This clash of cultures and institutional biases has been sub-optimal for both. For sport to become a priority in a government response that takes obesity seriously both the health and sports worlds need to change their positioning and to seek common ground. Sport development and health promotion can become effective allies as part of a multi-faceted system-wide response to the obesity challenge.
Public health needs to embrace community sport as an important contributor to overall activity levels and recognise its unique potential for getting to certain hard to reach populations and driving sustained behaviour change through its links to fun, enjoyment, social interaction and psychological wellbeing. The sports sector needs to up its game to increase its relevance to public health, improve the evidence base, and to be realistic in where it can best bring added value and more measured in the claims it makes. Most importantly sport needs to demonstrate that it can make a difference and that stagnating participation rates and structural inequalities in participation – a ‘divided sporting nation’ – can be overcome (Rowe, Observatory for Sport in Scotland, June 2019).
Sport needs to modernise, to adapt its ways of thinking and its models of delivery if it is to become an effective and valued player in the fight against obesity. It needs to become more flexible, more collaborative, more innovative, more community orientated and more evidence based. ‘Sport for change’ (Research Scotland, 2017) must also become ‘change for sport’ in a society that confronts and challenges the obesity epidemic with the level of intent and priority it deserves.
About the author
Nick Rowe is a Visiting Research Fellow at Leeds Beckett University and Chair of the Observatory for Sport in Scotland (OSS) Research Advisory Group. He was previously Head of Strategy Research and Planning at Sport England. He is author of ‘Sporting Capital: Transforming Sports Development Policy and Practice’ 2018, Abingdon, Routledge. Re-published in paperback Feb 2020.
References
Ashlesha D. and Nicosia N., 2018. Assessing social contagion in body mass index, overweight and obesity using a natural experiment. JAMA Pediatrics 172(3) pp 239-246. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29356816
Christakis N. and Fowler J., 2012. Social contagion theory: examining dynamic social networks and human behavior. Statistics in Medicine, 32(4). pp556-577. Available at: https://doi.org/10.1002/sim.5408
Huang, Andrew Y., 2020. Rapid Response. The confluence of the COVID19 epidemic with the obesity epidemic. British Medical Journal, 2020, 368. Available at: https:/doi.org/10.1136/bmj.m810.
Institute of Health Equity, 2010. Fair society, healthy lives (The Marmot review). London: The Marmot Review. Available at:
Institute of Health Equity, 2020. Health equity in England: The Marmot Review 10 years on. London: Institute of Health Equity. Available at: https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on
McKinsey & Company, March 2020. Beyond coronavirus: The path to the next normal. [online] Available at:https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/beyond-coronavirus-the-path-to-the-next-normal
Powell, K et al, 2015. The role of social networks in the development of overweight and obesity among adults: a scoping review. BMC Public Health. 15 (996). Available at: https://doi.org/10.1186/s12889-015-2314-0
Public Health England, 2017. Health matters; obesity and the food environment.
Research Scotland, 2017. Sport for change research for: The Robertson Trust, Scottish Government, sportscotland and Sport for Change Network. Glasgow: Research Scotland. Available at:https://sportscotland.org.uk/media/2274/sport-for-change_executive-summary.pdf
Rowe, Nicholas F., 2019. Sports participation in Scotland: trends and future prospects. Edinburgh: Observatory for Sport in Scotland. Available at: https://oss.scot/spsreport2019/
Scottish Government, 2018. Scottish health survey 2017: volume one – main report. Edinburgh: Scottish Government. ISBN 9781787812178.
Available at: https://www.gov.scot/publications/scottish-health-survey-2017-volume-1-main-report/pages/96/
World Health Organisation, nd. Controlling the global obesity epidemic. [online] Available at: https://www.who.int/nutrition/topics/obesity/en/
World Health Organisation, March 2020. Obesity and overweight. [online] Available at: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
Thought Piece from Charlie Raeburn for Reform Scotland