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Hello, everyone, and welcome to a conversation this afternoon on rethinking diet, weight and health and health policy.

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In and after the Kovik 19 pandemic, this is a conversation between May and Susan.

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Jeb is part of a series that we're running at the Oxford Martin School on

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Building Back Better the lessons and opportunities from the Konbit 19 pandemic.

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My name is Charles Godfrey. I'm the director of the Oxford Martin School.

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And before I introduced Susan, can I encourage everyone who's watching the talk alive to consider asking a question?

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If you look down at the bottom of your screen, the bottom right, you'll see a button you can press there, which says, ask a question.

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And not only can you ask a question, you can vote on other people's questions.

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And after we've chatted for 35 or 40 minutes, I'll be going to those questions.

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And it's really helpful for me to see which of the questions that have many votes and people are keen that they're answered.

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I would say that the title of the discussion is Round Obesity Policy.

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So we are really keen on questions around that rather than questions on what should I have for supper tomorrow or what is the best diet and things.

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So, Susan, thank you so much for joining us, Susan.

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Susan Jebb is professor of Diet and Population Health at the Nuffield Department of Primary Care, Primary Care Health Sciences here in Oxford.

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Susan came to Oxford in 2013 and before that was a programme leader at the MRC Human Nutrition Research Unit in Cambridge.

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Susan, before we start our conversation,

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might I ask you to tell us a little bit about your background and what's the fascinating research going on in your group at the moment?

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Hello, Charles. Really nice to join you this evening. I'm sorry it's not in person, but this is not a bad substitute.

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So I'm a nutrition scientist by my background. And I guess my early work was very much almost as a physiologist.

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And I was I'm interested in how in energy metabolism,

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an water weight control and over time that drifted into more of an interest in appetite and what we eat.

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And that went from being about physiology really into much more of the behavioural science of why to put it.

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What things? And it was about that time I moved to Oxford.

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And what I find now is trying to consider diet.

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But yes, there's some biological sciences in there.

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There's certainly a lot of behavioural science that I find myself doing more social science and the sociology of food.

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And of course, there's I have to do so. Well, it's a bit of economics and a certain amount of politics and that as well in my team.

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I guess what we're really interested in is how diet impacts on health.

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But even more important being, how do you encourage support, motivate or enable people to have a healthy diet?

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Because we've got a good sense of what a healthy diet is, but we actually are really struggling to bring about change at a population level.

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And so we tried to both develop and to test interventions which are either about supporting individuals to make different choices.

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But increasingly importantly, actually, how do you change the environment so that people just naturally end up with a healthier diet?

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But that's mostly focussed in relation to obesity.

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But we're also interested in people eating more sustainably as well.

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And you're an academic who's had a long term interest in policy and you find that you

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as a new you because of your work on the UK government's side project on obesity.

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You you, Chad, the industry responsibility deal.

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You've been seconded to D.H. How did you get into policy? Is that such a large part of your work?

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That's interesting. I mean, I very much see myself as as an academic, but actually I really, really enjoy the work that I've done with policymakers.

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And for me, that combination has been of just energising and exciting.

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And I think the more work I do in policy, the more that impacts on the type of research we do.

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And is obviously a real opportunity to translate the research we do into policy.

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So I love working at that at that interface. I think it's partly because I've always been very focussed on quite applied research.

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I don't think I have the sort of long term patience of the discovery scientists

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who are working on something which in 20 years time is going to be life changing.

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I guess I'm very focussed on the here now.

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And, you know, my team are familiar with me saying, you know, what do we need to know as a place to what might it be interesting tonight?

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Hopefully those two come inside. But I often think, you know, if we want to change the food system, if we want policymakers to take action,

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what did what what evidence do they need in order to be able to do that?

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And that very much drives research. So the foresight report was probably the first substantive thing I did with policymakers.

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Goodness only knows why they came to ask me to help with that. But anyway, they did.

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And I'm very pleased. And I spent two years working really closely with the Foresight team who were brilliant

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because what you've got is a very science focussed group working at the heart of government.

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And so it was a fantastic introduction for me. And on the back of that,

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I was asked by the Department of Health if I chair a new expert advisory group on obesity to really

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support the department as they tried to implement some of the work that the full site had suggested.

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So I did that probably for probably eight or nine years, working about a day, a week with with the policy teams.

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I've not done that for a while, but I continue to sit on various committees and I'm slightly more ad hoc relationship.

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But nonetheless, I would say that interest in how science in general is translated into policy is something that I think

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I'm very interested in and I think is tremendously important if we want our work to have impact.

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We really need to understand that translational process to understand the questions that policymakers have.

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And it's certainly, you know, really reminded me that just doing a randomised control trial, even if it is the most beautiful part,

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randomised controlled trial that gets into a big medical journal, you know, that just isn't enough for policymakers.

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They want to understand about the acceptability. They want to understand about the cost effectiveness of policies.

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They want to understand how acceptable this policy would be to the public.

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And unless we as researchers can provide them with that much more rounded evidence base,

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then it's unlikely that our research is going to have the traction that we want it to.

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Susan, we're going to be talking about how the pandemic is changing policy around obesity,

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but could you sort of a sample that discussion by just summarising why obesity is such a public health issue?

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The degree to which its importance has changed over the decades?

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Well, obesity is is is not new. I'm afraid.

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People have it in the UK and similar countries have been gaining weight steadily in a decade on decade four.

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Well, probably as long as we've been been recording it.

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So we're now in a position where one in four people and adults in the UK are identified as being klyn, as living with obesity.

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And if we think about children, there's a slightly different definition. But we've got one in 10 children starting school.

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So one in 10 four year olds who were already identified as living with obesity.

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And that, you know, it's just extraordinary. And I think it's that change in childhood obesity, which I've really seen over my career, you know,

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when I was at school, actually, I look back at old school photographs and everything looks quite.

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School and its children just have a very different shape.

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The whole distribution of white hats has shifted, so people are much happier.

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And the second thing is that we increasingly recognise that that excess weight leads to ill health.

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So particularly diabetes, somewhere around 90 percent of cases of Type two diabetes are attributable to obesity.

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It increases the risk of heart disease. It's directly linked to about 12 different kinds of cancer.

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And then you've got the mechanical problems like joint problems, knee replacements, much more likely for people who are overweight.

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So this obesity affects almost every organ system of the body.

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And it's one of those conditions that if only we could tackle obesity than actually we would do so much to prevent ill health.

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And it is ill health that really matters. I mean, being overweight, seriously overweight increases the risk of premature death.

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That affects quite modest.

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What it does instead is really harm people's quality of life because they're living with chronic conditions which require medications,

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visits to hospital and just generally impair their life. I we've got quite a few people who are viewing from five the United Kingdom,

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and we are going to be largely talking about UK policy and in fact, the English policy on obesity.

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But I think many of the problems we face, nay, in England, in the UK are similar to throughout the world.

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So the policy issues we are facing are the same. So I think, you know, UK, Europe, North America, Australia, very, very similar.

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What we're seeing in in some other countries is that obesity is developing very, very rapidly.

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Domestic systems are perhaps slightly different.

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So that the structure dropped differently so that some of the policies might be different in other countries.

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But there's a lot of crossover thinking about sort of English should be a strike.

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Yeah. The last 10 years or so. Am I right? Government finds it easier to talk about childhood obesity and harder to talk about obesity in adults.

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It certainly looks like that. So when we published the full site report,

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that was at a time when government had already announced a target to reduce the prevalence of obesity in children.

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And one of the points we made in that report was that, of course, tackling obesity in children matters.

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But there's a huge problem of adults obesity already and that actually, if we're serious, we need to take a whole population approach.

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To be honest, that wasn't really adopted. And so the strategy that came up was that remained very focussed on children.

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And that just continued until I would say this summer. And we saw the new plan announced by the prime minister,

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which I think for the first time overtly acknowledged that actually adults are suffering ill health as a direct consequence of excess weight.

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And so the new plan includes, yes, whole population strategies to try to help help everybody maintain a healthy weight,

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but also specific policies about treating obesity.

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So offering support to people, people ready got a weight problem in order to help them tackle that condition.

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I have just one question before we come on to the new strategy. That is the sugary drink intervention of I think it's about five, five years ago.

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Now, did you see that as a as a major change in government being willing to intervene in our diets in a way we hadn't seen before?

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You you might just explain because you'd explain it better than me what the sugary tax levy was.

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So you're actually right. This was a really quite remarkable intervention.

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Remarkable because academics have been talking about the potential brandnew of a tax on on sugary drinks,

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sugary drinks, because they add calories to the diet, but really of no nutritional value whatsoever.

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And so they would be an obvious thing that one might discourage consumption.

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So lots of work had been done, particularly actually by colleagues here in Oxford.

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Mike Rayner and Pete Scarborough published a lot of the underpinning work, which make the case that taxing sugary drinks would be a good thing to do.

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But government had never been shown that much interest in it. And then suddenly.

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It came round and, you know, this soft drink industry levy was announced.

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It's actually quite a clever policy because rather than making this a direct sales tax, they actually put the burden on business.

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So it was a levy on the industry and that nothing was proportional essentially to the amount of sugar that they were selling in in soft drinks.

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And the reason for doing it like that was essentially to incentivise business to reformulate their product and reduce the amount of sugar.

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And the reason why. But that's a clever idea because that means that everybody benefits.

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If you if you take down the sugar content of drinks, everybody benefits from that without actually requiring consumers to change their behaviour.

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Now, in addition, of course, companies have passed on some of that levy on to consumers, said the price of sugary drinks has gone up.

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And that's sort of small effect on consumer behaviour as well. But what I think it shows, firstly, it's been tremendous fear factor.

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It's reduced the sugar content of drinks by about 30 percent.

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So it's yeah, it's it's been it's been fantastically effective in stimulating reformulation.

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But it's also shown us it's easier to change products than it is to change people, because despite all of the news that sugar is bad for your health.

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And that sugary drinks are of particular concern, you know, they truly can't be anybody in the country that doesn't know that.

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Actually, the changes in consumer behaviour account for a very small part of the reduction that we've seen over time.

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You mentioned Pete Scarborough and in fact, he spoke in a different series of talks at the Oxford Martin School organises.

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And we've put a link to the recording of his talks.

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If there's anyone who's watching, who's interested in hearing more about Pete's analysis of the sugar tax.

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Have a look at that. They've done something. The thing is, they've done some not only did they help sort of develop it,

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but they've done some fantastic evaluation to really look how this is impacting and how it's really changed that the whole system.

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So it's it's a very neat support system. We've come to the pandemic and I guess March, April, it suddenly became apparent.

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But being overweight and obese really quite dramatically increased your risk of severe illness from Kofod.

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We have a curious occurrence that our prime minister got covered, was seriously ill,

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and said one of the reasons that he was highly likely he was ill was that he self identified himself.

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I think he used the phrase borderline borderline obese.

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When were you aware of that government must suddenly taking a PSA really quite seriously, suddenly looking from the outside?

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It appeared as if there was this sudden real increase in policy attention given to the issue, didn't I?

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As someone who's watched this for many years. Were you surprised by suddenly how obesity rocketed up the agenda?

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Oh, absolutely. I mean, firstly, it shot up the agenda.

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And secondly, we didn't think I ever had a prime minister who was so personally interested, invested and engaged in the issue.

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Certainly not. Not during my career. So I think a number of things have all come together.

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So the first is that some say there's this striking association between excess weight and the risk of Cambridge complications.

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That's things like admission to intensive care.

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So for people who are the most seriously overweight, you're talking about more than a fourfold increased chance of of ending up in intensive care.

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The chances of death are less strongly associated with Kofod.

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And that's what that's because age is such an important factor. You know, the average age of death from Cambridge related illnesses is over 80.

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Mostly, that's not where obesity lies. But in terms of complications, it's very clear the mechanism for that is poorly understood.

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But that's a conversation for another another time. So that's the first thing.

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This was a risk factor and it was a modifiable risk factor. You know, there's nothing any of us can do about our age that stuck with that.

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But that weight was something perhaps that was modifiable.

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Second, as you say, the prime minister himself affected, who knows at an individual level what the what the reasons are for the severity of illness.

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But certainly weight didn't help. And and so he suddenly became aware that this was.

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The chytrid problem and I think started looking into obesity and mental health more generally.

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And the fact is that there are 57 thousand avoidable deaths every year caused by excess weight alone even before we had case it.

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So COPD may be what's put it on the map.

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But actually, the even bigger reason for tackling that is this other burden, ill health that's affecting the NHS.

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So simply by reducing the pressure on the NHS from those other conditions, it would be a bonus.

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The third thing was that I think the public at large suddenly realised that their weight was not as control as they thought.

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So we know that many people struggled with their weight over many years.

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But I think during lockdown, when we were all thrown out of our usual routines, lots of people experienced difficulties managing their weight.

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And I was constantly being told by friends how much weight they'd put on during lockdown,

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people perhaps not travelling to work, not being able to go to the gym, etc. Not yet if I died from that.

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Do we do we actually know if we don't? We do.

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Absolutely. We definitely know free purchasing habits have changed.

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See, if you look at the supermarket sales data, sales of alcohol have shot up, confectionary have shot up.

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But of course, we're eating out less. It's a little better to absolutely nail that.

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I think that there will be some data which will come out to weight things like the National Diabetes Prevention Programme,

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which has been running before and ongoing.

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We can look at people's weight when they enter into that programme, and that will give us some sense of what's going on.

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My clinician colleagues tell me that people who they see regularly in their clinics

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are coming back significantly happier than they were six or nine months ago.

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So I think people suddenly started to realise that actually, you know, I need to do something about my weight.

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I need to take action. And they started to realise that the food environment, even just in their home, was beginning to affect their weight.

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And so all of these things came together. And suddenly governments, I think,

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realised that lots of people wanted help to manage their weight and that actually they

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government could step it to provide some of that support to help people lose weight,

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but to remove some of those factors which were encouraging overeating like food, appetising, for example.

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And also, I think, you know, in this context of so much state intervention,

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suddenly nationally intervening in the markets a little bit to stop them selling,

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you know, quite so much unhealthy food, felt like a more publicly acceptable thing to do than previously.

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So I think it was a real window of opportunity when people were looking to kind of reset their lifestyle.

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So might that be a danger of a backlash as we come out of the pandemic or as we get intolerant of continued lockdowns and restrictions?

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That sort of legitimacy for state intervention that we saw six months ago might become less and might even reverse.

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Now might be a reaction against state intervening. It's possible, although many of the things I think will just become part of of the new normal.

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So we take the restrictions on food advertising that are being proposed.

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You know, I very much doubt that anybody at the end of an evening, you know,

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goes to bed, think, oh, goodness me, there weren't nearly enough of television tonight.

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So, you know, what's the note there? That would be fine. They're just not there.

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And that would be that prompt for people to read. I find it highly unlikely that people will be petitioning to bring the food efforts back.

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It's a bit like when we ban smoking in public places.

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Even people who were kind of a bit indifferent to it actually wanted it happen, said, oh, my goodness, this is actually really nice.

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This is an improved environment. So I think it will be okay.

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I hope it will. And so what happens if I have the chronology right.

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Is that the government produced a strategy, I think it was in July, and presumably it was done so quickly.

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What sort of building on all the work you and others had done beforehand?

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And Patrick could talk a little bit about some of the elements of that strategy.

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The first is something that's very dear to your heart, because it's it's it's an area that you've researched.

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And this is the rollout of GP and primary care doctors in in helping people lose weight.

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Might you say what are the main strategies of that?

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And also tell us a bit about your work, which has shown that this actually works in terms of people losing weight and then.

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Saving the country money. Yes. And this is a really interesting bit of the strategy,

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because I think the prime minister had come into this whole area because of concern about his own weight,

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realising that he needed to lose some weight and his health would be better for that.

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Suddenly became interested in treatment.

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And the interesting thing about treating obesity is we have got effective interventions, but they're not being deployed at scale in the NHS.

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And we've been doing a lot of work on this.

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We've been able to show that we can train doctors to make what we call opportunistic, opportunistic interventions in primary care.

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If I can interrupt, we're talking we're not talking here about sort of radical interventions like surgery.

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We're talking about very modest interventions, but essentially doctors raising the issue with patients about their weight and importantly,

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freeing them access to support to help them lose weight.

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And what we showed is that it's possible to do that, that patients generally find that very, very acceptable.

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And indeed, about 40 percent of people who would never contemplated joining a weight management programme previously did so.

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And a year later, they had had lost about two and a half kilos.

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So we know that we can actually embed this in the system.

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And so we were able to take that evidence, present that to government.

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And that's now been adopted as part of the NHS plan,

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whereby everybody who who is living with obesity will be offered support to lose weight from early next year.

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Now, the wording of that is really important because this is offering support.

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It's offering people help for a condition that they have no compulsion.

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There's no conditionality on this. It's simply the offer of support.

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But all of the work that's been done with the public tells us that in general, people welcome that, that help.

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The second thing that is in the plan is recognise is some work with NHS England were already doing,

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which is about identifying people who are at high risk of developing diabetes and offering them more specific support.

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So slightly more intensive programme that's going to be expanded. And again, another thing that and it just will be specifically advise song.

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So that's conduct that's referral to weight management programmes, which are held over a year, which provide people with ongoing support,

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helping them to change their diet, become more physically active with a specific focus on reducing their risk of diabetes.

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And then the third element is something, again, that NHS England were already planning to do, but which builds directly on our research,

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is to offer something called a total diet replacement programme for people who already have diabetes.

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The interesting thing about this is that we know that people who have been fairly recently diagnosed with diabetes were offered this programme,

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actually. Almost one in two chance of being in remission from their diabetes a year later.

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So typically, people lose about 10 kilos.

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So what we have is a suite of interventions of increasing intensity which can be tailored to people's needs and to their level of risk.

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But the key thing is that the obesity plan marks a real step change in actually embedding support for weight loss into NHS systems.

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And that's you know, I think I hope we will look back and see this as a defining moment.

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So within the same way that nowadays doctors routinely talk to people who smoke about.

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About stopping smoking and offer support to help them to do that.

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I hope that what we'll see is weight management becoming embedded in routine NHS

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care so that everybody who wants help to lose weight can get support from the NHS

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because our research and other people shows really clearly that people do better with

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support from the health service than they do if they're trying to manage weight.

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This is probably a naive question, but it seems such an obvious thing to do.

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You mentioned smoking and we have an example of why smoking has worked.

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Why is it been so hard to bring this in? Oh, a whole raft of reasons.

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I gave a talk actually the opposite, Martin, a year ago now, which is probably also still in your archive where we talk about it.

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I mean, I think that there's been a concern that interventions weren't effective, that people want it.

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And I worry about weight gain. And, you know, what we've shown is there are effective.

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Pensions. People do better with support, weight, regain.

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Is a persistent problem. But it's much, much slower than people imagine.

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And also there are some lasting metabolic benefits.

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So I think that we are increasingly recognising that with a condition like obesity, which is a chronic relapsing condition,

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potentially people are going to need intermittent bouts of treatment in order to manage that.

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And that it's not it's not a failure.

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If if your weight goes back on again, it's it's an unfortunate consequence of the fact that, you know, we're all struggling to manage our weight.

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And people who have been overweight in the past probably got an underlying biological susceptibility.

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So for them, it's going to be extra hard. You know, that's another good reason why, yes, these new treatment programmes are tremendously important.

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But what's good about the strategy is it recognise that whilst we need to help people lose weight,

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we also need to put in place other policies which are going to help everybody to avoid putting

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weight on in the first place or to avoid regaining it after they successfully lost weight.

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So there's one view which in its extreme form says that actually a problem, obesity is a problem of lack of information.

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So we're all rational individuals. We should all make the optimal decisions about our weight going ahead.

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And the issue is we don't have enough information about it. And so we should have traffic lights and detailed calorie information and obesity plan.

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If I have it right, then talks about improving information available for the consumer.

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I think in particular, having calorie labelling in restaurant menus and things like that.

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So I guess my question for you is, surely this can't be bad.

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But what evidence is there that consumers make use of evidence such as this and making decisions about their diets?

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And how important do you see this strand of obesity, of helping people lose weight?

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So I think giving people information is important.

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You know, people broadly have a sensible, healthy diet is they know fruit and veg, a good many biscuits and cakes.

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But when it comes down to it, if you want people to choose between two different kinds of pizza or some know,

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actually they need to know what's what's in that thing. So I think it's hard to argue that labelling isn't a good thing.

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You know, if you want to make an informed choice, you need the information to do that.

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So I am a supporter of it. However, I do not think we should overestimate the effect it's going to have.

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Know we've done systematic reviews which have looked at the evidence.

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The evidence isn't brilliant, but, you know, it points in the direction of having a modest effect.

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It's probably modest because actually only a small proportion of people noticed or use the information.

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So, yes, it's a piece of the jigsaw. It's probably a rather modest piece.

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And certainly on its own, it's not going to do a lot.

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But what it might do is, in addition to changing consumer behaviour, it might actually change industry behaviour a little bit as well,

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because companies start looking at the calories on their menu and just reflecting a little bit, you know.

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Twelve hundred calories for a meal for one is maybe a little bit too high.

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So it might actually encourage reformulation of the menu, but it's it's one small piece in a much, much bigger jigsaw.

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So I was going to ask you if you are a nut job,

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but you think you may have arsenate that you're a nut job when it comes to industry rather than consumer?

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You know, think I might nudge means and this kind of I certainly am of a nut job.

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Yes. Of industry and a number of government into taking more taking more action.

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This term nudge in the obesity context is really come about from the from the Thaler and Sunstein book nudge.

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So behavioural economics or what some people would describe as behavioural science and the idea that,

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you know, mostly we don't make terribly rational, conscious, thoughtful choices about what to eat.

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We just do the take the easy option. We sort of take the default.

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We choose food quite automatically. And so if you rearrange the sort of what's sometimes called the micro environment or the choice architecture,

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then actually people will make a different choice perfectly freely, perfectly happily, just because it's become the easier choice.

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So, you know, a good example would be do you offer people a sugary drink and you have to actively opt in to having the low calorie drink?

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Or do you start with a low calorie drink and allow people to opt into the higher calorie one?

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So there are lots of nudges which. Shame to work, particularly in things like supermarkets.

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If you take confectionary off the end of an aisle, you can still buy elsewhere in the store.

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You take it off the end of an aisle. People buy a lot less confectionary. So, you know, not just do work,

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but there's a limit and there's a limit because we cannot realistically expect

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to be able to nudge every single decision making movement in people's lives.

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And so there's a place for them. But we've also got to come up a level and think that a much more system level.

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How do we change the broader food system or what people sometimes call the food environment?

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That's a I mean, moving on to the food environment. That's that rather vivid phrase that people use obesogenic landscape.

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But today we live in a landscape where we're bombarded by posters for foods high and in salt, sugar and fat.

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Our television is many adverts, and especially in low income areas.

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You can walk down a street and it's one fast food outlet after an after another.

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To what degree did the obesity strategy address issues around the obesity obesogenic landscape and.

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It's definitely try. You're absolutely you're absolutely right. This is a huge, huge issue.

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I mean, you know, you might say that obesity is a function of, you know, abundance, convenience and choice.

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We own all of these things that come together, just sheer availability. I think it's absolutely everywhere.

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No, it's not just in grocery stores. It's in almost every shop you go into.

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You can buy a three course meal in a petrol station. You know, food is just everywhere.

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Vending machines. And if it's not the actual product, it's an advert for it.

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And that, we do think is is fuelling overconsumption because it makes food more available pretty well.

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Any time of day you want it. But we're also being constantly prompted and nudged, if you like, into eating or primed to see an advert for food.

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And even if we weren't actually hungry, we stopped. Well, actually, quite fancy a biscuit with my cup of coffee.

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We don't even realise it's happening,

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but there's really good experimental data which shows us these are facts and shows how seeing food outlets nudges people into into the consuming.

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So what the obesity plan did this time around with was take on two particular areas.

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One was around advertising, both from television and online.

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And of course, online is increasingly important because people are watching less television and more online viewing to control appetising,

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free time, fat, sugar and salt. And the second was around in-store promotions.

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So this is sort of at the interface of those nuch type interventions,

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but it committed to introducing mandatory controls on what are called location based promotions,

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things like the end of the aisle or on volume based promotions.

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So that's things like multi. So buy one, get one free, which effectively encourages us to purchase.

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And once you over purchased, all the evidence says that you'll get what not to consume.

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And so I think it's really important. But those are in the plan as well, because it does recognise that the food industry,

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phenomenally successful business, incredibly important part of our economy.

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But it has tended to grow on the basis of selling more calories.

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And that is simply unsustainable for our health. And that actually the business models got to change.

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We've got to get people away from this emphasis on volume and actually put it on to higher quality food.

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So I'm gonna go to questions in a second.

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And just before I do that.

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Let's suppose that you're given the choice of either of you being made on obesity, Sarre or whatever an equivalent, an equivalent position is,

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and you're asked what are the three most important things the government should do in addition to what it has done at the moment?

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Well, what would be the things you would suggest?

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OK, I mean, I take your point about in addition, but I think that although there are commitments in the plan, they absolutely got to be seen through.

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And so these these controls on promotions and on unappetising absolutely need to introduce the need to make sure that they're comprehensive.

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So, for example, it's one thing to stop grocery stores selling sweets on the checkout.

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But let's also make sure we stop all the other stores doing that as well.

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So we need really to enact what's already in those plans.

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The other thing I mean, one area that I'm really concerned about at the moment is confectionary.

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So sales of confectionary are not decreasing in practise.

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Quite a bit of evidence that during lock down and through the pandemic, it's actually increased.

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And, you know, these are foods which really, again, bring no nutritional benefits.

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And I think we need to focus on confectionary in the same way that we had on sugary drinks where

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we identified this is a separate category which we had to take particular policy action on.

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I think confectionary really, really needs some attention. And then the other thing that I would do, I think,

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is to really recognise that if we want to prevent the city and we want people, it's about people having a healthy diet.

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And that healthy diet will be beneficial for a whole range of other outcomes as well.

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And what we need is a more comprehensive food policy. Yes, obesity is the kind of lightning rod that remain.

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That's what's drawing all the attention. But, you know, it's just a symbol of what's wrong with our food system.

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And so I think we need a much more integrated food policy.

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And that has to be good for health across the board. But it also needs to pick up issues of environmental sustainability with our food system, too.

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And so, although that's not one specific policy,

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I think we need an Indian food policy because otherwise we'll be doing this a little bit piecemeal at the end of the day.

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That's not going to be the most efficient thing to do. That's really interesting.

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I'm going to get to some questions now. And the question that has most folks says from Francis answer in two parts and I can ask both parts.

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But one after the other. And the first is around issues of corporate interest.

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And I guess the private sector makes food, makes money by adding value up the up the value chain.

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And as you mentioned, one of the ways I do this is by making food more attractive, which is more sugary and salty.

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So is it possible for the private sector to make money?

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Bye bye bye. Marketing healthy foods?

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Or will it inevitably come down to government? I have to intervene either fiscally or regulatory.

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It's absolutely possible. The great advantage that the food industry has is that we all need to continue eating.

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This is not an industry that we're trying to get rid of. It's an industry that we really badly.

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But it's about helping them and incentivising them to change the types of foods that they're providing.

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And so it's perfectly possible to add value to healthy things as well.

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And we've seen a little bit of this happening. So, you know, the rise in kind of convenience meals.

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But where this is a little bit made from fresher ingredients, which people kind of assemble for themselves.

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Milk the microwave, for example. But, you know, there's real opportunities for innovation with healthier snacks.

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So the food industry definitely can make money out of selling unhealthy food.

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That will be easier for some companies. They've got a very broad portfolio.

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It'll be harder for others. But I think that a mix of things need to have consumers stop buying healthier things.

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That industry will jump to provide it. And then you'll get a sort of virtuous circle.

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But to get that started, I think we probably need policies which incentivise industry to make that change because it's expecting too much.

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The consumers have to entirely direct the industry to these healthier products.

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We need industry to move. That probably needs government incentives and it certainly needs government to ensure that there's a level playing field.

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One of the reasons why I'm so keen that we have mandatory controls to restrict unhealthy

385
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promotions is so that the companies who are trying to do the right thing don't get penalised.

386
00:43:02,190 --> 00:43:07,560
Francis also asks, and I'll paraphrase a question slightly about food literacy.

387
00:43:07,560 --> 00:43:13,050
How important do you think it is that our children should be better educated both

388
00:43:13,050 --> 00:43:19,950
about the health and environmental consequences of consuming different types of food,

389
00:43:19,950 --> 00:43:27,120
as well as the sort of traditional the skills of preparing food and preparing vegetables in particular?

390
00:43:27,120 --> 00:43:33,520
Are we missing the curriculum at the moment? Of course, it's important, but it is absolutely education, I think,

391
00:43:33,520 --> 00:43:39,820
by learning and education, by exposure and by role modelling rather than rote learning.

392
00:43:39,820 --> 00:43:47,240
So it's important that the food children have access to and are provided with, particularly in schools, is healthy.

393
00:43:47,240 --> 00:43:53,770
And of course, we want to see more of that kind of provision at home. That is really tricky to make that to make that happen.

394
00:43:53,770 --> 00:44:02,110
But of course, it matters. You know, we often say that it is possible to eat healthily relatively cheaply,

395
00:44:02,110 --> 00:44:08,110
but to do so requires quite some lot of cooking skills required quite a bit of time often as well.

396
00:44:08,110 --> 00:44:18,410
So it's definitely part of the overall mix. But I think, you know, we need to be careful not to overemphasise it or it's not the only thing.

397
00:44:18,410 --> 00:44:23,980
Perhaps what I should say, you know, there are very few children, certainly by the time they're at secondary school.

398
00:44:23,980 --> 00:44:29,470
But we have a pretty good idea that broccoli is good for you and that chocolate is not.

399
00:44:29,470 --> 00:44:34,810
This isn't just a question of, if you like, basic education, but, yes, skills matter.

400
00:44:34,810 --> 00:44:45,280
But it's much more important just about role modelling, help to grow up, enjoying it if they never experience good, delicious, healthy food.

401
00:44:45,280 --> 00:44:50,320
It's not surprising they find that a bit alien and don't want to try it.

402
00:44:50,320 --> 00:44:56,090
So Paul Calvert asked a question about what he calls the elephant in the surgery.

403
00:44:56,090 --> 00:45:02,380
And you've addressed some of them when you were talking about how primary care doctors and GP's can can give advice.

404
00:45:02,380 --> 00:45:13,460
I think the broader issue he raises is just it seems to be much harder to persuade governments to invest in prevention rather than cure.

405
00:45:13,460 --> 00:45:15,160
And Paul says, shouldn't they?

406
00:45:15,160 --> 00:45:23,830
Shouldn't the doctors be giving us much more lifestyle advice or should we be getting this through other health and welfare,

407
00:45:23,830 --> 00:45:29,190
health and wellbeing, community initiatives? It's not just about advice.

408
00:45:29,190 --> 00:45:34,150
I mean, as I said many times over the last half hour or so,

409
00:45:34,150 --> 00:45:39,670
people know essentially the elements of a healthy diet and they know they should be more physically active.

410
00:45:39,670 --> 00:45:44,380
What they need is support to do that.

411
00:45:44,380 --> 00:45:51,970
And so that's what we need. We need policies which make it easier to walk and cycle, for example, the physical activity side when it comes to food.

412
00:45:51,970 --> 00:45:56,740
We need policies which mean we're not being actively encouraged to eat the wrong

413
00:45:56,740 --> 00:46:01,990
things and instead that we're actively encouraged to eat healthier things.

414
00:46:01,990 --> 00:46:05,080
So I think it's so much better by second. It's about support.

415
00:46:05,080 --> 00:46:11,550
And there's every so there's a small part of that which actually comes down to the health service, per say.

416
00:46:11,550 --> 00:46:22,790
But where the health service absolutely can do something is in providing help for people specifically who would benefit from losing weight.

417
00:46:22,790 --> 00:46:28,240
We have a couple of questions, slightly more specific questions. And one is around.

418
00:46:28,240 --> 00:46:34,570
They eat well, guide. I wonder if you might just mention what or describe what that is.

419
00:46:34,570 --> 00:46:41,340
And the question is, would it be worthwhile promulgating that more?

420
00:46:41,340 --> 00:46:48,920
And there's also a question which is quoting, I think it's originally from Michael Pollan says from Paul Shelton on.

421
00:46:48,920 --> 00:46:59,650
But a simple good advice is eat a wide variety of foods, not too much, mostly vegetables the size sort of so sick.

422
00:46:59,650 --> 00:47:08,750
So that is a good thing. What about would you just say what the well guy doesn't say, whether you eat well, guide is is the sort of UK, I guess,

423
00:47:08,750 --> 00:47:14,650
health promotion to which is designed to bring together a whole mass of information about the kinds

424
00:47:14,650 --> 00:47:19,710
of foods that constitute a healthy diet and which is often displayed at the kind of a plate,

425
00:47:19,710 --> 00:47:23,560
a circle at least, with which about half is covered with fruit and veg.

426
00:47:23,560 --> 00:47:31,330
And then a small segment, the of the protein rich food, some of the carbohydrates and a little bit for France.

427
00:47:31,330 --> 00:47:36,570
So, you know, again, this just keeps revolting back to advise.

428
00:47:36,570 --> 00:47:41,920
I personally, I just don't think the problem is that people don't know what to do.

429
00:47:41,920 --> 00:47:48,160
I think what we need moral is support and practical tools which enable people to do it.

430
00:47:48,160 --> 00:47:53,830
And mostly that's not going to be at an individual level. Let's come back to the point you made earlier.

431
00:47:53,830 --> 00:47:59,180
People are just on automatic pilot when they come to eating.

432
00:47:59,180 --> 00:48:05,800
And and so we need to just change the default so that you're much more likely to end up with a healthy diet.

433
00:48:05,800 --> 00:48:08,920
We've all got such busy, complicated lives.

434
00:48:08,920 --> 00:48:15,180
You've not got the brain space to devote to every micro decision about every single thing we put into our mouths.

435
00:48:15,180 --> 00:48:22,720
We're just doing it on remote. And that that's why the environment really matters.

436
00:48:22,720 --> 00:48:32,080
Just on that last point, this sort of bandwidth one has, I've read the arguments that people who have very stressful lives because I might be ill,

437
00:48:32,080 --> 00:48:40,400
because I might be on very low incomes, then they have even less time than the rest of us to make considered decisions.

438
00:48:40,400 --> 00:48:45,140
Dick, do you think that as an explanation? My, my. Absolutely.

439
00:48:45,140 --> 00:48:48,760
I mean, there's a growing evidence base around that.

440
00:48:48,760 --> 00:48:58,570
And, you know, you see it and expands when people are a highly stressed book for whatever reason, actually, they tend to make poor choices.

441
00:48:58,570 --> 00:49:02,790
And it's almost like your mental. The mental.

442
00:49:02,790 --> 00:49:06,400
It takes the cognitive effort is just too great.

443
00:49:06,400 --> 00:49:15,590
So, you know, I absolutely identify to myself. So if I've, you know, coming in those days when I used to get to London on the train,

444
00:49:15,590 --> 00:49:21,910
I managed, you know, at the end of a long day, you just missed the train and half an hour.

445
00:49:21,910 --> 00:49:28,730
And those are the moments I am most likely to buy a bar of chocolate because, you know, so you in the grand scheme.

446
00:49:28,730 --> 00:49:36,610
So I haven't got the energy, the mental energy to sort of say, you know, this is not such a great idea.

447
00:49:36,610 --> 00:49:42,250
I've heard you use the phrase that occasionally you have a what is is an unexpected chocolate moment.

448
00:49:42,250 --> 00:49:49,540
What was surprise is an unexpected chocolate eating instant because it's the point where actually.

449
00:49:49,540 --> 00:49:55,540
Sometimes I really feel like a piece of chocolate. But actually, I don't eat chocolate because there actually isn't any around.

450
00:49:55,540 --> 00:50:01,180
And I'm not going to go off in search of it. So that moment kind of passes. But when two things come inside,

451
00:50:01,180 --> 00:50:05,410
which is that I just really want to eat this or I haven't got be able to resist

452
00:50:05,410 --> 00:50:10,860
it and it's available and suddenly that's when poor food choices happen.

453
00:50:10,860 --> 00:50:17,410
You know, that's a very anecdotal account. But the point is that if you are leading a complicated stress life,

454
00:50:17,410 --> 00:50:29,650
when your your mental resources devoted on things which are perhaps acutely more significant right now, then it's much harder to worry about things.

455
00:50:29,650 --> 00:50:34,240
And this comes back to eating healthily should not be this hard.

456
00:50:34,240 --> 00:50:39,190
But at the minute it is the default is you end up with an unhealthy diet because mostly

457
00:50:39,190 --> 00:50:45,250
things that are available and convenient and cheap are often the less healthy things.

458
00:50:45,250 --> 00:50:54,190
And until we change that around, until the healthier becomes the easy option, the default option, then healthy eating will remain to heart.

459
00:50:54,190 --> 00:50:56,110
And that is, you know,

460
00:50:56,110 --> 00:51:06,340
one of the reasons why we have such marked inequalities in food is I think because the healthy choice is just not the easy choice.

461
00:51:06,340 --> 00:51:12,600
You have to have an awful lot of all of, you know, innate resources to be able to.

462
00:51:12,600 --> 00:51:18,610
Well, Susan, I want to ask you a question, as several people have asked us in different ways,

463
00:51:18,610 --> 00:51:26,680
what I suspect may be the single hardest bit of your job as someone who is campaigning to try and help people lose weight.

464
00:51:26,680 --> 00:51:33,760
And that is how do you get a supportive message across without in any sense?

465
00:51:33,760 --> 00:51:42,980
And there's the phrase fat shaming in any sense, sort of lowering the status of the respect given to people who are currently overweight.

466
00:51:42,980 --> 00:51:54,680
And of course, without risking some of the diseases that we see associated with diets such as anorexia and bulimia,

467
00:51:54,680 --> 00:52:01,780
it must be really quite difficult path to tread to get over the positive messages, but to avoid the negatives.

468
00:52:01,780 --> 00:52:11,290
It's incredibly difficult. And it's and it's difficult because as a society, we treat people who are overweight, really baffling.

469
00:52:11,290 --> 00:52:17,250
I mean, the discrimination and the stigma in society, particularly for people who are very overweight,

470
00:52:17,250 --> 00:52:23,830
is is marked and it's cute and, you know, it's completely unacceptable.

471
00:52:23,830 --> 00:52:32,980
But it continues day in, day out. And people who are very overweight, of course, and rightly extremely sensitive to that.

472
00:52:32,980 --> 00:52:39,940
So but at the same time, we know we know that there are effective interventions.

473
00:52:39,940 --> 00:52:45,200
We know there are treatments. And we need to find ways to offer those in a supportive context.

474
00:52:45,200 --> 00:52:47,250
I think that's the important thing.

475
00:52:47,250 --> 00:52:53,890
And I think what our research and another has shown is managing your weight is really hard know in the world we live in.

476
00:52:53,890 --> 00:52:59,980
Frankly, I'm amazed that more people on tape are white. And so what people need is they need more help.

477
00:52:59,980 --> 00:53:04,630
They need more support. They don't need to be made to feel bad about this.

478
00:53:04,630 --> 00:53:12,400
They actually need and deserve more help and support. And the fact, you know, the world is set against them.

479
00:53:12,400 --> 00:53:17,050
And so I think that's an important part of it is recognising that it's difficult,

480
00:53:17,050 --> 00:53:23,020
recognising that there's a very powerful biological susceptibility to weight gain.

481
00:53:23,020 --> 00:53:27,310
You know, genes do matter. Like being overweight, inevitable.

482
00:53:27,310 --> 00:53:31,980
But they make it harder for some people to manage their weight than for others.

483
00:53:31,980 --> 00:53:37,660
And actually, people need need extra help. So I think it's partly not framing.

484
00:53:37,660 --> 00:53:40,890
It's also the language we use.

485
00:53:40,890 --> 00:53:53,890
And, you know, it's it's it's so embedded, this incredibly stigmatising language that we so often used in relation to overweight.

486
00:53:53,890 --> 00:53:56,740
That's got to change. So big issues that.

487
00:53:56,740 --> 00:54:08,800
And then on the other hand, as you say, there is this concern that in talking more about overweight, in authoring treatments for obesity,

488
00:54:08,800 --> 00:54:20,470
in encouraging people to look at calorie labels or to or to watch what they eat, that's a worry that we might be fostering eating disorders.

489
00:54:20,470 --> 00:54:28,750
Now, if there's any good evidence of that. But nonetheless, it's an absolutely legitimate concern.

490
00:54:28,750 --> 00:54:37,600
But we've got to ensure that that these offer of treatment is targeted correctly and it's targeted at people who need that help.

491
00:54:37,600 --> 00:54:41,290
And secondly, on the more prevention side,

492
00:54:41,290 --> 00:54:50,030
I think it's important to remember we're not by putting the emphasis on changing the environment so that the whole environment offers healthy.

493
00:54:50,030 --> 00:54:54,140
You are actually moving away from this narrative,

494
00:54:54,140 --> 00:55:01,220
the individual should should be doing specific themselves that actually just creates

495
00:55:01,220 --> 00:55:05,360
an environment which offers healthy things where people have a healthy diet.

496
00:55:05,360 --> 00:55:17,480
I do. So I think that helps to remove that from the sense of personal responsibility or personal failure if if it doesn't work out, actually.

497
00:55:17,480 --> 00:55:24,920
We need to think about the wider environment. Sorry, that was sort of a muddled answer about this difficult such a complicated area.

498
00:55:24,920 --> 00:55:27,800
But I think that we are beginning to make progress.

499
00:55:27,800 --> 00:55:36,890
And Charlotte Oldbury and our team has produced a fantastic resource called Language Matters with one of the with Obesity UK,

500
00:55:36,890 --> 00:55:47,030
which is a group of people living with obesity in order to try to help and train up,

501
00:55:47,030 --> 00:55:49,580
particularly health professionals for doctors,

502
00:55:49,580 --> 00:55:58,410
about how we can really step away from some of the some of the discriminatory language that that often often keeps.

503
00:55:58,410 --> 00:56:02,330
And so I'm afraid this is gonna be the last question.

504
00:56:02,330 --> 00:56:12,400
And that's the one with my folks at the moment by some large para. And it says, should we decrease our consumption of animal sourced food?

505
00:56:12,400 --> 00:56:19,040
I'm going to ask a specific question on that, because there are environmental reasons why one might want to do that.

506
00:56:19,040 --> 00:56:24,500
But when it comes so if one thinks of the many arguments for or against eating animal food,

507
00:56:24,500 --> 00:56:32,030
if we focus in on obesity, then is there an obesity argument that that bears on this issue?

508
00:56:32,030 --> 00:56:34,400
Well, it probably is certainly.

509
00:56:34,400 --> 00:56:41,570
I think this now, as you say, animal so screwed ASIC with huge environmental harms is a good reason to reduce on health.

510
00:56:41,570 --> 00:56:49,880
We know that there's an increased risk, but certainly colorectal cancer, there's an increased risk of cardiovascular disease.

511
00:56:49,880 --> 00:56:57,090
We Tinti and colleagues in Oxford, I looked at the relationship with diabetes and at first sight it looked like there was a strong link.

512
00:56:57,090 --> 00:57:02,690
But then actually we realised that was an almost entirely mediated through overweight.

513
00:57:02,690 --> 00:57:11,770
And so that was some insight into the fact that that high, high meat diet or associated with an increased risk of being overweight.

514
00:57:11,770 --> 00:57:17,030
And we're now beginning to see one or two intervention studies where people reduce their meat intake.

515
00:57:17,030 --> 00:57:26,090
What we see is they tend to lose a little bit of weight. So I think that that probably is part of the story.

516
00:57:26,090 --> 00:57:29,670
But it's much more about the dietary the whole dietary pattern.

517
00:57:29,670 --> 00:57:39,400
It's not that meat is particularly calorific, but it's about the type of dietary pattern that people who consume a lot of meat have, which.

518
00:57:39,400 --> 00:57:47,220
Which does seem to be associated with an increased risk of obesity. And Susan, literally just a sentence response.

519
00:57:47,220 --> 00:57:54,590
Are you optimistic about the momentum in obesity policy that we have seen build up over the

520
00:57:54,590 --> 00:58:00,620
last six months will be maintained when hopefully we come out of the pandemic next year?

521
00:58:00,620 --> 00:58:05,270
I gosh, I hope so. I am hopeful.

522
00:58:05,270 --> 00:58:10,220
I really do think that the government has has woken up to this and is on the case.

523
00:58:10,220 --> 00:58:13,700
And the obesity plan was very well received from people. You know,

524
00:58:13,700 --> 00:58:21,890
the public largely have welcomed that some of the even more restrictive measures on things like advertising and that's encourage them to continue.

525
00:58:21,890 --> 00:58:29,090
So I am hopeful, but of course, we are going to be facing such difficult times as we commemorate the pandemic.

526
00:58:29,090 --> 00:58:37,370
There'll be so many competing priorities and trying to remind people that obesity will be a health concern long after case.

527
00:58:37,370 --> 00:58:42,960
It is going to be tremendously important to make sure it stays high on the agenda because,

528
00:58:42,960 --> 00:58:48,480
you know, this has been decades in the making and it's not going to be solved.

529
00:58:48,480 --> 00:58:54,800
Next, we'll have a vaccine before we close it, before we go so that we have to stop that.

530
00:58:54,800 --> 00:59:01,460
Just before thanking Susan. I'd like to say two things. First of all, many thanks for everyone who has asked questions and voted.

531
00:59:01,460 --> 00:59:07,670
And I'm sorry, I've only been able to get to the top seven or eight next week.

532
00:59:07,670 --> 00:59:14,850
We have what will be a really fascinating thought, and Nigel Shadbolt will be in conversation with Tim Berners Lee.

533
00:59:14,850 --> 00:59:21,290
And the title of that conversation is the Web. The Internet and Data during the pandemic lessons learnt the new directions.

534
00:59:21,290 --> 00:59:24,160
And that's got to be really fascinating.

535
00:59:24,160 --> 00:59:34,580
And let me finish, Suzanne, as always, you have this just fabulous ability to talk so clearly and cogently about as complex an issue as a bee snake.

536
00:59:34,580 --> 00:59:43,059
I really am grateful for the conversation. I've learnt a lot and I'm sure everyone listening has said thank you very much indeed.