Healthinnovations on the BBC World panel on the Danish ‘Fat Tax’ [unedited]


We know that obesity kills, we know that obesity costs the global economy billions, what we don’t know is how to sustainably treat obesity to bring the former points to a manageable level.  Or maybe some do but as yet nothing has been implemented to begin to counteract this growing epidemic.  And an epidemic it is, I speak with clinicians about it, I speak with other writers, I have spoken with psychologists about it and last Monday I spoke on a BBC panel about it.

The reason for this panel was the Danish ‘Fat Tax’.  This ‘Fat Tax’ has been put in place to drive up the prices of foodstuffs which contain saturated fats, foods that tend to be bought by low-income families, foods that tend to be bought by the obese or overweight.  A logical outcome and hope for this would be that healthy foods become more accessible to beacon communities, an assurance we’re still waiting for the Danish government to make, and that awareness is raised with reference to saturated fats as people start questioning the price hike.

The panel comprised a quick word from a Danish MP, a Danish food manufacturer, a Danish member of the public, a KOL and writer (me) and last, but by no means least, an obese patient from Bracknell, England called Hazel.  The first thing to mention is that was a good representation of the sub-section involved in the debate from the BBC, what was not so good was the lack of time the patient suffering from obesity had to speak about it.   The chance, therefore, was lost to gain a precious and sorely needed insight into this stigmatised condition.

The panel session was only half an hour, with many points of view to put across, which is of course correct in line with freedom of speech.  And freedom speech was most certainly reached by the Danish member public who angrily asked the patient why they should pay for their lack of control.  This was, I felt wrongly, omitted from the podcast by the BBC and summed up the general consensus and on the somewhat pigeon-holed condition of obesity.  Fruitless anger over a lack of control with no view or insight into the psychology or the lack of health literacy pertaining to the condition.

We know that obesity can be purely physiological, with links between Type 2 diabetes and obesity firmly established as one being a totality of the other, infinitely the causal element of the other.  We know obesity can be caused by certain syndromes such as Momo and Cohen Syndromes respectively.  We also know obesity can be caused by lack of health education & literacy, depression, insecurity, addiction and many other psychological conditions.  However, these conditions are very rarely addressed or spoken about, with obese people socially scorned, in some cases met with disgust and as we saw in the BBC panel session, met with a questioning anger.

Please also note that none of the aforementioned have been described as a ‘non-medical’ condition.  Mental health costs the global economy $16 trillion per annum and has finally been addressed by the WEF (World Economic Forum) for the first time ever this year, it’s time to list mental health as an NCD AND a medical condition.  I would also include the discipline of psychology in this even though pharmaceuticals are not always involved in it’s regime.  Why must a medical condition be defined by it’s use of drugs?  Even when the causal element i.e. mental health can cause such tangible, physiological manifestations such as obesity.  A condition which costs the NHS £4 billion a year, a figure set to rise to £6.3 billion in the next four years.

The fact that the most important person, the patient, Hazel, was literally brought in 30 seconds before the end of the broadcast did nothing to dispel or expand on the psychology of this disease.  I, as a specialist, was brought in early to give the argument a balance, the public awareness as to how important health literacy and health education is, how it affects us all in the long run.  How mental health issues are under treated or ignored and are causing a global economic deficit.   How patients find themselves on drug regimes without the support of a palliative or mental health team.  How, without proper social care in place, drugs tend to mask or deflate the problem as opposed to curing or enabling a self management of the condition, giving the patient a ‘sustainable treatment’.

As a specialist I research constantly, I brainstorm, I read white papers, blogs, articles but what is theory without the practical.  What is all this knowledge worth if we can’t speak or listen to the people this knowledge is used and learnt for.  Hazel should have been present in that conversation from the onset to give the angry Danish member of the public some empathy, the worried Danish food manufacturer some responsibility.  Hazel, did however, briefly clarify the lack of health and nutrition education whilst growing up, leading to bad food habits, which in later life when health literacy arrived turned into an addiction.  This clarification was a valuable and important statement.

Psychologists describe obesity as an eating disorder, and are usually called in when patients are morbidly obese whether the cause is physiological or not.  So we see obesity reach a stage where the patient will eat until they literally die and the physicality of any existing, tangible, medical condition is no longer taken into account as a mental health team is set to work to find out why this person will eat until they die.  So why is it listed as an eating disorder?  Why not an addiction?  With support groups and medical teams in place.  With unhealthy food manufacturers held to account.  If we were referring to leisure drugs would we say, well that’s their problem or would we be more accepting of the psychology and physicality of the addiction.  Are the obese so vilified that society will not even give them this avenue of understanding?

Mental health and it’s tangible manifestations are here and affect us all, not just by causing a massive global downturn but also watching loved ones and friends being either too afraid to admit they have a mental health problem or being stigmatised when they do.  So let’s listen to Hazel, let’s not get angry with her for a complex problem we don’t really understand and let Hazel put a human face on obesity, in fact let all patients put a human face on their illness.  Human physiology does not end at the physical, it’s where the complexity of the human psyche begins.  It’s where the totality of your patient begins, it’s where the effect of their illness and treatment lies.  It is the human face of the disease.

For the BBC World Service panel on Danish ‘Fat Tax’ click here.

As with all Healthinnovations articles this is open to discussion and innovation.

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12 comments

  • Hey Michelle

    Just coming to the end of the podcast. Interesting that you mention literacy, focusing on the importance of health education.

    It seems that the message is unclear as to why they are implementing the tax. It could be me, but I would rather like to think that the Danish Government are introducing this so called “Fat Tax” (an awful name for it) to protect the future generations.

    I’m actually in favour of such a tax and would hope that if this was to be implemented elsewhere that they do for the right reasons, whilst also making provisions for the so called healthy foods to be cheaper and attainable. Then and only then can their be no excuses.

    Without getting personal, It would be interesting to profile the lady who was very much against the tax and to also find out exactly what sort of lifestyle is lead. All in all she was very defensive and seemed to side track from the conversation. Eg: Neighborhood Watch? Hmmm?

    As you pointed out, the most important person of the conversation was drowned out until the very last minute again showing that people lack awareness and fail to see the big picture.

    Great stuff Michelle!!!

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  • My humble opinion:
    30 seconds out of 30 minutes given to Hazel is a big fail.
    Without deeper understanding of the problem and without the involvement and cooperation of the ones affected I see no real chance of taking steps towards any kind of positive change in case of obesity. (or anything…)

    Fact1:
    Health Barometer 2011 by Edelman:
    http://healthbarometer.edelman.com/2011/10/health-barometer-2011-global-findings/
    on page nine it can be seen that neither law&regulation nor negative incentive qualifies as a top motivator for positive health behaviour change.

    Fact2:
    A similar tax – referred to as ‘chips tax’ – took effect from 1st September this year in Hungary. As far as I know, the range of products is: soft drinks, energy drinks, pre-packaged sweets, salty snacks and (artificial) flavors.

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  • Good blog entry!

    Taxing food that we know leads to unhealthy outcomes makes sense. Even more if those new earnings are utilized to help people struggling with obesity (not fat, fat is OK, we all have it in one degree or another, what’s not OK is being ill because of obesity). Blaming individuals for what it is clearly an illness emerging from inequality is simply wrong. We know that most vulnerable populations have less access to healthy foods and the ability to carry on a lifestyle that allows for a healthy weight.

    What we need is to modify contexts, to offer safe public areas for people to exercise and walk. We need good public transportation to stimulate walking to the subway, bus, etc. Automobile driving encourages sedentarism but without alternatives people need to go to work. As often happens, blaming those struggling with obesity without offering real alternatives for them to move forwards is another way of keeping things where they are.

    Yes, lot of individuals suffering from obesity are struggling with mental health issues, makes sense. Aiding them means not only to offer more services but again ways of moving towards the community, towards integration, towards a healthier place. Just focusing on individual change doesn’t make a huge difference and it is expensive (of course, it helps more the helpers …)

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  • I applaud your insightful and balanced commentary, your focus on the patient’s views (which of course were not well represented by the panel!), and your understanding + emphasis on the complex psychological issues that are often relevant to many people’s ‘physical’ conditions.

    However. You have assumed, as has the Danish Government and your commentators so far (each of which has a balanced view that I can relate to), that people can have conscious & deliberate control over their weight and body form in virtually all cases… And you have also assumed that where psychological issues occur, or lack of education exists, through ‘correction’ obesity can become fully subject to conscious and deliberate modification, and therefore, with focused application, eliminated.

    I am, far more than most medical doctors, a great believer in patient enablement by every means including via psychological approaches and empowerment through education.

    I do believe that many people become obese because they frankly do exercise too little, do eat too much, eat the wrong things, lack understanding of food combinations, don’t have knowledge of biophysiology at play in obesity etc etc etc.

    However I also find that very many people who do have insight, tackle their weight with the best of intentions, exert discipline and effort… still have complex weight issues that do not ‘fit’ with any current medical, psychological, biophysiological understanding. Indeed I would go as far as to say that the majority of well-educated, conscientious people I know personally who are overweight or obese fall into this category, and to them this whole focus on obesity and ‘persecution’ of the obese is eroding the psychological wellbeing they once had, and, everything tried, creating a sense of social inadequacy, and of hopelessness and failure.

    I don’t personally notice many people who would seek to be overweight or obese given a true choice! And I notice that people who generally comment professionally on obesity are not people who struggle with these sorts of challenges – ie are people who are fortunate enough to be able to apply discipline and actually see the results.

    I believe that we are constantly swinging in our assessment of ‘conditions’ between emphasis on the psychological or the physical, and then swinging between internal and external, innate and behavioural factors in our micro-assessment of causation.

    I personally support a far more comprehensive system of assessment that makes it possible to be absolutely clear about what is *actually relevant* in any given individual’s case… and which makes it clear when it is patently not their lack of endeavour that is creating or has created the problems that they are facing. This systemic, systematic approach features as part of our ‘New-Paradigm Medicine’ Initiative.

    Both personally and professionally I would also like further emphasis on TOTAL wellbeing. Such that proposals that further erode an individual’s psychological wellbeing – because it is stigmatising in the most presumptive manner – are considered more carefully. And such that the plethora of diets which yield initial results that cannot be sustained on a healthy, balanced intake – and which create ever greater system resistance – are seen to be erosive of overall bio-physiological ‘fluidity’ and wellbeing.

    And finally I believe that we are probably overlooking key factors relevant to the current epidemic, just because it is just so easy to target blame and liability at increasingly-peripheralised individuals… while looking past many other factors at play, which relate to sequential un-informed, poor or simply self-serving political/economic decisions that influence people’s sleep, quality of life, sports/exercise capability, stress levels, wider educational levels (ie beyond ‘information’ eg decision-making), livelihoods, realistic choices, downtime etc etc etc.

    Many adult problems reflect childhood & teenage habituation – eg chemicals in our foodstuffs, lack of certain metabolically-optimising nutrients in our foods, and issues that affect our neurotransmitters, autonomic nervous system control, and moities such as NPY, leptin, gherelin etc… all of which are related to stress/calibre of sleep. So even factors like constant exams, selling off playfields, health and safety curbation of spontaneous play activities, outdoor risks of crime, stressed parents working all hours, lack of community centres, poor job prospects etc etc etc have a difficult-to-eliminate imprint.

    So while I would like to see every individual empowered to be able to achieve and retain an ideal weight, I would also like better assessment of relevance, some acceptance of inevitability without stigmatisation where it truly occurs, and a greater emphasis on total wellbeing, body composition, nutritional intakes etc. And a bit of joined up thinking wouldnt go amiss in government!

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  • Hi Michelle,

    Thanks so much for sharing your brave and straight thoughts on this – as you point – complex condition called obesity.

    Needless to say that the reaction of the public at the BBC set studio is the clear picture of the society general opinion: “eating addiction and it´s up to the sufferers to deal with their problem” and “why to have to pay taxes intended to help them”.

    As you say, it is absolutely right that lack of proper education and literacy can be one of the reasons why as starting point to get into this condition. Despite living in “developed countries”, social layers differences still remains.

    But I would like to point out that lack of education and holistic perspective in health is a common denominator in all social lays. And this is a reflect of the big room still existing to spread Healthcare education and general skills to all the general population. Not from the scientific codes, but from divulgative and understandable ones…and obviously not hiding its relation to health economics.

    Why diseases such as Parkinson and Alzheimer in terms of not what are costing now, but what it comes in just 10-20 years is being addressed and understood as politically correct whereas obesity is stigmatized as an addiction?

    Think that Social Media it´s a great platform to match this objectives of getting a proper and basic education of the big picture on what it takes Healthcare from a multidisciplinary perspective.

    So, let´s address this issue, lets change current beliefs into objectives ones. This is the essence of communication to positioning a brand, right? Why don´t define an strategy and a tactical action plan to change beliefs and modify behaviour in Healthcare towards the right direction?

    Beliefs and behaviour concepts belong to the Psychology territory; how we behave is driven but our beliefs. And this is right, not only to get the right big pic of the obesity condition, but also to educate and get empowered in Healthcare to societies, regardless if their members are now suffering any condition or not.

    Congrats for your post. Would like to see you on the TV set! Do you have the clip?

    Keep going!

    All the best

    Angel

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  • Hi Michelle,

    Well, good to hear your voice on the BBC internet radio! That’s cool.

    In Japan, phizer reported 60% people, try to quit tobacco due to tax increase, fail to quit smoking in one year.
    As @drpenzesjanos showed on his comment, negative incentives seem to work a little bit, but it doesn’t make a big change.

    As you said, mental stuff might affect obesity. It means we have 2 think abt how we live, how we wrok, how we spend time with family etc. etc. I think it doesn’t just abt “food.”

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  • An excellent perspective!

    I think healthcare is more of common sense and adopting self-discipline in eating habits. What’s lacking in present day world is common sense hence all diseases are escalating. Governments, care providers and the patients are equal culprits in the situation that is arising especially in developed world. Hopefully, someday some common sense will prevail upon the citizens of the world to lead a simple life that can lead to good health and peaceful living!

    At DocGlobal too the focus is to give equal voice for all stakeholders of healthcare so that eventually the world would not only be flat but healthy too!

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  • What an interesting discussion the Danish “Fat Tax” has triggered. And having that discussion in itself is a positive step toward better understanding of the impact of unhealthy eating habits, their causes, and the potential solutions.

    After listening to the podcast, reading your post, and going through the truly excellent comments above, it seems that there is one thing that we mostly all agree on … it would have been nice if Hazel, the obese patient, could have been introduced earlier in the discussion and been given more time. That said, the Danish “Fat Tax” targets the consumption of saturated fat, for which the effects are well documented as being harmful to people of all shapes and sizes. It’s a dietary concern far beyond its contribution to obesity. And my take on it has to do with that larger picture.

    In my opinion, your focus on health literacy gets right to the core of the problem. My wife is a Registered Dietitian and Certified Diabetes Educator who does outpatient counseling at a local community hospital to patients of all ages, social and economic backgrounds. She also specifically has worked in programs serving the morbidly obese and obese children. Over the years she’s related to me the common lack of understanding that so many people have when it comes to healthy eating. Understanding the different fats, proper food portions, the ingredients that are contained in so called “convenience foods” … these are all things that are surprisingly misunderstood by even the otherwise well-educated of our society. How many of us know someone who chooses to have a “healthy salad”, only to dump dressing that contains 300 calories, 35 grams of fat, and 370 milligrams of sodium onto those greens?

    In the U.S., like other places, we’ve got our “sin-taxes” on alcohol, tobacco and the like. But a proposed tax on sugar packed drinks such as Coke, Pepsi, and Sprite has been met with serious opposition. Some who have commented above speak of evidence that negative reinforcement, such as increasing the cost of unhealthy foods, is not an effective way to change behavior. But there are other studies (http://archinte.ama-assn.org/cgi/content/abstract/170/5/420) that suggest charging more for unhealthy food will directly decrease consumption of that food.

    While the two sides to the tax issue may never agree, there are some legislative steps that can be taken that don’t directly involve taxes. Starting with our youth, we can offer healthier food choices in school lunch programs, rid school campuses of vending machines that dispense Coke, Pepsi, etc., and incorporate healthy eating guidelines into existing physical education programs, just to name a few of our options. Helping the next generation to make better choices is easier and less expensive than trying to change behavior that has been established over a lifetime. Consequently, I’d say that this is where the first steps should be taken.

    As an adult consumer, I’ve been very appreciative of two recent laws enacted in the U.S. The first addressed food product labels and advertising claims. Labels became more standardized in terms of content. And terminology used in advertising, such as “low fat”, became defined so as to be required to meet certain standards. The second law requires “chain restaurants” with 20 or more locations to list nutritional information on their menus beginning in 2012. California, where I live, enacted a similar, local law that was rolled out in two phases starting in 2009. I use these to help me make my choices all the time.

    Thank you, Michelle, for providing an opportunity to participate in this important conversation.

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  • An interesting speech is couturier annotate. I suppose that you should make many on this substance, it power not be a preconception refer but generally group are not sufficiency to verbalize on such topics. To the next. Cheers like your Healthinnovations on the BBC World panel on the Danish ‘Fat Tax’ [unedited] HEALTH INNOVATIONS.

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  • Its like you read my mind! You appear to know so considerably about this, like you wrote the book in it or something. I think that you can do with some pics to drive the message home a bit, but instead of that, this is great blog. A fantastic read. I’ll surely be back.

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  • In my opinion, your focus on health literacy gets right to the core of the problem. My wife is a Registered Dietitian and Certified Diabetes Educator who does outpatient counseling at a local community hospital to patients of all ages, social and economic backgrounds. She also specifically has worked in programs serving the morbidly obese and obese children. Over the years she’s related to me the common lack of understanding that so many people have when it comes to healthy eating. Understanding the different fats, proper food portions, the ingredients that are contained in so called “convenience foods” … these are all things that are surprisingly misunderstood by even the otherwise well-educated of our society. How many of us know someone who chooses to have a “healthy salad”, only to dump dressing that contains 300 calories, 35 grams of fat, and 370 milligrams of sodium onto those greens?
    +1

    Like

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