Anabtawi, Ola
(2020)
The bigger picture: the hidden consequences of the sugar reduction strategy for tackling childhood obesity in the UK.
PhD thesis, University of Nottingham.
Abstract
The focus on reducing rates of childhood obesity has become one of the main public health priorities in the United Kingdom. The government is addressing this through various strategies including Public Health England’s sugar reduction programme, which aims to decrease free sugar intake to 5% of individuals’ total energy intake (PHE, 2015a).
There is precedent in the UK of using a single-nutrient approach in the management of non-communicable diseases (NCDs), with salt being used to address hypertension, and dietary fat for cardiovascular diseases and obesity. Using a four mixed- method studies, this PhD aims to investigate possible unintended consequences associated with the one-nutrient focus on sugar, including demonising the single nutrient targeted, promoting unhealthy dieting, detracting from a balanced healthy diet, creating stigma around obesity and exacerbating other health-related inequalities.
Study one: Sugar looks brighter on Traffic Light Nutrition Labelling: Choice-Based Conjoint Analysis and Cross-sectional Survey
With the current emphasis of public health on sugar reduction, this two-part study aimed to investigate the influence of Traffic Light Labelling (TLL) information about total sugar compared to other macronutrients when making decisions about the healthiness of products. The first part was a Choice-Based Conjoint analysis (CBC) assessing the relative importance of four macro-nutrient attributes commonly used in TLL (sugar, fat, saturated fat, salt) and the colour of each based on three food products (biscuits, cereal, and sandwich). The second part was a cross-sectional survey assessing public knowledge of the recommendations underpinning the TLL.
The results suggest that, when participants decided upon the healthiness of biscuits, cereal or sandwich, sugar was the most important factor compared to fat, saturated fat, salt and price. While this may be considered a success in terms of sugar-reduction efforts, the lower level of attention paid to other macro-nutrients illustrates the potential negative impact of a single-nutrient focus to wider health campaigns. This is especially significant since participants had poor and overestimated nutritional knowledge.
This research was published in the Journal of Human Nutrition and Dietetics: https://onlinelibrary.wiley.com/doi/abs/10.1111/jhn.12741 (Anabtawi et al., 2020)
Study two: Are SSBs the devil? An exploratory analysis of children who consume sugar sweetened beverages in the UK
The Soft Drinks Industry Levy (SDIL) came into effect on the 6th of April 2018 and was designed to reduce the intake of Sugar-Sweetened Beverages (SSBs), identified to be the largest contributor of sugar in children’s diets in the UK. This study used data collected as part of the National Diet and Nutrition Survey (NDNS) to explore the underlying characteristics of children who drink SSBs, through the application of a bias-free technique called hierarchical agglomerative clustering (HAC).
The results demonstrated that there is no clear association between drinking SSBs and BMI among children aged 4-10. The logistic regression analysis illustrated that there is no specific trend across clusters in terms of significant association between children with different drinking habits and other variables.
This analysis confirms the complexity of relationships across demographic and other health-related variables and emphasises the problematic nature of simplistic interventions that aim to tackle a particular behaviour or address a particular bodyweight category.
Study three: The effect of three “Ps” on public perception of childhood obesity policy in the UK; Parenthood, Perceived weight and Political orientation
A survey was conducted to investigate the perception of a representative sample of adults living in the UK (n=990) on the solutions to the childhood obesity issue and the effectiveness and appropriateness of interventions proposed by the UK Government in “Childhood Obesity: a Plan for Action”, parts 1 and 2. In the analysis there was a specific focus on how participants’ parenthood status, perception of their own bodyweight status and political orientation affects their views.
The results showed a high level support from the public for most interventions proposed by the Government related to childhood obesity. Individuals’ political orientation played a role in shaping their attitudes and beliefs, with more conservative participants reporting higher support for individualistic solutions including biological, psychological and behavioural interventions. Being a parent had an influence on individuals’ attitudes toward the likelihood of childhood obesity solutions being effective and suitable. However, the effect of participants’ perceived weight status on their perceptions was less influential.
These results demonstrate the importance of considering individuals’ different characteristics when developing policies and interventions to ensure that they are effective.
Study four: Problems hiding in plain sight: A thematic analysis of the UK Government Policy “Childhood Obesity: a Plan for Action” parts 1 and 2
This study aimed to conduct a thematic analysis of the content of the documents representing the current Government position on childhood obesity and its policies relating to public health interventions: “Childhood Obesity: a Plan for Action” parts 1 and 2. This was undertaken through the application of Bacchi’s “What’s-the-Problem-Represented-to-be?” (WPR) approach. (Bacchi, 1999). The objectives were to (1) conduct a critical thematic analysis of “Childhood Obesity: a Plan for Action” parts 1 and 2 and (2) consider the potential negative consequences of promoting a specific obesity narrative.
Three main themes identified using the interpretative inductive thematic analysis (Fade and Swift, 2011), were Where does responsibility for action lie?, Weight-centrism and Think inside the box.
Using the WPR approach, three themes and two main issues were identified to be problematised in these documents: responsibility and weight. The analysis explored how and why these ‘problems’ were presented in a specific manner in the documents, through the process of examining the language and supporting evidence that were used to reflect the values and assumptions underlying the proposed interventions. The possible unintended consequences of these representations were considered. In particular, this research highlighted some negative effects that are correlated with the simplistic approach in tackling childhood obesity through focusing on individual behaviour and individuals’ control over their lifestyle for weight loss. These consequences include weight-bias, stigma, discrimination and cultural imperialism. For these reasons, health policies should be analysed comprehensively to increase their potential effectiveness and decrease associated concerns and negative unintended consequences.
Discussion and Conclusion
Each study individually, and the analysis of the studies and literature review combined, demonstrated that current strategies to reduce the rates of childhood obesity in the UK focus on reducing sugar intake. This linear and simplistic approach has not taken into account the complexity of the determinants and the interactions between them. The other significant issue is the pervasive theme of weight problematisation and sugar demonisation, both of which carry negative framing. This framing, as well as the complexities and interactions mentioned, may have potential negative consequences.
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