World Obesity Federation’s response to WHO Discussion Paper
‘Draft recommendations for the prevention and management of obesity over the life course, including potential targets’
This document contains feedback compiled by World Obesity Federation from its members, Board, volunteers, staff and allies working in obesity, in response to the WHO Discussion Paper. We will submit this, listing names of those who have contributed to the response. We encourage all our members to also submit your own response directly to WHO based on the points below, which can be adapted to your context and priorities. As well as these general points, World Obesity will also be submitting an annex with a number of specific language changes we would like to see included in the final version. If you would like more information on the detailed language changes proposed, or have any other questions on the process, please contact Rachel Thompson.
World Obesity Federation reports in 20191 and 20202 show that no country is on track to meet the WHA nutrition targets, reinforcing the need for a much more robust and well-coordinated response. As such, we welcome the draft recommendations and congratulate the WHO on the efforts to produce this draft.
This report marks an important moment where our improved understanding of the complexities and drivers of obesity are being used to develop comprehensive policy recommendations for prevention and treatment in adults and children alike.
World Obesity calls on WHO’s Executive Board to adopt this document as a draft resolution to be presented before the 75th World Health Assembly.
The document highlights a number of important considerations for the prevention and treatment of obesity throughout the lifecourse, and steps that are needed to help support people living with obesity, and countries to meet the targets. It captures some of the complexities of obesity, and the need for a whole-of-society, cross-governmental approach to obesity. In particular, we are pleased that the draft:
- Recognises obesity as a complex multifactorial disease
- Acknowledges the stigma and bias experienced by people living with obesity in some cultures
- Recognises the need to prevent and manage obesity throughout the lifecourse
- Makes recommendations for improving the training of healthcare providers (HCPs) in obesity management
- Makes recommendations for obesity to be included in UHC packages, and managed through multidisciplinary teams
- Recognises the need to build on existing strategies, such as ECHO and the Global Action Plan on NCDs
- Highlights the importance of integrating obesity management into primary care, which is of particular importance in in low- and middle-income countries (LMICs)
- Highlights the importance of regulating food environments through taxation and incentives
- Recognises the cost of obesity, not only on health systems but also in terms of reduced quality of life
However, there are a number of important areas where the document could be improved to ensure that it is comprehensive in its recommendations.
Firstly, although the document calls for multisector approaches and covers a comprehensive range of actions, it lacks an overarching framework that Member States can adopt (and be held accountable towards) to help shape the implementation of national obesity plans. In 2020, World Obesity in consultation with its members, developed the ROOTS framework which sets out an integrated, equitable, comprehensive and person-centred approach to addressing obesity (See Annex 1). The framework is based on 5 key pillars which encompass recognition of obesity as a disease, enhanced monitoring and surveillance, prevention of obesity throughout the life-course, the provision of improved health services and treatment for people living with obesity, and the need for a systems approach. We strongly encourage such an approach to be included in the recommendations, and for WHO and Member States to integrate this framework and associated principles into their approach for addressing obesity, especially when developing national action plans.
In addition, we have identified a number of specific issues that could be enhanced in the document.
WHO's own definition of obesity is abnormal and/or excessive accumulation of body fat that presents a risk to health, yet this is missing from the text. The role of epigenetics in causing obesity is also not adequately referenced. Categorising obesity as a chronic disease is an important omission, which could help strengthen obesity action within the context of existing NCD policy frameworks, initiatives and targets.
There are a number of examples throughout the document where people first language is not used. People first language refers to putting an individual before the medical condition that is being discussed and is important to help avoid de-humanising individuals living with chronic diseases and ensure that we are not labelling an individual with their disease. Failing to use to people first language risks simplifying obesity and its causes, fails to capture the wider drivers and determinants of obesity, and creates a negative image of people living with obesity.
This in turn can reinforce misconceptions about obesity and contribute to weight stigma, which the document itself highlights as an important issue. It would be important to include reference to the inaccurate and stigmatising narrative around “personal responsibility” and lifestyle choice, referencing the complexity of the biological mechanisms of obesity. Related to this, stigma in the health system has been identified as a major barrier to people living with obesity accessing quality care and increased training of health providers is required to ensure they can approach the topic in a sensible, culturally appropriate, non-stigmatising manner.
People living with obesity (PLWO) should be involved in all obesity efforts, from education to the development, implementation and evaluation of prevention, treatment and management strategies, due to their lived experience. The meaningful engagement of PLWO amplifies the needs and concerns of PLWO and help ensure policies and services available are non-stigmatising, sustainable and promote health equity an empowers people to act on individual, community, societal and global level. This document would be enhanced with a greater emphasis on the importance of including PLWO in policy development, and also as a key part of civil society. We call for governments to ensure meaningful inclusion of people living with obesity in all policymaking processes from development to implementation and evaluation.
Building on the recommendation for governments to develop comprehensive and evidence-informed national actions plans for the prevention and management of obesity in all age groups, we call for these plans to be based on the ROOTS framework, include the whole-of-government, be multi-sectoral and involve PLWO.
While the document covers obesity throughout the life course, it places a greater emphasis on childhood obesity. While much of this is historic due to previous WHO work, it is vital that healthcare provision for adults is addressed as an equal priority, and that WHO develops guidance accordingly. Poor health undermines social and economic development throughout the world. People with obesity require respectful and equitable access to treatment and clinical management services. Improving health care provisions for adults can ensure an individual’s ability to contribute to and benefit from community resources, improving social stability and reducing the risk of poverty.
While not explicitly included in the SDG framework, obesity has relevance across a number of the SDGs. Recognising that addressing obesity has much wider benefits for global health and development is important and should be reflected in the document. Failing to act on obesity holds back economic development and will inhibit progress towards the Sustainable Development Goals and the Triple Billion Targets. Recommendations for more investment from global health and development funders are needed to help governments and civil society address obesity in LMICs.
As recognised in this document, obesity is rising most rapidly, and affects more people, LMICs face many unique challenges and it is vital that policies and actions are adapted and identified for a range of settings. At present the document focuses disproportionately on assumptions and research which are predominately true in HICs, and as such focuses on a HIC narrative on obesity. However, overweight and obesity, including how it is perceived, is affected by differences in culture and geography amongst other factors, and these recommendations should reflect this.
At present our knowledge and evidence on obesity is largely HIC focused, however LMICs are experiencing the greatest rise in obesity rates. Yet data is often scarce and recommendations need to be contextualised, recognising regional and cultural differences in how obesity manifests. We need to decolonise obesity and understand the diversity of experiences worldwide in order to support development of appropriate solutions. More investment in research is needed. Global health philanthropies and academics should fund research to better understand the context, determinants and possible solutions for obesity in LMICs and other low-resourced settings.
Crucially, the document fails to mention the commercial determinants of health (CDH) and we would like to see this document drawing from the 2021 WHA Social Determinants of Health resolution, as well as the growing body of evidence on the CDH, especially around the role of ultra-processed foods (UPFs) in driving obesity. Working with economic actors in the food system will be essential. However, robust governance mechanisms are needed to minimise conflicts of interest, as developed by WHO’s nutrition department.
Policies, partnerships and dialogues relating to nutrition must conducted with principles of engagement to protect from inappropriate and vested interests undermining health by implementing strong accountability, monitoring and evaluation mechanisms. At the same time, there should be reference to the need for market-relevant strategies to incentivise industry engagement and change beyond the traditional public health toolbox and consider them as a way to incentivise behaviours and promote change.
Alongside food system policies, government action is needed to promote physical activity. We commend the whole-of-government and whole-of-society approach called for but would like to see greater recognition of the environmental roots of obesity in the actions identified. Policies to facilitate and promote active lifestyles should be implemented and encompass cross-sector, multi-stakeholder collaboration to build walking and cycling infrastructure, increase the access and quality of public open and green spaces, improve road safety, and promote active transport, among other things.
Currently, there is a lack of a robust monitoring and accountability mechanisms to address obesity making it challenging to track progress and hold Member States and other relevant stakeholders accountable. The adoption of an accountability framework to support these recommendations would increase the accountability of governments to act and ensure the necessary resources are available and accessible to all. This would also allow for best-practices and draw from previous wins and challenges when developing and implementing new policies/interventions.
Once finalised with comments from World Obesity and input other civil society and member states, these recommendations should be tabled as a Resolution on obesity for the WHA. World Obesity calls on WHO’s Executive Board to adopt this document as a draft resolution to be presented before the 75th World Health Assembly.
As we know from World Obesity reports in 2019 and 2020, no country is on track to meet the WHO targets for overweight and obesity, thus making intermediate and process targets vital for ensuring some progress monitoring and accountability is possible.
The proposed targets are good and draw on measures that are monitored by WHO as part of existing programmes of work. However, arguably the targets proposed are conservative, and we would encourage the inclusion of additional targets in line with the recommended actions laid out in the document.
To ensure targets can be monitored in an accountable way, all governments should establish robust surveillance systems, including rolling measurement programmes to identify trends, drivers and priority populations
Two additional targets we propose include:
- The number of countries with national action plans for obesity in adults and children
- The number of health care professionals who have received specialise training in obesity science and management.
Other targets that could be considered include national expenditure on obesity research, number of obesity centres of excellence and number of governments recognising obesity as a disease.