Fuelled by economic growth, industrialisation, mechanised transport, urbanisation, an increasingly sedentary lifestyle, and a nutritional transition to processed foods and high-calorie diets over the last 30 years, our country has witnessed the prevalence of obesity in its citizens double and even quadruple.
In June of 2014, Opposition Members Robert Cutajar and Mario de Marco presented in Parliament a Private Member's Motion that gave birth to the Healthy Lifestyle Bill. In 2016, Parliament unanimously approved a law aimed at combating obesity. Implementation, however, was neither done in full nor in an effective manner.
It is estimated that obesity costs Malta €45-€50 million per year. Malta has the highest obesity rate in the EU. While acknowledging the investment and efforts undertaken, including legislative changes and policy developments, as well as implemented projects, measures, and initiatives, the National Audit Office continues to be of the opinion that sustained high prevalence rates raise concerns about whether the government is fully cognizant of the scale of the problem and taking sufficient action. A World Health Organisation report discovered that between 40% and 36% of Maltese children and adolescents are overweight.
Obesity is endemic in Malta. It has far-reaching consequences for individuals, society, and the economy. Just being overweight reduces life expectancy, increases healthcare costs, decreases workers' productivity, and lowers GDP. The time has come to make the urgent economic case to scale up investments in policies to promote healthy lifestyles and tackle this growing public health problem.
Children in particular are paying a high price for obesity. Children who are overweight do less well at school, get lower marks, are more likely to miss school, and, when they grow up, are less likely to complete higher education. They also show lower life satisfaction and are up to three times more likely to be bullied, which may contribute to lower school performance.
In adulthood, individuals with at least one chronic disease associated with being overweight are less likely to be employed the following year. When they have a job, they are more likely to be absent or less productive. Adults with obesity are at greater risk of chronic illnesses and a reduced life expectancy.
The role of weight in mental health, too, faces causal challenges. Obesity in children and adolescents has been associated with smaller orbitofrontal cortex grey matter volumes and poorer performance in inhibitory control. Being overweight in midlife increases the risk of Alzheimer's disease, vascular dementia, or any type of dementia. Being overweight can contribute to stigmatisation, poor socialisation, and emotional difficulties.
A rise in the number of people with high body mass index (BMI) is squeezing health budgets due to the high cost of chronic diseases linked to overweight, such as diabetes, cancer, and heart disease. People with overweight use health care services more, undergo more surgery, and have more than twice as many prescriptions as people with a healthy weight.
It is good that we have a national action plan on obesity and a specific action plan to tackle obesity in children, as well as national guidelines to promote healthy diets and active lifestyles. But the response needs to be stepped up. Every Euro spent on preventing obesity generates up to a six-fold economic return. Food and menu labelling, regulation of advertising of unhealthy foods to children, and the promotion of exercise, including by doctors and schools, are among the measures that need to be stepped up.
Currently, our greatest gap in knowledge is not regarding the numbers of risk factors, nor in their independent impact on risk, but rather in how they interact with one another, their confluence, to produce today’s aptly if unfortunately named "globesity" epidemic. Obesity arises as the result of an energy imbalance between calories consumed and calories expended, creating an energy surplus and a state of positive energy balance, resulting in excess body weight. This energy imbalance is partially a result of profound social and economic changes at levels well beyond the control of any single individual.
Obesity poses a nearly unprecedented challenge not just to those tasked with addressing it at the public health level or at the healthcare provider level, but to each of us as individuals, for none of us are immune. Obesity is complex. Although its risk factors are myriad and compounding, there is an urgent need for a deeper understanding of the way risk factors interact with each other, and the potential solutions to the epidemic are as multi-levelled and complex as its causes.
The government, communities, and businesses must continue to take action to change the factors that promote unhealthy weight gain and to support those living with overweight and obesity.
Despite the many unknowns, we can be cautiously optimistic about our ability to address the obesity epidemic. Indeed, we have relatively successfully faced similarly daunting public health challenges before: smoking, to name just one. Smoking provided numerous lessons in multi-level solutions to a major health threat in terms of both mitigation and prevention. We began by developing an understanding of smoking’s epidemiological impact and the healthcare costs borne by society, uncovered its biological basis, learned about and applied behaviour change, and initiated and carried out vast public health, public policy, political, and economic strategies that ultimately affected whole environments as well as sociocultural norms.
It took over half a century to achieve the immense success we have with regard to smoking in Malta, and we are still not yet tobacco-free. It has only been less than a decade since we first deeply appreciated that obesity was an epidemic. We clearly still have a long way to go.
Dr Mark Said is a lawyer