I’ve tried to avoid saying very much about obesity in this blog before, largely because I think more than enough column inches and air time are devoted to the issue already. However, BBC ran a short piece on the issue one morning last week, which put the issue back in my head at around the time I was thinking about this month’s blog.

It worries me that the tone of our media commentary on obesity is usually hectoring or patronising, and there’s an implicit “fat equals ignorant or lazy” message that I think would benefit from some more scrutiny. However, that’s not really what I want to talk about. The thought for this column is: “has obesity switched from being a signifier of wealth to a signifier of poverty?”

I think I’m right in saying that there is an emerging social gradient in obesity – not yet as strong as for smoking, for instance, but still noteworthy. So how is it that people who have less disposable income are, even so, consuming more calories or burning less of them when historically the opposite was true? The switch to white collar jobs and the related unemployment amongst communities that until recently were dominated by manual work probably explains some of it. And the essentially sedentary nature of 21st century urban living probably explains some more. But then why aren’t affluent white collar urban families showing the same increase in obesity as their less affluent peers?

It’s been suggested to me that more affluent groups may in fact be insuring themselves against obesity, deploying their wealth to protect their health in just the same way as if they were buying private health care or pensions. Except this time they are investing in gym memberships and more expensive, healthier foods. So they are using their affluence to insulate themselves from some of the causes of obesity in a way their less affluent counterparts can’t. So are we facing the emergence of another dimension of social inequality? Or am I just trying to find an excuse to make up for a lack of personal responsibility?

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You’ll probably have seen the headlines: Scots are living longer, but there remains a real and disturbing inequality in life expectancy across the country, with just over 6 years difference between the best council area and the worst. Most disturbingly, the gap has not improved at all, and Scotland remains towards the bottom end of the EU25 league for life expectancy at birth.

I gave a presentation on wellbeing at a professional development event the other day and was gently rebuked for not being optimistic enough about progress on health and wellbeing in Scotland. I apologised at the time: I’m an optimist by instinct and upbringing (thanks, Mum), but when I read headlines like that it’s difficult. Scotland’s approach to public health is acknowledged by many as leading the field – but spokespeople from both the Scottish government and the BMA highlighted just how long it may take before it makes any difference.

It seems to me that the figures raise a fundamental question – many current efforts on health improvement are focused on those at the wrong end of health inequalities, and they have been since devolution, if not before. That approach feels morally right, but is it working? The evidence of life expectancy is that it isn’t – and that’s before we get into the much trickier questions of quality of life and ‘healthy life years’, where I suspect the inequalities are even wider. So what else do we do? Or is it that we’re actually still not doing enough? I don’t know – what do you think?

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I recently attended a seminar in Manchester, with public sector officials and community health workers from across the North-West of England. The aim was to settle on a working definition of ‘wellbeing’, and to identify a set of indicators that they could use to measure change. A tough task – we came up with a definition, but the indicators proved very difficult.

As usual, I came away from the session with a lot to think about (every day is a school day), but the main thing that stuck in my mind was a statement made by one of the speakers: “My wellbeing may erode someone else’s.”

It seems I may have a selfish streak, because the idea had never occurred to me, at least not in those very personal terms. I accept the idea that our current economic model creates ‘winners and losers’ in a systemic way, but I hadn’t really considered that in pursuing my own wellbeing, I might harm someone else’s. I didn’t think it was a ‘zero-sum’ game.

My wife and I moved to a new flat recently (nothing spectacular, just a comfortable flat with a bit more space and a nice view) and our sense of wellbeing has definitely improved. Does that harm someone else’s wellbeing? We had to pay a fair bit of money for it (we live in Edinburgh), so I suppose we contributed in our own small way to spiralling property prices. So does that mean that, for example, we harmed the wellbeing of a low-paid worker who can’t afford to buy their own home as a result of price inflation? Or is that a case of the ‘system’ creating winners and losers? Is buying a new flat rather than adapting to the limitations of the old one the type of conspicuous and harmful over-consumption that we may all have to learn to avoid in future? I don’t know, and it bothers me.

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Nicole and I recently spent a stimulating morning in Dundee, facilitating a seminar discussing wellbeing and how to promote it in the city. The most memorable contribution of the morning had to be when one participant shared a piece of research she had uncovered: the ‘Greedy Bastards hypothesis’.

In a nutshell, the hypothesis suggests that the inequalities and therefore the challenges to wellbeing that our society faces are the inevitable result of weakly-globalised national state elites interacting with strongly-globalised corporate elites. The disparity in power this creates means that the national governments are always on the back foot when they have to deal with the ‘downstream’ impacts of globalised business. To summarise even further, the global ‘greedy bastards’ have a free rein, and we all suffer.

As you’d expect, that prompted a fair amount of comment! One professional trying to promote individuals’ wellbeing said something that really stuck in my mind afterwards. She highlighted that she often encouraged the people she saw, to try to improve their mental wellbeing by redefining themselves and their relationships. She encouraged them not to think of themselves as ‘an employee’ or ‘a consumer of goods and services’. Instead, they should think of themselves as a person of value to others – ‘a volunteer’, ‘a good neighbour’, ‘a close friend’.

Emphasising those human relationships helps feed something in us that is neglected by our culture’s emphasis on having things, and wanting other things. It seemed to me to be saying that one way to protect ourselves from the potential harms of our culture is not to the play the game, or at least to engage with it on our own terms. In a world where it often seems like people who we will never meet decide our destinies, there is still the chance to take back some control.

My conclusion from our visit to Dundee: play the game you want to play, not the one being sold to you. You’ll feel better for it.

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I had an interesting conversation earlier today around the question of how best to tackle issues such as irresponsible drinking or obesity. Basically, the debate boiled down to the question of whether it was better to focus on the social and environmental factors like poverty or work, or the physical environment, or to try to promote personal responsibility as the answer. I suspect the right answer is probably ‘a bit of both’, but to be honest I can’t quite decide.

The fact is, not everyone who faces disadvantage drinks irresponsibly, smokes, or eats badly. Equally, there are plenty of better-off people who are obese, or drink or smoke too much. That suggests that it’s the personal choices that make all the difference. But then, we know that rates of smoking, obesity and alcohol-related problems all tend to follow disadvantage – the populations of deprived areas tend to exhibit more of these problems than their peers in better-off areas. So that suggests that the ‘environment’ – in its widest sense – has a big impact.

The SCF’s Working the System report, that formed the basis of this project, proposed that we need to find the big environmental factors that lead to poor wellbeing. We stand by that proposal, but that doesn’t seem to be enough on its own – individual choice matters. So if it’s not an ‘either or’ situation, but ‘a bit of both’, then where do we start? Is it realistic for government, or health professionals, or anyone else for that matter, to set about trying to change the way individuals think about their behaviour? Or will they always be stuck trying to undo the worst effects of individuals’ and groups’ behaviours? Or should they all just shut up, focus on doing what they can to improve the environment in which people live, and accept that the population make their own choices, for better or worse?

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First of all, a slightly belated Happy New Year to you! After the festive season, a lot of people decide they’re going to ‘detox’ in January. Perhaps reflecting the time of year, the Scottish Parliament Futures Forum’s first event of 2007, on 15 January, was a conference on alcohol and substance abuse.

As you would expect for a Scottish event, irresponsible drinking dominated the discussion, and many suggested that alcohol should be tackled as part of the same debate as drug abuse. I have to say, I’m not sure I agree – after all, alcohol is not illegal, and its supply, sale and use are not marked by the degree of violence and fear associated with the supply of illegal drugs. But it is an interesting marker of the strength of feeling around the subject that irresponsible drinking is increasingly seen in the same terms as illegal drug use.

Focusing on alcohol, it struck me that responsible drinking is one of the two big wellbeing issues of the current decade, alongside obesity. With its implications for physical and mental health, for social capital and quality of life, irresponsible drinking has a huge impact on population health. However, unlike smoking for instance, it is possible to have a drink and not damage your health – quite the opposite in fact. Social marketing seems to suggest that we need a clear, consistent message to change attitudes – but the message is not as consistent for alcohol as it is for other drugs. So can we ever hope to achieve the same transformation of attitudes to alcohol in Scotland that seems to have occurred towards smoking?

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Okay, the last posting didn’t get many replies.  Nevertheless, we’re going to stick at it.  In case it was the topic that was the problem, I’m going to try something a bit more provocative.  One of the Big Ideas in our ‘Working the System’ report got some people sufficiently exercised to write letters to the papers, so let’s see what happens here.                    

Instead of economic growth, the publicly-stated top priority for the Scottish government should be to improve the health and wellbeing of the Scottish population.  Economic growth is important – growth tends to mean higher employment, for instance, and employment rates strongly influence the wellbeing of the population.  But the shape of the economy, and the type of jobs and levels of income we can create, are more important than the rate of growth.  Meanwhile, there’s plenty of evidence to show that improved health and wellbeing will promote better economic performance – if only improved productivity.  I have other arguments: recent approaches to promoting economic growth have widened inequality, which erodes health and wellbeing.

It’s been suggested to me that, for all their rhetoric, the current Scottish government actually do put social objectives like wellbeing ahead of economic growth.  Maybe so, but I’m not sure that’s helpful.  Our research has emphasised the importance of leadership in promoting population wellbeing, that we need ‘special persons’ to make things happen.  Government needs to publicly put our wellbeing at the top of the agenda, because then others will too. We should promote economic growth for a reason – wellbeing – and not for its own sake.  Discuss…

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So where to start for the first one? Well, this is the Wellbeing Project website, so that narrows it down a bit. Let’s start at the beginning - the difference between ‘health’ and ‘wellbeing’. As you’ll see from our recent report, a panel of ordinary folk in Dundee suggested that “People have a sense of wellbeing, but a state of health.” I like that distinction - a doctor might be able to tell me whether I’m healthy or not, but they can’t tell me how ‘well’ I feel. But it does pose a bit of a problem if we want government and others to work to promote wellbeing as opposed to health. If wellbeing is individual and subjective, can we come up with a sensible and practical way of identifying it, which will let us develop sensible and practical ways of promoting it? As far as I can tell, wellbeing is about more than just good physical and mental health, it also includes things like resilience, confidence and ‘purpose’. So, is there something we can put our finger on, or a set of things, that we can say: ‘that’s wellbeing’ and, more importantly, understand where it came from and how to promote it elsewhere? I don’t want to engage in a philosophical debate about definitions, but I do think it would be good to debate whether and how we’ll know wellbeing when we see it. Over to you… who’s first?

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