[00:00] Hugo Harper:Are GLP-1 drugs cost effective? Yes. Are mental health services, talking therapies, cost effective? Yes. But they do cost money, and wouldn't it be better if the people weren't sick in the first place?
[00:13] Ravi Gurumurthy:One of the areas that's been less talked about in previewing Andy Burnham's tenure as Prime Minister is the issue of health, which is strange given he himself is a former Health Secretary. It's something he's taken very seriously in Manchester. Uh, he's focused on a prevention demonstrator because he thinks we need to actually get upstream in tackling health issues. And today we're going to be talking about prevention and what might a Burnham government do to really turbocharge prevention in the next couple of years. With me is Hugo Harper, who's the mission director of our Healthy Life Mission. Welcome, Hugo.
[00:43] Hugo Harper:Hello.
[00:43] Ravi Gurumurthy:Andy Burnham has historically talked a lot about how we need to shift from treatment to prevention. It's what every Health Secretary says at some point. Um, he's very interested in more holistic treatments, tackling the social determinants of ill health. He's—he's—he's pushed that in—in Greater Manchester. What I want to start with is: if you—if you think about all the most important causes of ill health, um, how could you sort of rank order them in terms of their importance to ill health, but also what are tractable? Because, frankly, if you've got really important things that are impossible to tackle, frankly, we should not be saying to them, "Prioritize it right now." But what are the areas which are uh important and tractable? So give us a portrait.
[01:26] Hugo Harper:So, yeah, great—great question and really helpfully, there's this wonderful database called the Global Burden of Disease, and that allows you to rank risk factors for all the different countries in the world, but it has it for the UK as well. The things that come up top probably aren't going to surprise you, you know, top sort of five things be smoking, obesity, air pollution, mental health, physical activity, alcohol—the things you hear about all the time. But the thing is, the absolute impact of each of those actually varies wildly, you know.
[01:52]So uh obesity—and obesity sort of includes dietary-related health because we have like a general overconsumption problem—um, that's much, much bigger than, say, physical activity or drugs or alcohol. So like the two—the two—the sort of three big ones are smoking, obesity, and mental health.
[02:10] Ravi Gurumurthy:Mhm.
[02:10] Hugo Harper:Now, that's really interesting then on tractability, because smoking is easy, or it should be easy, right? The ideal amount of smoking is no smoking. That's the stated ambition of everybody, and it's just a question of how quickly do we get there. Um, we have no qualms sort of hiking up the prices, making it harder and harder to do it in places, because we know—we know the harms. We know what to do. So that's—that's good, it's tractable, but we're—we're getting there.
[02:36]On the flip side, mental health—huge, burgeoning problem. Well, you know, it's been a problem for a long time, but it seems to be ever-increasing not just in the UK, but the rest of the world. Um, the problem is the exact causes of it are a little harder to understand, or rather what lever you could pull to dramatically improve mental health. Directionally, people probably know, but the exact relationship, how much it would change things, is—is a little tricky, which means sort of selling a policy on it is a little tricky because you're not sure what kind of return you're going to get for your investment.
[03:07] Ravi Gurumurthy:Mhm.
[03:07] Hugo Harper:With obesity, it's a bit more simple. And perhaps it's not actually more simple; it's just we've been studying it properly for longer, so we've got a better idea of what actually works. You know, the—the underlying physiology is pretty well understood. You know what leads to weight gain in terms of energy excess, um, the rate at which that occurs either with weight gain or weight loss—all of this—this stuff is like pretty well understood. There's like thousands of papers academically on obesity every year, and that's—that's a good thing and a bit of a challenge.
[03:37]Um, and everyone, you know, like you said at the beginning, everyone's been saying what you need to do about it for ages: prevention, you need to pre—you know, prevent this in the first place. If you look back 25 years, all the health policies are the same: "We need to do more prevention." No one's really done it.
[03:52]Um, so what we—in terms of obesity, the really interesting thing is that you could change it quite dramatically. So to—to put that in perspective for you, um, the obesity rate now in the UK is about 30%, so about one in three adults living with obesity. Um, that's about double what it was in the '90s. So this—this has been a pretty recent change, certainly recent in terms of any like genetics or stuff, you know. Um, it's not like everybody was just like chopping wood or tilling the fields in the '90s. Like, lifestyles broadly look pretty similar to what they do now. Um, but the national weight was much lower.
[04:29]And so that should give us a real reason to be hopeful about this. Like, halving obesity, getting back to that '90s level, the change would be about 220 calories a day. That, to put that in perspective, because there's no reason people would know what that actually means, that's about an 8% reduction, 8-12% um, is about the same as like a bottle of Coke, big—bigger bag of crisps. It—it's not a lot.
[04:54]And so this is why we're so interested in the area. Something that requires actually quite small changes on an individual level can have this massive effect at a population level. And we're relatively confident that if those calorie or energy changes occurred, that would be what you would get.
[05:08] Ravi Gurumurthy:So everyone always goes on about prevention being necessary, um, but just give us the sort of size of the prize, uh, because if we basically—if we don't get on top of prevention, NHS costs are going to go up and up and up with demographics. It becomes incredibly hard to pay for that. So there is a sort of hard-headed Treasury case for being pretty aggressive on prevention.
[05:28] Hugo Harper:Yeah. Even if you don't care at all about human suffering, you should care about this, right? So there's—there's sort of three main things that make up the value of prevention, uh, and that's the—the QUALYs (Quality-Adjusted Life Years), the human suffering that you're saving from it, the productivity gains that you get from it—so people being healthier, so being in work or in better work—uh, and the NHS costs or social care costs, the reduced cost that we have of giving people treatment or care.
[05:50]Um, and the numbers here are massive. So for obesity and excess weight, the total value is £126 billion per year. It's huge. Um, in terms of the amount: productivity, £31 billion; NHS costs, about £19 billion. You know, and so those—that, you know, if you eliminated that, those would be the savings. That's not, you know, potentially not immediately available, but you'd half it, right? Get about half of those savings: £10 billion savings in the NHS, £15 billion productivity. These are massive numbers.
[06:24]And the reason they're particularly massive numbers is primary prevention is cheap. The policy is cheap. You don't need an outlay of cash immediately to start going on this. And that's the thing that people miss on this left-shift idea. Yes, you do need to shift money towards uh prevention and prevention services, but the best version is primary where, um, you know, it's regulatory largely in nature.
[06:43] Ravi Gurumurthy:Yeah, exactly. Like, are GLP-1 drugs cost effective? Yes. Are mental health services, talking therapies, cost effective? Yes. But they do cost money, and wouldn't it be better if the people weren't sick in the first place? Um, so the—the issue that sometimes comes up with this is like, "Well, when do you see the benefits?" But we don't seem to have those issues in other policy areas. You know, a railway takes a while to build; everyone's still okay with building the railway. No one says, "I need this within the term of my parliament, otherwise it's not a useful thing to do."
[07:15]Yeah, and a lot of people would say like, "Forget about uh alcohol, food environment; really got to tackle the sort of even more underlying issues, housing and poverty." Like, what's your argument about how—how true is that, and—and what does it miss?
[07:28] Hugo Harper:Yeah, so I want to be specific here. Like, there's lots of good reasons to tackle poverty or housing, right? But so—but if you're just talking about health stuff, you know, like there is a social gradient on obesity, for example; it's probably not as steep as people think it is. So if you solve poverty, you wouldn't solve obesity. That's one way to put it.
[07:50]So even in the most affluent areas, sort of all the least deprived communities, you've got an average rate of about 22%. So one in five adults living with obesity. That's still pretty high, right? And those are the people—the areas that have sort of the best off. That jumps up to about 36% in the sort of most deprived areas. And so, yeah, that is, you know, roughly—roughly 50% more. So it—it is—it is definitely exacerbated by these things. These things are—are not helpful for it; they're actively harmful. But by solving them, you don't solve the issue.
[08:20] Ravi Gurumurthy:But to—just to push you on that one, um, does it have the same consequence for poor health? Because if you are—if you're living on a low income, you might have all sorts of other issues: you might have worse air pollution, you—you may be suffering from gross stress, and the—you know, the cumulative impact may be—maybe—maybe worse.
[08:39] Hugo Harper:Yeah. It's—so the—you want to have fewer people living with comorbidities, multiple issues. Um, and when you look at sort of some of the ambitions, you know, half uh the disparity in healthy life expectancy, uh re—the regional disparity in this, huge differences in terms of the years of healthy life lived um across different communities. You get a lot of people with lots of issues that means their quality of life, their like years of health, are bad.
[09:05]Um, and so the—the number one thing that cuts across is obesity as a risk factor. And so you can kind of come at it either way. You could say, "Oh, well, if you remove obesity, they'll still have all these other issues, so what's even the point?" Or you can say, well, actually, a lot of these things are bidirectional, right? If you've got musculoskeletal disorders, that is not helped by being an absolute heavier weight, you know? And it's not clear if you've got a dodgy knee whether you can't do enough exercise and that's why you put on weight, or you put on weight so you don't do as much exercise. That relationship is poorly understood.
[09:41]The—but the idea that you should—I think it sometimes comes down to like, you shouldn't do anything unless you can solve everything, which we just really disagree with, you know? If you can make these improvements, even if they're incremental—like if somebody loses, you know, 3, 4, 5 kilos, their life isn't transformationally different, maybe, but marginal improvements, and at a population level you reduce the incidence of things like diabetes, heart disease, certain cancers. So it's not just—I think sometimes—sometimes people mistake sort of obesity as this like, well, people can just live with it and it's sort of their choice, it's not, you know, really an issue. It has strong links to sort of more like proper diseases that people might think, diabetes being like the big one, musculoskeletal being another huge one.
[10:26] Ravi Gurumurthy:Okay.
[10:26] Hugo Harper:Um, and so then if you link that to like work, big two things for people being off work: mental health issues and musculoskeletal issues. Those are the big ones. Um, musculoskeletal is very clear line of impact around obesity. Um, mental health, again, bidirectional relationship, a little tricky to work out. You know, there's certainly a lot of like emotional eating that occurs. Um, but the—yeah, it—it's—that's less well understood.
[10:50]The other thing that—that £126 billion number, that's not the only thing out there on this. There was a recent report by the OECD looking at sort of the potential benefits, and they look—they found that over 60% of the total benefits that you could get from prevention, as in like any of the risk—risk factors, 61% was purely attributable to obesity in the UK as like the thing to focus on. And that's because we've done a pretty good job on smoking already. You know, in other European countries higher smoking rates, that's what they should probably focus on. For us, we need to do what we did for smoking with obesity: need to half the rates in a decade.
[11:26] Ravi Gurumurthy:Okay, let's come back to obesity in a bit more detail, but can we just maybe go through all the other areas first? So, smoking, um, to some degree, huge effect already, and the Tobacco and Vapes Bill is a great step in that direction, but there's huge amounts of people who are already smoking. Uh, and how do we actually increase take-up of smoking cessation services? Is that not still a kind of gap that we're not necessarily filling?
[11:50] Hugo Harper:Yeah, so it's—there's—there's still gaps. The smoking is an interesting area, particularly with the vaping side of things. So vaping is much, much better for you than smoking, but it is much better to not vape than to vape. And so you've got this balance where, for people who are currently smoking, you want to make vaping as easy, accessible, cheap as possible. But you really don't want kids starting it instead.
[12:09]And so there's lots of interesting stuff being positioned in the recent consultation on this about how do you get that balance right. So, you know, removing things like bright colors and fruity flavors that probably overly appeal to children. Um, and on that, the service provision—yes, stopping smoking services uh are still really important. They actually tend to work a lot better if they're done with e-cigarettes—some really good RCT evidence on this; they found about—they're about twice as effective.
[12:38]I'm not sure what the exact sort of usage rate is at the moment, but one of the key problems there is you don't have an e-cigarette or a vape that's on prescription yet. So there's this mistrust within the medical community, whereas like you do have uh like um nicotine patches on prescription, this stuff that is like less effective as a quitting mechanism has been sort of institutionalized and it's been—been medicalized. It feels safe, so people can sort of feel like they want to go down that—like that route, which is probably at the detriment to the actual efficacy of the interventions.
[13:09]Sort of behavioral support programs versus nicotine replacement versus e-cigarettes/vapes—the latter are much, much more effective because they're a closer substitute, yeah, in conjunction with the behavioral support. So you—you give people the coaching; you don't just say like, "Here's a vape, on you go." Um, but if the comparison is behavioral support with nicotine patches or behavioral support with e-cigarettes, the e-cigarettes ones are likely to be a lot better. Um, that's poorly understood in even in the medical community. Lots of people think that vapes are just as bad as cigarettes for your health, and to the best evidence available at the moment, that is not true.
[13:40] Ravi Gurumurthy:So, okay. If—if—if someone said, "Right, we really want to finish the job on smoking and not just phase it out for the next generation, but get people off it now more aggressively," um, what would you do? You'd pres—you'd create a prescription e-cigarette to kind of build trust amongst the medical community in particular—that's a safe thing to do—but also maybe consumers. But you've also got to reach people; you've got to actually persuade people, haven't you?
[14:05] Hugo Harper:Yeah. It's—so, well, sort of like most smokers have tried to quit at some point. So, you know, there is a desire there. So it's a bit about making it easier for people. Um, and how much you—that on—on the two sides of like convincing people it's safe, you know, if you're—if you stop calling them like "ex—extreme toxic death black ice" flavor, then maybe people will stop thinking it's total poison. Um, and so that—like there's—you're coming at it from both sides: you want to make it sort of easily more accessible to the medical community; you want to make it sort of less appealing to people.
[14:37]We've sort of had that initial phase of early adoption, right? Like, people know what vaping—the problem isn't that people don't know about e-cigarettes now; everybody knows about it. Um, so then it's, what's the right balance of availability, accessibility, price points? And that's one of the interesting things about the disposable uh vape ban, which hasn't really worked because they've just stuck USB chargers on all the vapes. Um, but in theory, it's a good idea, right? So you want a pack of cigarettes costs quite a lot of money; disposable vape much cheaper. And so if you're a kid with not loads of money, maybe it's easier to buy the disposable vape. Idea of banning these disposable ones was to sort of stop that, get people onto the more like refillable ones. They have a higher initial price point, less likely that you just sort of go in when you're buying your chocolate bar to buy it. That hasn't really worked. The idea is good, right? You want to like balance that point of accessibility: you want it to be cheaper than cigarettes, but not like as cheap as some snacks, um, to look at like who is getting it.
[15:33]And then there's—there's been some also interesting outreach programs on this as well, actually. We—I was involved a long time ago in an initial pilot in Salford where we sort of gave vouchers for e-cigarettes to people who are smoking who are living in social housing in the area, so, you know, just giving that first step because the initial barrier, you know, spending 30 quid on a tank thing, that's quite a lot of money.
[15:53] Ravi Gurumurthy:I guess nobody right now is in charge, though, and held to account for massively increasing take-up of smoking cessation services and getting people switched from um smoking to—to—to something else. Are they—does...
[16:06] Hugo Harper:Yeah, I mean, if anything, I—as far as I'm aware, budgets for stop smoking services have probably actually been in decline. And I think this is—this is a really easy error to make when looking at policy: you look at a trend over time, and you think it's driving itself. So there's this great graph of smoking policy where you just see smoking rates declining over—and to be clear, smoking has halved in the UK over the last 15 years, so we've done a really great job. Um, and there's one version of it which is unannotated—it's just a line going down. You're like, "Great! People just don't like smoking anymore. We'll just leave it; it'll just continue going on as it is."
[16:39]There's a different version of it which is fully annotated with all of the different policy interventions that have happened: all of the like rate increases on it, all of the restrictions, all the advertising thing, all that stuff. And then it makes it much clearer like, "Oh, this has declined because of the action that we're taking, and so if we stop taking action, the decline will probably stop." That's the right way to think about it. Um, so it's not like rolling down a hill; it's more like sort of you're propelling yourself against resistance.
[17:05] Ravi Gurumurthy:Can I take you to alcohol? We'll come back to mental health in a second because it's, as you said, the etiology of—of mental health is—is harder. But on alcohol, both we've got some potential trend towards lower alcohol consumption for younger generations, you've also had some interesting policy interventions in terms of uh trying to incentivize reformulation through tax bands. Can you just say a little bit about what's happened that's worked so far, but also what—what more could be done to continue that process?
[17:34] Hugo Harper:Yeah, the—the tax stuff is kind of amazing if you're into this sort of thing. Um, so uh initially it sounds really bad: "We're going to have lower taxes for higher strength beer than we did before." That sounds like a bad thing, right? Um, but actually it was really clever. So originally the tax band uh for sort of lower strength alcohol ran from I think 1.2 to 2.8% ABV for beers. Um, and they were suggesting let's actually increase that rate from up from 2.8% to 3.5%.
[18:05]And why would you do that, right? Well, it's because most beer that's sold is about at 4% mark. So the idea that you could incentivize industry with a slightly lower tax rate to cut the amount of alcohol in the top-selling beers, if you can get, you know, if you can get the things that people actually drink from a 4% to 3.5%, that's actually massive in terms of absolute alcohol consumption in the country. Whereas people who are sort of already picking something that's advertised as low/no beer, they're probably not the people who need to cut down on the drinking the most, or when I say "need to," would benefit the most in terms of health.
[18:36]Um, and so this has been really successful, right? You've seen massive reductions in ABV—actually, and when I say massive, small percentage reductions, but that apply to huge volumes of sales. Um, and it's totally in the background. People don't really realize it's happening, and it's been sort of gradual over time. And, you know, unless you're specifically looking to go out drinking for a certain outcome, you probably don't care if your beer is 4.5% or 3.5%, and that might not be what you're optimizing for.
[19:07] Ravi Gurumurthy:Yeah. Is there more mileage in that direction for other spirits? It's harder, isn't it? Beer is easier than wine.
[19:14] Hugo Harper:Beer—beer is easier than wine, and same with spirits. And the reason for that is beer is somewhat self-limiting in terms of the volume. So if beer is weaker, you probably don't drink another three pints of it because you're full of beer at a certain point. It takes time to drink. Shots are obviously the opposite, right? Like if uh all vodka was 20%, could people just double the measures of it? Maybe. Maybe it worked for a little while. Um, so it's—it's not quite as clear what you do in the those things, but there's been a big rise of package—wine, though, is a bit akin to—to—to beer in the sense that you don't necessarily open a second bottle of wine.
[19:50]Um, yeah. Yeah, and there's—there's been some interesting work on like default serving sizes with wine. So the default serving size for wine in the UK sort of crept up over time. Like now most pl—now sort of a small is 125 mil, most places medium 175, large is 250. Some places will just sort of serve you a large anyway. Um, the—and so can you sort of bring that back down to what sort of a normal portion size is from this? Um, I forget the exact reference. I think it was—it was either from Bristol or Cambridge did some research on this previously where they went into a pub and changed the default uh glass setting.
[20:23] Ravi Gurumurthy:Can—can policy do anything on that? Isn't that just a—a business practice? How can you actually shift defaults?
[20:28] Hugo Harper:Yeah, it's—it's tricky. Like, you know, you're not—you're not about to change the size of a bottle of wine. Well, you know, may—maybe it would happen over time. Like the—so pints, you know, a pint if you're sort of proper imperial pint, 568 milliliters; most places you'll get it's 500 milliliters now. So, you know, sort of imperial/metric things. So it's not—not impossible.
[20:48] Ravi Gurumurthy:Beer shrinkflation.
[20:54] Hugo Harper:Yeah, like—well, yeah. Like, um, but did you know—should we have maximized it? You know, when—when the sort of original pint was made, beer was much weaker than it is now, so, you know, you could argue it's sort of correcting itself a little bit. Um, you know, liquor is sold in 70 cent—so 700 mil rather than 750 generally. Like, I'm—to—to be clear, like, I'm not advocating for that as a mechanism on what—on like wine.
[21:18]You—you could—the other—the bit on alcohol is you want to look at where the harmful thing is. So the—an amazingly well-evidenced policy that we are still for some reason not doing, despite our closest neighbors having done it for ages, is minimum unit pricing.
[21:30] Ravi Gurumurthy:Mhm.
[21:31] Hugo Harper:Um, ask anyone in public health, it's a slam dunk.
[21:33] Ravi Gurumurthy:Mhm.
[21:35] Hugo Harper:And the thing is, and people just misunderstand the policy because they're like, "It'll put up the price of my pint." No, it won't. Uh, it applies a minimum price to the units that can be sold anywhere, and your pint is already a lot more expensive than that minimum price. And so what it would do is it would change like—it would—it's the White Lightning, isn't it?
[21:52] Ravi Gurumurthy:Yeah. I mean, that doesn't even really exist anymore. You know, that's like that—you know, my age uni um days. Uh, but the...
[22:01] Hugo Harper:...like the—you know, but that—that sort of same sort of thing, you know, stronger ciders, um, uh, sort of like off-brand spirits, those sorts of things. Things that tend to be associated with problem drinking, increases the price—price of those things. Um, and that's been successful in Scotland. And I don't—I—I think the reason we don't do it in England is like a policy comms issue, 'cause it just—people just think you're putting up the price of alcohol generally rather than...
[22:28] Ravi Gurumurthy:Yeah, you do. And there's maybe a different line to that which is like: how do you stem the decline of pubs? Well, maybe you change the relative pricing, right? At the moment, it's much cheaper to buy your vodka in a supermarket if you're just looking to get really drunk. And I'm not saying that's why everyone would go to a pub, right? But like the price disparity between what you get in a supermarket and what you get in a pub is large now for the most part. Um, and so that—like if you can rebalance that, maybe it's a different way of shifting that to say, "Look, we're trying to push people more back into more social environments, you know, more public environments, trying to sort of uh reignite the high street, you know, nightlife." So you would rebalance alcohol duties between out of home and—and pubs.
[23:11] Hugo Harper:Yeah, there are lots of things that kind of go into the pricing. And I, you know, I'm no expert on sort of small business rates or anything like that, but broadly like the idea that you can get very strong alcohol that people can drink like alone in their home is probably not a great thing. All things being equal, you'd probably prefer those people to be drinking in a social situation where there's some kind of monitoring and there's some sort of like...
[23:32] Ravi Gurumurthy:Although peer effects presumably also get you to drink a lot more.
[23:38] Hugo Harper:Uh, it probably depends where you're hanging out. I don't know what pubs you go to, but the um—uh, you know, and the football, maybe. Um, yeah, so that's—you that like drinking culture, but even, you know, sports events, Australia's done some really interesting things. Like, if you try and get uh drunk at the rugby in Australia, you're going to struggle.
[23:53]Um, so uh I was in when I was working at BIT in Sydney uh for a bit, um, you'd go and they have a—I think this—I'm not sure if this exactly still the case, but like directionally this is right—um, you can get cans, but the little cans are 330 mls, and you get maximum four a person, and they're maximum 3.5% strength. That's very different from what I think—I'm pretty sure it's eight pints a person uh and 5% beer at like, you know, in England. Um, so those sorts of like if there's particular events where you tend to get like policing issues or those sorts of things, there are some other like more specific interventions that you could borrow from.
[24:31] Ravi Gurumurthy:Yeah. Okay. So, let's turn to—to—to mental health. Um, as you said, this is a bigger problem than it was potentially, um, but it's also a bit less tractable. Give us a sense of what we'd actually do, where's most promising.
[24:43] Hugo Harper:Yeah, it's really hard. I mean, the biggest gap at the moment is provision of services for adolescent mental health. So child adolescent mental health services, often known as CAMHS, the waiting lists are really, really, really, really long. Um, and that's problematic for a couple of reasons. One, if you're experiencing a mental health crisis, you need help soon, otherwise things can get worse. And in terms of like what we do know about the etiology of mental health issues, it tends to develop in adolescence; that tends to be when people have their first issues. And so almost the—like our treatment services are worst where they should be best. You know, that's if you were—so, you know, everyone always asks for more money for stuff, and that's hard and there aren't enough people, but, you know, it's probably some reportioning of like in more preventative areas, which is tricky because, you know, you might say, "Well, you need to give the resources to the most serious, most extreme cases," which might have taken some years to develop, but that might mean you're not helping prevent the cases that are sort of emerging now.
[25:42] Ravi Gurumurthy:Um, I mean, this government sort of talked about prevention support within schools. I'm—I'm not sure the evidence is that strong on that, is it?
[25:49] Hugo Harper:Um, depends if you're, you know, what you're pointing people to. So, a lot of this idea of like predictive prevention or, you know, finding, you know, who really needs the help, well, if you don't have the services to like work out the increased demand that you're generating, that can almost be worse, right? "Hey, you weren't sure if you had an issue before; now I'm telling you, you've got an issue. You should find help. See you in six months." You know, that that—that's uh the—the intention's really good, but [clears throat] you need to sort of line it all up.
[26:18] Ravi Gurumurthy:Okay.
[26:19] Hugo Harper:Um, otherwise you can be sort of increasing your demand, not increasing your supply. It's already overwhelming, and then, you know, you might be see—and you are, and on mental health, like, we are seeing increases at the more extreme end of the spectrum. You know, some people, like, "Young people are snowflakes, etc., etc." But, you know, on the like hard measures, like rates of like self-harm, suicide, those things, you know, it's—it's not just a sort of intergenerational difference between what like "okay" means to people.
[26:45] Ravi Gurumurthy:Mental health has come into particular sharp focus I think recently for two reasons: one is the—the number of young people not in education, employment, training (NEETs), or people just not in work who are claiming disability benefits because of mental health—that's risen significantly; and the other is the sort of debate about social media and—and young people and—and mental health. Um, let's leave social media for now, because I think that's a whole other issue. But on the kind of—particularly on NEETs and—and economic inactivity, what's the sort of—is there good evidence actually about what—what works in that space on—on—on mental health?
[27:19] Hugo Harper:Yeah. So there's some really promising stuff around like better packaging mental health support and job-seeking support, and sort of really good evidence that if people—like, work is good for mental health. Now, there's obviously a caveat to that, right, which is good work is good for mental health; like, bad work is bad for mental health. You know, if you're stuck in a job where your boss is like abusive to you, that's obviously not a good thing. Um, and so there—this is outside of my area now, and, you know, there's—there's some people raise questions about, well, what's the supply of jobs? You know, is AI decimating entry-level jobs for young people? Does that mean there's sort of an—there's not the good work to sort of get people into?
[27:56]Um, and so some people also argue that people aren't ready for work now because they're too anxious, and so it's not my job as an employer to get somebody to be okay speaking to people in real life. Um, and so that—that's a—I think that it's clear where that the ambition—where the ambition should be, right? That like even if you just care about human suffering and you don't care about economics at all, you probably want people in work.
[28:19] Ravi Gurumurthy:Yeah.
[28:20] Hugo Harper:Um, and so that's sort of a nice like, you know, sort of join-up where we should be able to agree. I think that problems lie in the dosage of it, you know? What support's available, and how can you set up systems so that people don't need the support in the first place?
[28:31] Ravi Gurumurthy:Okay. [snorts] Let's move on to sort of physical activity. Um, because in—some people think physical activity is very important for tackling obesity. Um, I think you're less confident on that for various reasons, which we can get into, but physical activity in its own right is still really, really important and incredibly uh strong protective factor for—for people's health. It's just quite hard, isn't it, to shift that habit, particularly amongst those who really need it?
[28:57] Hugo Harper:Yeah. The phys—I mean, physical activity is great, like, don't get me wrong. Uh, it's got really interesting dosage effects, right? If you go from completely sedentary to walking a bit, you see big improvements in health, right? If you go from running 10k a week to 15k a week, me—doesn't, you know, it doesn't do so much. Um, and the issue particularly for weight is a couple of things: one, you don't burn that much energy doing exercise generally, like as—as much as—as much as you think; and then the problem is, anyone who's sort of put it onto calories on a treadmill when they're running in a gym can attest to this, like, it doesn't go up very quickly.
[29:34]Um, and then the problem is, particularly if you've done exercise of that nature, um, it's very effortful. You know, you've done it, and you maybe get some compensation effects. These can be psychological or physiological, right? So people either think like, "Ah, I was good. I'll go to—I went to the gym; I can have some dessert." Uh, or sort of less consciously, they are fatigued from that exercise and so they sort of move around less for the rest of the day. It's called non-exercise activity thermogenesis (NEAT). Um, and uh this is the idea that you get this sort of compensatory effect.
[30:05]And so when you look at this, like, broadly—broadly, the calories that people like would burn off in exercise, the weight loss that you see is something like half that. So the absolute number of calories you burn off initially isn't that big, and then the actual impact is about half of what you get for these compensatory measures. Um, and so it's really tricky because people are like putting in their effort into this thing, and it's, you know, it's not this bad thing, but if—if weight loss is the goal, it's perhaps not the easiest way.
[30:31]And then, you know, how do you—how do you increase it? A lot of the policies that are really effective in this kind of area can be quite expensive. You know, like cycle lanes are great, but they're quite expensive. They take—take a long time to build, and so it's not that those things shouldn't be pursued, but if you want sort of a change in national weight and you want it quickly, the—the rule of thumb that I use that is like broadly—broadly accepted by people if you push them to be specific would be like 80/20: so 80% energy uh energy in, 20% energy out.
[31:01]Um, now, of course, there's nuances to this, right? Like, physical activity is great, is important for mental health; physical activity is important to stop muscle wasting in elderly people, balance, preventing falls, all that sort of stuff.
[31:12] Ravi Gurumurthy:It'll be increasingly important with GLP-1 use as well, shouldn't we?
[31:18] Hugo Harper:Yeah, hugely. So, with the GLP-1 use, you get lots of weight loss. A lot of that weight loss comes from muscle loss. Um, and so you want to reduce that. And the greater your resistance activity, your exercise, you know, the stuff you do whilst you're in a large calorie deficit, the less muscle mass you use—you lose. Like, there's lots of um—there's interestingly lots of research on this in like strength and conditioning research. So like bodybuilding, like track and field athletics, like strength coaches for like American football, uh, where they want people to be like as lean as possible and as strong as possible. So they want like very low fat and very high muscle. And so, uh...
[31:49] Ravi Gurumurthy:Sounds exhausting.
[31:53] Hugo Harper:It's—yeah. And it's—but it's interesting when you like uh when you see very different like groups of people coming to the same recommendations. You like bodybuilders and like public health folk both being like, "Actually, this is sort of, you know, this is the—this is the way to go here." Um, it gives you greater confidence.
[32:16]Um, so um let me talk a bit now about—we've circled around obesity; I want to come back to it now. Um, let's start with actually GLP-1s because um I don't know what the penetration of GLP-1s is right now, but it could easily end up being pretty huge. What proportion of the 30% of people who are obese in this country do you think will end up having GLP-1s in 5-10 years, and—and—and what—what do you think is desirable?
[32:48] Hugo Harper:Yeah, it's a great question, and the—the big thing here is cost from public perspective. So at the moment they cost a lot, you know? It's thousands of pounds a year, uh, and lots of people don't have thousands of pounds a year. So when you look at the penetration rate for PE—and when particularly when you um account for people living with obesity across deprivation, Health Foundation have some lovely research on this, um, that you see much higher uptake in more affluent communities. Unsurprising.
[33:14]And, you know, with how easy it is for the private—on the private side of things to like claim you have, you know, sleep apnea or a higher BMI, like gut feel, a lot of those people aren't really on the clinical high need area. I know lots of people, you know, like you could—people will—people you probably know people who are on these drugs, uh, and whether that's conferring a huge public health benefit, you know... But to—to go back to the sort of specific point, like, some—by some research states that like maybe up to 9% of households might have someone on this drug at the moment. Um, but if you say people living with obesity is about 30% of people, so about one in three people, um, what would be—what would be a—a good case for this?
[33:57]Well, it depends a little on who's paying for it. So, you know, if people are funding these things privately and they've got plenty of money to do it, you can kind of see this going away in 10 years time—and this being like obesity. You can imagine the case that, you know, in high-income groups you basically do not see people living with obesity. Um, you know, if the drugs come down a bit in price and it's people—you know, it's already manageable in the budget if it becomes sort of like socially unacceptable now because you can kind of buy your way out of it, um, those things, you know, it's sort of like fancy teeth in America, um, or like wrinkles now don't really exist.
[34:34]Um, and so, you know, that maybe goes away. But several thousand pounds a year is still a lot of money for a lot of people.
[34:38] Ravi Gurumurthy:Well, it's a lot of money in general, but particularly...
[34:41] Hugo Harper:And so then the—the problem is you might get this massive social gradient, but you basically eliminate obesity in affluent communities and you see it sticking pretty much the same. Because the—from, you know, our research on the area, it's like 5 years, the price are not going to drop big time. Mhm. Like, when the p—15 years, probably quite a lot cheaper, you know, really difference there.
[35:01] Ravi Gurumurthy:And by "quite a lot," are you talk—talking about half the price, a quarter of the price?
[35:03] Hugo Harper:A quarter of the price, you know, meaningfully a lot cheaper. Um, there's some stuff that's saying like places in India are producing some generic versions for like 50 bucks a month, you know? That sort of like—it's not—it's not nothing, but it's sort of like—it's maybe like more like a bill, you know? Like, it's sort of like fancy phone contracts are about that. Um, so you can imagine people sort of going for it.
[35:26]The amount of people we can imagine being on it is—it also depends on when you mean. So right now you probably want more people on it than you want longer term. And that's because at the moment the food environment isn't conducive to weight loss. So we have lots of people who are living with this problem. So, you know, anybody living with sort of severe obesity, if you've got a BMI over sort of 40, over 35, it's probably a good thing if you have access to these drugs.
[35:52]And now the—this isn't just like my take on it. The NICE guidance originally recommended the access to these drugs on the NHS for about 3.6 million people. The current provision, uh, the sort of scaled provision of it, is for about 1.2, I think. But the problem is that 1.2 would occur—occur over 12 years.
[36:11] Ravi Gurumurthy:Yeah.
[36:12] Hugo Harper:And so in the next couple of years you're more getting like a couple hundred thousand people on it. That's nowhere near enough.
[36:17] Ravi Gurumurthy:Yeah, right. So just—let's just stop on that because that's massive. If—if—if NICE are saying 3.6 million should get it, and we're only going to get 200,000 people on it in the next year, what would we need to do to—it is cost effective and healthy, presumably, to get to that 3.6 million. How would we get to that, close to that target?
[36:34] Hugo Harper:So there's something about how can you deliver these things safely? And here you got this really interesting distinction between the private and the sort of NHS supply. A lot of the private uh market is essentially like, "Here are your drugs, off you go, check in in 3 months." Uh, whereas the wraparound care that's available on one of the NHS provision is like a high number of clinical appointments. Uh, I—I forget, I think some of the pathways is something like 20, you know, like a lot of clinician time. And that has cost, but it also has time constraints. And so maybe there aren't enough clinicians to be doing that, and then if there aren't enough clinicians you need to wait to train more clinicians, and that is not just a cost thing, it's a time thing.
[37:09]And so one of the things would be, as you scale the drugs to people with lower clinical need—so at the moment the people getting it on the NHS, probably sort of BMI of over 43, comorbidities, so people who are not well—um, it's plausible that it is appropriate to give a high amount of wraparound care to those people, you know? Um, as you sort of move down the intensity gradient, plausible that you draw out some of that wraparound care. The wraparound care is a substantial amount of the costs, and it can be a substantial amount of the operational constraints as well.
[37:41]So what's the sweet spot in terms of the delivery? It's probably not, "Here the drugs, off you go." Um, but it might not be, you know, very, very regular checkups on this. The interesting meta-analysis uh from Susan Jebb's group at Oxford found that whilst more behavioral support with the drugs improved outcomes a bit, effects weren't massive, you know? The drugs are doing the heavy lifting, and once you removed the—once people came off the thing, they all put the weight back on anyway.
[38:05] Ravi Gurumurthy:Yeah.
[38:05] Hugo Harper:And so that's the other problem, right? People don't want to sign up to a bill that's endless.
[38:09] Ravi Gurumurthy:Yeah.
[38:12] Hugo Harper:Um, and here's where—here's where we can sort of wrap—wrap it. Like, you don't want to have a situation where you're paying thousands of pounds a year for 30% of the population on these drugs. Um, but, you know, maybe at the moment we think 5—5% of the population, 10%, something like that, it would be helpful for them to be on these drugs. Maybe the long-term 3% of the population, something like that, you know, people with real genuine genetic predisposition to sort of excess weight. How can you help these people?
[38:39]Um, the idea, you know, that what we would posit is: you get your short-term benefit from the drugs now, you line up all your prevention policies, you enact them, and so you have all the benefits of your prevention policies hitting after, say, like 3 to 5 years, and then you can dampen down your drug costs.
[38:52] Ravi Gurumurthy:Yeah, okay. But if we—if—if someone said to you right now, "How do we get 3.6 million people that NICE suggest should be having this drug to have this drug in the next 5 years?" um, you'd basically have to hire quite a lot more people, put a lot more money into this, but it'd have to be a real sort of mission for the NHS, wouldn't it?
[39:14] Hugo Harper:Yeah, exactly. And the—there's always opportunity cost to that sort of stuff, right? You know, I think the reason this is particularly interesting...
[39:19] Ravi Gurumurthy:Or would you say it's r—a rational thing to do that, to distort the system to focus on that group, or are there more high priority health needs that should be focused on?
[39:29] Hugo Harper:Why we think it might be a rational priority is because it could be a short-term priority, which is not the case for a lot of treatment stuff. You know, uh the, you know, if you just have people on diabetes medication, they tend to be just on that for life. Um, here, the idea would be you, if you line up a sufficient activity on prevention policy, then you're focusing on this to get sort of a shock into the system to massively reduce the rates of obesity, and then you can sustain that with the prevention policy in a much lower dosage of the drugs.
[40:00] Ravi Gurumurthy:Okay. So on the prevention policy, what is the kind of high-dose version of this?
[40:04] Hugo Harper:Yeah, so everyone talks about prevention policy and then what actually ends up happening is like, "Here are some leaflets," or "Here's a bit of information." Um, which is just not sufficient, right? Um, the—what you actually need to do that, the sort of the three main learnings: we did this big thing called—we call the blueprint for halving obesity, reviewed thousands of papers, talked to a bunch of eminent academics in the UK to work out like, what—what's actually the cost, the benefit, and strength evidence of about 30 obesity policies?
[40:32]And the—the sort of the thing that came—comes out really, really, really clearly is:

1. You need meaningful incentives to change the behavior of the food industry to make food healthier for people.
   
2. You need to upscale treatment for the people who need it.
   
3. Education and information is totally insufficient to the scale of the problem at the moment.
   

They're not bad things to do, but they're not going to solve it.
[41:00]And so, what is that incentive that we're providing to the food industry? Because voluntary action hasn't worked; we've been trying voluntary action for a long, long time. And it's interesting because if you talk to the food industry people, they'll say sometimes, "We support regulation. You know, we think what we want is a level playing field." And that's exactly what we're trying to do, but a level playing field that brings health into the value equation for them.
[41:21] Ravi Gurumurthy:Okay. Do you want to set out just two options then? Because basically you only need to regulate, you need to tax. Set out the regulation option, and also let's talk tax with you as well.
[41:27] Hugo Harper:Yep. Uh, so the regulation option comes back to the scale of the problem. So, massive problem nationally, but individually could be quite a small change in calories. And so that's why regulation's—the other reason regulation's appealing is because a small number of businesses, about 11 large retailers, contribute the vast majority of what people eat. So it's sort of tractable; you can get—you can kind of get your hands around it.
[41:48]Um, and so here you could—the problem at the moment is, in our view, that regulation has focused on changing sort of practice, banning things. It's not—not a bad start, right? But what we've seen for like the end-of-aisle restrictions, you know, no chocolate bars at the checkout or at the end of the aisle—um, not just chocolate bars, sort of uh HFSS food, sort of junk food if you like—um, is that you just come up with alternative ways to get people's attention, right? You have spotlights in the middle of the aisle, you have these shelf wobblers come out, you can still put things on sort of price discounts.
[42:21]And so it's like the—and then the policy, you know, takes years to come in, is only updated every so often, and businesses have changed their practice in a month. Yeah, and so it's this cat-and-mouse game, but you're a really slow cat and it's a really quick mouse, maybe. Um, and so—and also businesses hate it because you—you're really micromanaging them. You know, you're like, "You—this product can't be within X feet of the entrance of this size store," and, you know, all of this sort of stuff.
[42:48]And so what we're—what we've been trying to push for is outcome-based regulation: say, "Look, you guys know how to sell stuff to people. That's your whole bit. You know how to make food. That's your whole bit. Um, just make it healthier." And being really specifically, healthier, right? We're not saying no crisps anymore, it's only carrots. We're saying like if you could switch to like if someone has a pack of Wotsits instead of a pack of Walkers, that's probably for the best.
[43:15]And so this is—this is really key: we're looking to incentivize regulation that's outcomes-based, that isn't too prescriptive, that gets to the changes that we want in a way that's good for people (their diets still look similarish to what they do now, they still have the joy of food) and works for business, you know? It's not sort of really hardline; it's changing people's tastes over a period of time. I've seen some improvements on this in salt, for example.
[43:35] Ravi Gurumurthy:Yeah. So, precisely what would you do if, you know, what exactly would you do when?
[43:39] Hugo Harper:Uh, so I—I am Andy Burnham uh and uh f—maybe not the first day at the first day in office, but certainly in the first sort of 10 days, first 100 days, you're looking at this uh regulation on s—on supermarkets. You're looking at implementing the Healthy Food Standard. This is already government sort of stated policy; they're saying they want to do this. It's part of the 10-year plan, so it shouldn't be controversial. Um, it was as of today, actually, from when we're recording this, uh, the like primary recommendation from the Health Select Committee coming out on on uh on weight.
[44:09]Uh, the—what this means is you would set an a target, an absolute target for the average health of what is sold in uh m—in large food businesses, and f—moving first on retailers or big supermarkets, and you say, "If you—you need to hit this, and if you uh don't, there'll be some—something bad will happen; there'll be a big, big fine." Could look at positive incentives as well: "If you do, maybe something really good, good will happen." But you need to change incentives in a way that matters for these massive businesses.
[44:35]Um, and the—the the sort of nerdy first step to this is you need to have the data to be able to make this regulation. If you want to know the average health of what people sell, you need to know how much stuff they sell and what the average health of that—and what the health of that stuff is. And that requires mandatory reporting. That's another aspect of it. That is data that many of these businesses already have. You know, some of these businesses publish their sales-weighted average Nutrient Profile Model score, which is like the score that underpins it, already online.
[45:02] Ravi Gurumurthy:Yeah.
[45:02] Hugo Harper:And so this is—this is doable, but you need to go—you need to step forward on that, so that you could plausibly do by next year.
[45:06] Ravi Gurumurthy:Okay. One other option, of course: there will be a fiscal event, probably there'll be a budget in the autumn. You could also go for a tax.
[45:10] Hugo Harper:Yeah, tax it. Um, it would work, right? Like, and it's not a new idea. So, uh, well, one, sugar tax—incredibly successful, but applied to a very small amount of uh what we eat. So soft drinks now have a lot less sugar in than they used to, but we don't consume that many soft drinks. Uh, also the salt and sugar tax as in the National Food Strategy that Henry Dimbleby did. Those things uh—they're effective; they have—and we've got a—we've got our own version, sort of a slightly more nuanced version on this NPM.
[45:43]The idea here would be you would only have a tax on unhealthy food. So anything that falls into the healthy category, totally the same as it is now. And the more unhealthy food is, the higher rate of tax would be.
[45:54] Ravi Gurumurthy:Okay, right.
[45:54] Hugo Harper:Uh, so if something's just on the wrong side, like it's a cereal bar with a little bit of chocolate in, uh, then maybe that's get—that's a little bit more expensive. If something's like, you know, chorizo or like uh um Lindt chocolate balls, that's probably quite a bit more expensive.
[46:06] Ravi Gurumurthy:Yeah, okay.
[46:10] Hugo Harper:We think that's also a plausible route here. Our modeling suggests that it would have a 1% increase in food prices, which isn't super palatable, right? 1% actually isn't that much. Um, uh, and could have like a roughly comparable, so 20% reduction in obesity.
[46:24] Ravi Gurumurthy:Okay. So you can get it either way: you can regulate, or—or you can tax. There are two ways that you could get a roughly 20% reduction in obesity, and you need a roughly 20% reduction in obesity or something comparable to that if you want to make a dent on this national health crisis.
[46:35]Yeah, okay. So you're Andy Burnham, first 100 days: what are the three things you're going to get done?
[46:40] Hugo Harper:Uh, so, firstly, I'd progress on the Healthy Food Standard—so this regulation of uh retail supermarkets to sort out obesity, get data reporting uh in.
[46:54]Second thing I'd do is try to come up with a plan to massively upscale the provision of GLP-1s on the NHS so the people living in high deprivation, people who can't afford the private supply, aren't left behind.
[47:05]Thirdly, I'd really get cracking on sort of finalizing the job on smoking. We've made great progress; the consultation's out on the Tobacco and Vapes Bill at the moment, and that could be a really nice early win. You want to reduce the amount of kids vaping, you want to increase the amount of people quitting smoking, and the very specific thing I'd prioritize is getting that prescription e-cigarette on so that—and increasing those stop smoking services for people.
[47:26] Ravi Gurumurthy:Hugo, thanks very much. That was great. We'll see what Andy does in the first 100 days.
[47:30] Hugo Harper:Very good. Thanks for having me.
[47:33] Ravi Gurumurthy:If you enjoyed this episode, please do like, share, and subscribe wherever you get your podcast. We've got more coming. For those of you who don't know us, Nesta is a research and innovation foundation based in the UK. We design, test, and scale solutions to the big challenges of our time. We're funded by a charity endowment and are politically neutral. For more, do visit www.nesta.org.uk.

[00:00] Hugo Harper:Are GLP-1 drugs cost effective? Yes. Are mental health services, talking therapies, cost effective? Yes. But they do cost money, and wouldn't it be better if the people weren't sick in the first place?
[00:13] Ravi Gurumurthy:One of the areas that's been less talked about in previewing Andy Burnham's tenure as Prime Minister is the issue of health, which is strange given he himself is a former Health Secretary. It's something he's taken very seriously in Manchester. Uh, he's focused on a prevention demonstrator because he thinks we need to actually get upstream in tackling health issues. And today we're going to be talking about prevention and what might a Burnham government do to really turbocharge prevention in the next couple of years. With me is Hugo Harper, who's the mission director of our Healthy Life Mission. Welcome, Hugo.
[00:43] Hugo Harper:Hello.
[00:43] Ravi Gurumurthy:Andy Burnham has historically talked a lot about how we need to shift from treatment to prevention. It's what every Health Secretary says at some point. Um, he's very interested in more holistic treatments, tackling the social determinants of ill health. He's—he's—he's pushed that in—in Greater Manchester. What I want to start with is: if you—if you think about all the most important causes of ill health, um, how could you sort of rank order them in terms of their importance to ill health, but also what are tractable? Because, frankly, if you've got really important things that are impossible to tackle, frankly, we should not be saying to them, "Prioritize it right now." But what are the areas which are uh important and tractable? So give us a portrait.
[01:26] Hugo Harper:So, yeah, great—great question and really helpfully, there's this wonderful database called the Global Burden of Disease, and that allows you to rank risk factors for all the different countries in the world, but it has it for the UK as well. The things that come up top probably aren't going to surprise you, you know, top sort of five things be smoking, obesity, air pollution, mental health, physical activity, alcohol—the things you hear about all the time. But the thing is, the absolute impact of each of those actually varies wildly, you know.
[01:52]So uh obesity—and obesity sort of includes dietary-related health because we have like a general overconsumption problem—um, that's much, much bigger than, say, physical activity or drugs or alcohol. So like the two—the two—the sort of three big ones are smoking, obesity, and mental health.
[02:10] Ravi Gurumurthy:Mhm.
[02:10] Hugo Harper:Now, that's really interesting then on tractability, because smoking is easy, or it should be easy, right? The ideal amount of smoking is no smoking. That's the stated ambition of everybody, and it's just a question of how quickly do we get there. Um, we have no qualms sort of hiking up the prices, making it harder and harder to do it in places, because we know—we know the harms. We know what to do. So that's—that's good, it's tractable, but we're—we're getting there.
[02:36]On the flip side, mental health—huge, burgeoning problem. Well, you know, it's been a problem for a long time, but it seems to be ever-increasing not just in the UK, but the rest of the world. Um, the problem is the exact causes of it are a little harder to understand, or rather what lever you could pull to dramatically improve mental health. Directionally, people probably know, but the exact relationship, how much it would change things, is—is a little tricky, which means sort of selling a policy on it is a little tricky because you're not sure what kind of return you're going to get for your investment.
[03:07] Ravi Gurumurthy:Mhm.
[03:07] Hugo Harper:With obesity, it's a bit more simple. And perhaps it's not actually more simple; it's just we've been studying it properly for longer, so we've got a better idea of what actually works. You know, the—the underlying physiology is pretty well understood. You know what leads to weight gain in terms of energy excess, um, the rate at which that occurs either with weight gain or weight loss—all of this—this stuff is like pretty well understood. There's like thousands of papers academically on obesity every year, and that's—that's a good thing and a bit of a challenge.
[03:37]Um, and everyone, you know, like you said at the beginning, everyone's been saying what you need to do about it for ages: prevention, you need to pre—you know, prevent this in the first place. If you look back 25 years, all the health policies are the same: "We need to do more prevention." No one's really done it.
[03:52]Um, so what we—in terms of obesity, the really interesting thing is that you could change it quite dramatically. So to—to put that in perspective for you, um, the obesity rate now in the UK is about 30%, so about one in three adults living with obesity. Um, that's about double what it was in the '90s. So this—this has been a pretty recent change, certainly recent in terms of any like genetics or stuff, you know. Um, it's not like everybody was just like chopping wood or tilling the fields in the '90s. Like, lifestyles broadly look pretty similar to what they do now. Um, but the national weight was much lower.
[04:29]And so that should give us a real reason to be hopeful about this. Like, halving obesity, getting back to that '90s level, the change would be about 220 calories a day. That, to put that in perspective, because there's no reason people would know what that actually means, that's about an 8% reduction, 8-12% um, is about the same as like a bottle of Coke, big—bigger bag of crisps. It—it's not a lot.
[04:54]And so this is why we're so interested in the area. Something that requires actually quite small changes on an individual level can have this massive effect at a population level. And we're relatively confident that if those calorie or energy changes occurred, that would be what you would get.
[05:08] Ravi Gurumurthy:So everyone always goes on about prevention being necessary, um, but just give us the sort of size of the prize, uh, because if we basically—if we don't get on top of prevention, NHS costs are going to go up and up and up with demographics. It becomes incredibly hard to pay for that. So there is a sort of hard-headed Treasury case for being pretty aggressive on prevention.
[05:28] Hugo Harper:Yeah. Even if you don't care at all about human suffering, you should care about this, right? So there's—there's sort of three main things that make up the value of prevention, uh, and that's the—the QUALYs (Quality-Adjusted Life Years), the human suffering that you're saving from it, the productivity gains that you get from it—so people being healthier, so being in work or in better work—uh, and the NHS costs or social care costs, the reduced cost that we have of giving people treatment or care.
[05:50]Um, and the numbers here are massive. So for obesity and excess weight, the total value is £126 billion per year. It's huge. Um, in terms of the amount: productivity, £31 billion; NHS costs, about £19 billion. You know, and so those—that, you know, if you eliminated that, those would be the savings. That's not, you know, potentially not immediately available, but you'd half it, right? Get about half of those savings: £10 billion savings in the NHS, £15 billion productivity. These are massive numbers.
[06:24]And the reason they're particularly massive numbers is primary prevention is cheap. The policy is cheap. You don't need an outlay of cash immediately to start going on this. And that's the thing that people miss on this left-shift idea. Yes, you do need to shift money towards uh prevention and prevention services, but the best version is primary where, um, you know, it's regulatory largely in nature.
[06:43] Ravi Gurumurthy:Yeah, exactly. Like, are GLP-1 drugs cost effective? Yes. Are mental health services, talking therapies, cost effective? Yes. But they do cost money, and wouldn't it be better if the people weren't sick in the first place? Um, so the—the issue that sometimes comes up with this is like, "Well, when do you see the benefits?" But we don't seem to have those issues in other policy areas. You know, a railway takes a while to build; everyone's still okay with building the railway. No one says, "I need this within the term of my parliament, otherwise it's not a useful thing to do."
[07:15]Yeah, and a lot of people would say like, "Forget about uh alcohol, food environment; really got to tackle the sort of even more underlying issues, housing and poverty." Like, what's your argument about how—how true is that, and—and what does it miss?
[07:28] Hugo Harper:Yeah, so I want to be specific here. Like, there's lots of good reasons to tackle poverty or housing, right? But so—but if you're just talking about health stuff, you know, like there is a social gradient on obesity, for example; it's probably not as steep as people think it is. So if you solve poverty, you wouldn't solve obesity. That's one way to put it.
[07:50]So even in the most affluent areas, sort of all the least deprived communities, you've got an average rate of about 22%. So one in five adults living with obesity. That's still pretty high, right? And those are the people—the areas that have sort of the best off. That jumps up to about 36% in the sort of most deprived areas. And so, yeah, that is, you know, roughly—roughly 50% more. So it—it is—it is definitely exacerbated by these things. These things are—are not helpful for it; they're actively harmful. But by solving them, you don't solve the issue.
[08:20] Ravi Gurumurthy:But to—just to push you on that one, um, does it have the same consequence for poor health? Because if you are—if you're living on a low income, you might have all sorts of other issues: you might have worse air pollution, you—you may be suffering from gross stress, and the—you know, the cumulative impact may be—maybe—maybe worse.
[08:39] Hugo Harper:Yeah. It's—so the—you want to have fewer people living with comorbidities, multiple issues. Um, and when you look at sort of some of the ambitions, you know, half uh the disparity in healthy life expectancy, uh re—the regional disparity in this, huge differences in terms of the years of healthy life lived um across different communities. You get a lot of people with lots of issues that means their quality of life, their like years of health, are bad.
[09:05]Um, and so the—the number one thing that cuts across is obesity as a risk factor. And so you can kind of come at it either way. You could say, "Oh, well, if you remove obesity, they'll still have all these other issues, so what's even the point?" Or you can say, well, actually, a lot of these things are bidirectional, right? If you've got musculoskeletal disorders, that is not helped by being an absolute heavier weight, you know? And it's not clear if you've got a dodgy knee whether you can't do enough exercise and that's why you put on weight, or you put on weight so you don't do as much exercise. That relationship is poorly understood.
[09:41]The—but the idea that you should—I think it sometimes comes down to like, you shouldn't do anything unless you can solve everything, which we just really disagree with, you know? If you can make these improvements, even if they're incremental—like if somebody loses, you know, 3, 4, 5 kilos, their life isn't transformationally different, maybe, but marginal improvements, and at a population level you reduce the incidence of things like diabetes, heart disease, certain cancers. So it's not just—I think sometimes—sometimes people mistake sort of obesity as this like, well, people can just live with it and it's sort of their choice, it's not, you know, really an issue. It has strong links to sort of more like proper diseases that people might think, diabetes being like the big one, musculoskeletal being another huge one.
[10:26] Ravi Gurumurthy:Okay.
[10:26] Hugo Harper:Um, and so then if you link that to like work, big two things for people being off work: mental health issues and musculoskeletal issues. Those are the big ones. Um, musculoskeletal is very clear line of impact around obesity. Um, mental health, again, bidirectional relationship, a little tricky to work out. You know, there's certainly a lot of like emotional eating that occurs. Um, but the—yeah, it—it's—that's less well understood.
[10:50]The other thing that—that £126 billion number, that's not the only thing out there on this. There was a recent report by the OECD looking at sort of the potential benefits, and they look—they found that over 60% of the total benefits that you could get from prevention, as in like any of the risk—risk factors, 61% was purely attributable to obesity in the UK as like the thing to focus on. And that's because we've done a pretty good job on smoking already. You know, in other European countries higher smoking rates, that's what they should probably focus on. For us, we need to do what we did for smoking with obesity: need to half the rates in a decade.
[11:26] Ravi Gurumurthy:Okay, let's come back to obesity in a bit more detail, but can we just maybe go through all the other areas first? So, smoking, um, to some degree, huge effect already, and the Tobacco and Vapes Bill is a great step in that direction, but there's huge amounts of people who are already smoking. Uh, and how do we actually increase take-up of smoking cessation services? Is that not still a kind of gap that we're not necessarily filling?
[11:50] Hugo Harper:Yeah, so it's—there's—there's still gaps. The smoking is an interesting area, particularly with the vaping side of things. So vaping is much, much better for you than smoking, but it is much better to not vape than to vape. And so you've got this balance where, for people who are currently smoking, you want to make vaping as easy, accessible, cheap as possible. But you really don't want kids starting it instead.
[12:09]And so there's lots of interesting stuff being positioned in the recent consultation on this about how do you get that balance right. So, you know, removing things like bright colors and fruity flavors that probably overly appeal to children. Um, and on that, the service provision—yes, stopping smoking services uh are still really important. They actually tend to work a lot better if they're done with e-cigarettes—some really good RCT evidence on this; they found about—they're about twice as effective.
[12:38]I'm not sure what the exact sort of usage rate is at the moment, but one of the key problems there is you don't have an e-cigarette or a vape that's on prescription yet. So there's this mistrust within the medical community, whereas like you do have uh like um nicotine patches on prescription, this stuff that is like less effective as a quitting mechanism has been sort of institutionalized and it's been—been medicalized. It feels safe, so people can sort of feel like they want to go down that—like that route, which is probably at the detriment to the actual efficacy of the interventions.
[13:09]Sort of behavioral support programs versus nicotine replacement versus e-cigarettes/vapes—the latter are much, much more effective because they're a closer substitute, yeah, in conjunction with the behavioral support. So you—you give people the coaching; you don't just say like, "Here's a vape, on you go." Um, but if the comparison is behavioral support with nicotine patches or behavioral support with e-cigarettes, the e-cigarettes ones are likely to be a lot better. Um, that's poorly understood in even in the medical community. Lots of people think that vapes are just as bad as cigarettes for your health, and to the best evidence available at the moment, that is not true.
[13:40] Ravi Gurumurthy:So, okay. If—if—if someone said, "Right, we really want to finish the job on smoking and not just phase it out for the next generation, but get people off it now more aggressively," um, what would you do? You'd pres—you'd create a prescription e-cigarette to kind of build trust amongst the medical community in particular—that's a safe thing to do—but also maybe consumers. But you've also got to reach people; you've got to actually persuade people, haven't you?
[14:05] Hugo Harper:Yeah. It's—so, well, sort of like most smokers have tried to quit at some point. So, you know, there is a desire there. So it's a bit about making it easier for people. Um, and how much you—that on—on the two sides of like convincing people it's safe, you know, if you're—if you stop calling them like "ex—extreme toxic death black ice" flavor, then maybe people will stop thinking it's total poison. Um, and so that—like there's—you're coming at it from both sides: you want to make it sort of easily more accessible to the medical community; you want to make it sort of less appealing to people.
[14:37]We've sort of had that initial phase of early adoption, right? Like, people know what vaping—the problem isn't that people don't know about e-cigarettes now; everybody knows about it. Um, so then it's, what's the right balance of availability, accessibility, price points? And that's one of the interesting things about the disposable uh vape ban, which hasn't really worked because they've just stuck USB chargers on all the vapes. Um, but in theory, it's a good idea, right? So you want a pack of cigarettes costs quite a lot of money; disposable vape much cheaper. And so if you're a kid with not loads of money, maybe it's easier to buy the disposable vape. Idea of banning these disposable ones was to sort of stop that, get people onto the more like refillable ones. They have a higher initial price point, less likely that you just sort of go in when you're buying your chocolate bar to buy it. That hasn't really worked. The idea is good, right? You want to like balance that point of accessibility: you want it to be cheaper than cigarettes, but not like as cheap as some snacks, um, to look at like who is getting it.
[15:33]And then there's—there's been some also interesting outreach programs on this as well, actually. We—I was involved a long time ago in an initial pilot in Salford where we sort of gave vouchers for e-cigarettes to people who are smoking who are living in social housing in the area, so, you know, just giving that first step because the initial barrier, you know, spending 30 quid on a tank thing, that's quite a lot of money.
[15:53] Ravi Gurumurthy:I guess nobody right now is in charge, though, and held to account for massively increasing take-up of smoking cessation services and getting people switched from um smoking to—to—to something else. Are they—does...
[16:06] Hugo Harper:Yeah, I mean, if anything, I—as far as I'm aware, budgets for stop smoking services have probably actually been in decline. And I think this is—this is a really easy error to make when looking at policy: you look at a trend over time, and you think it's driving itself. So there's this great graph of smoking policy where you just see smoking rates declining over—and to be clear, smoking has halved in the UK over the last 15 years, so we've done a really great job. Um, and there's one version of it which is unannotated—it's just a line going down. You're like, "Great! People just don't like smoking anymore. We'll just leave it; it'll just continue going on as it is."
[16:39]There's a different version of it which is fully annotated with all of the different policy interventions that have happened: all of the like rate increases on it, all of the restrictions, all the advertising thing, all that stuff. And then it makes it much clearer like, "Oh, this has declined because of the action that we're taking, and so if we stop taking action, the decline will probably stop." That's the right way to think about it. Um, so it's not like rolling down a hill; it's more like sort of you're propelling yourself against resistance.
[17:05] Ravi Gurumurthy:Can I take you to alcohol? We'll come back to mental health in a second because it's, as you said, the etiology of—of mental health is—is harder. But on alcohol, both we've got some potential trend towards lower alcohol consumption for younger generations, you've also had some interesting policy interventions in terms of uh trying to incentivize reformulation through tax bands. Can you just say a little bit about what's happened that's worked so far, but also what—what more could be done to continue that process?
[17:34] Hugo Harper:Yeah, the—the tax stuff is kind of amazing if you're into this sort of thing. Um, so uh initially it sounds really bad: "We're going to have lower taxes for higher strength beer than we did before." That sounds like a bad thing, right? Um, but actually it was really clever. So originally the tax band uh for sort of lower strength alcohol ran from I think 1.2 to 2.8% ABV for beers. Um, and they were suggesting let's actually increase that rate from up from 2.8% to 3.5%.
[18:05]And why would you do that, right? Well, it's because most beer that's sold is about at 4% mark. So the idea that you could incentivize industry with a slightly lower tax rate to cut the amount of alcohol in the top-selling beers, if you can get, you know, if you can get the things that people actually drink from a 4% to 3.5%, that's actually massive in terms of absolute alcohol consumption in the country. Whereas people who are sort of already picking something that's advertised as low/no beer, they're probably not the people who need to cut down on the drinking the most, or when I say "need to," would benefit the most in terms of health.
[18:36]Um, and so this has been really successful, right? You've seen massive reductions in ABV—actually, and when I say massive, small percentage reductions, but that apply to huge volumes of sales. Um, and it's totally in the background. People don't really realize it's happening, and it's been sort of gradual over time. And, you know, unless you're specifically looking to go out drinking for a certain outcome, you probably don't care if your beer is 4.5% or 3.5%, and that might not be what you're optimizing for.
[19:07] Ravi Gurumurthy:Yeah. Is there more mileage in that direction for other spirits? It's harder, isn't it? Beer is easier than wine.
[19:14] Hugo Harper:Beer—beer is easier than wine, and same with spirits. And the reason for that is beer is somewhat self-limiting in terms of the volume. So if beer is weaker, you probably don't drink another three pints of it because you're full of beer at a certain point. It takes time to drink. Shots are obviously the opposite, right? Like if uh all vodka was 20%, could people just double the measures of it? Maybe. Maybe it worked for a little while. Um, so it's—it's not quite as clear what you do in the those things, but there's been a big rise of package—wine, though, is a bit akin to—to—to beer in the sense that you don't necessarily open a second bottle of wine.
[19:50]Um, yeah. Yeah, and there's—there's been some interesting work on like default serving sizes with wine. So the default serving size for wine in the UK sort of crept up over time. Like now most pl—now sort of a small is 125 mil, most places medium 175, large is 250. Some places will just sort of serve you a large anyway. Um, the—and so can you sort of bring that back down to what sort of a normal portion size is from this? Um, I forget the exact reference. I think it was—it was either from Bristol or Cambridge did some research on this previously where they went into a pub and changed the default uh glass setting.
[20:23] Ravi Gurumurthy:Can—can policy do anything on that? Isn't that just a—a business practice? How can you actually shift defaults?
[20:28] Hugo Harper:Yeah, it's—it's tricky. Like, you know, you're not—you're not about to change the size of a bottle of wine. Well, you know, may—maybe it would happen over time. Like the—so pints, you know, a pint if you're sort of proper imperial pint, 568 milliliters; most places you'll get it's 500 milliliters now. So, you know, sort of imperial/metric things. So it's not—not impossible.
[20:48] Ravi Gurumurthy:Beer shrinkflation.
[20:54] Hugo Harper:Yeah, like—well, yeah. Like, um, but did you know—should we have maximized it? You know, when—when the sort of original pint was made, beer was much weaker than it is now, so, you know, you could argue it's sort of correcting itself a little bit. Um, you know, liquor is sold in 70 cent—so 700 mil rather than 750 generally. Like, I'm—to—to be clear, like, I'm not advocating for that as a mechanism on what—on like wine.
[21:18]You—you could—the other—the bit on alcohol is you want to look at where the harmful thing is. So the—an amazingly well-evidenced policy that we are still for some reason not doing, despite our closest neighbors having done it for ages, is minimum unit pricing.
[21:30] Ravi Gurumurthy:Mhm.
[21:31] Hugo Harper:Um, ask anyone in public health, it's a slam dunk.
[21:33] Ravi Gurumurthy:Mhm.
[21:35] Hugo Harper:And the thing is, and people just misunderstand the policy because they're like, "It'll put up the price of my pint." No, it won't. Uh, it applies a minimum price to the units that can be sold anywhere, and your pint is already a lot more expensive than that minimum price. And so what it would do is it would change like—it would—it's the White Lightning, isn't it?
[21:52] Ravi Gurumurthy:Yeah. I mean, that doesn't even really exist anymore. You know, that's like that—you know, my age uni um days. Uh, but the...
[22:01] Hugo Harper:...like the—you know, but that—that sort of same sort of thing, you know, stronger ciders, um, uh, sort of like off-brand spirits, those sorts of things. Things that tend to be associated with problem drinking, increases the price—price of those things. Um, and that's been successful in Scotland. And I don't—I—I think the reason we don't do it in England is like a policy comms issue, 'cause it just—people just think you're putting up the price of alcohol generally rather than...
[22:28] Ravi Gurumurthy:Yeah, you do. And there's maybe a different line to that which is like: how do you stem the decline of pubs? Well, maybe you change the relative pricing, right? At the moment, it's much cheaper to buy your vodka in a supermarket if you're just looking to get really drunk. And I'm not saying that's why everyone would go to a pub, right? But like the price disparity between what you get in a supermarket and what you get in a pub is large now for the most part. Um, and so that—like if you can rebalance that, maybe it's a different way of shifting that to say, "Look, we're trying to push people more back into more social environments, you know, more public environments, trying to sort of uh reignite the high street, you know, nightlife." So you would rebalance alcohol duties between out of home and—and pubs.
[23:11] Hugo Harper:Yeah, there are lots of things that kind of go into the pricing. And I, you know, I'm no expert on sort of small business rates or anything like that, but broadly like the idea that you can get very strong alcohol that people can drink like alone in their home is probably not a great thing. All things being equal, you'd probably prefer those people to be drinking in a social situation where there's some kind of monitoring and there's some sort of like...
[23:32] Ravi Gurumurthy:Although peer effects presumably also get you to drink a lot more.
[23:38] Hugo Harper:Uh, it probably depends where you're hanging out. I don't know what pubs you go to, but the um—uh, you know, and the football, maybe. Um, yeah, so that's—you that like drinking culture, but even, you know, sports events, Australia's done some really interesting things. Like, if you try and get uh drunk at the rugby in Australia, you're going to struggle.
[23:53]Um, so uh I was in when I was working at BIT in Sydney uh for a bit, um, you'd go and they have a—I think this—I'm not sure if this exactly still the case, but like directionally this is right—um, you can get cans, but the little cans are 330 mls, and you get maximum four a person, and they're maximum 3.5% strength. That's very different from what I think—I'm pretty sure it's eight pints a person uh and 5% beer at like, you know, in England. Um, so those sorts of like if there's particular events where you tend to get like policing issues or those sorts of things, there are some other like more specific interventions that you could borrow from.
[24:31] Ravi Gurumurthy:Yeah. Okay. So, let's turn to—to—to mental health. Um, as you said, this is a bigger problem than it was potentially, um, but it's also a bit less tractable. Give us a sense of what we'd actually do, where's most promising.
[24:43] Hugo Harper:Yeah, it's really hard. I mean, the biggest gap at the moment is provision of services for adolescent mental health. So child adolescent mental health services, often known as CAMHS, the waiting lists are really, really, really, really long. Um, and that's problematic for a couple of reasons. One, if you're experiencing a mental health crisis, you need help soon, otherwise things can get worse. And in terms of like what we do know about the etiology of mental health issues, it tends to develop in adolescence; that tends to be when people have their first issues. And so almost the—like our treatment services are worst where they should be best. You know, that's if you were—so, you know, everyone always asks for more money for stuff, and that's hard and there aren't enough people, but, you know, it's probably some reportioning of like in more preventative areas, which is tricky because, you know, you might say, "Well, you need to give the resources to the most serious, most extreme cases," which might have taken some years to develop, but that might mean you're not helping prevent the cases that are sort of emerging now.
[25:42] Ravi Gurumurthy:Um, I mean, this government sort of talked about prevention support within schools. I'm—I'm not sure the evidence is that strong on that, is it?
[25:49] Hugo Harper:Um, depends if you're, you know, what you're pointing people to. So, a lot of this idea of like predictive prevention or, you know, finding, you know, who really needs the help, well, if you don't have the services to like work out the increased demand that you're generating, that can almost be worse, right? "Hey, you weren't sure if you had an issue before; now I'm telling you, you've got an issue. You should find help. See you in six months." You know, that that—that's uh the—the intention's really good, but [clears throat] you need to sort of line it all up.
[26:18] Ravi Gurumurthy:Okay.
[26:19] Hugo Harper:Um, otherwise you can be sort of increasing your demand, not increasing your supply. It's already overwhelming, and then, you know, you might be see—and you are, and on mental health, like, we are seeing increases at the more extreme end of the spectrum. You know, some people, like, "Young people are snowflakes, etc., etc." But, you know, on the like hard measures, like rates of like self-harm, suicide, those things, you know, it's—it's not just a sort of intergenerational difference between what like "okay" means to people.
[26:45] Ravi Gurumurthy:Mental health has come into particular sharp focus I think recently for two reasons: one is the—the number of young people not in education, employment, training (NEETs), or people just not in work who are claiming disability benefits because of mental health—that's risen significantly; and the other is the sort of debate about social media and—and young people and—and mental health. Um, let's leave social media for now, because I think that's a whole other issue. But on the kind of—particularly on NEETs and—and economic inactivity, what's the sort of—is there good evidence actually about what—what works in that space on—on—on mental health?
[27:19] Hugo Harper:Yeah. So there's some really promising stuff around like better packaging mental health support and job-seeking support, and sort of really good evidence that if people—like, work is good for mental health. Now, there's obviously a caveat to that, right, which is good work is good for mental health; like, bad work is bad for mental health. You know, if you're stuck in a job where your boss is like abusive to you, that's obviously not a good thing. Um, and so there—this is outside of my area now, and, you know, there's—there's some people raise questions about, well, what's the supply of jobs? You know, is AI decimating entry-level jobs for young people? Does that mean there's sort of an—there's not the good work to sort of get people into?
[27:56]Um, and so some people also argue that people aren't ready for work now because they're too anxious, and so it's not my job as an employer to get somebody to be okay speaking to people in real life. Um, and so that—that's a—I think that it's clear where that the ambition—where the ambition should be, right? That like even if you just care about human suffering and you don't care about economics at all, you probably want people in work.
[28:19] Ravi Gurumurthy:Yeah.
[28:20] Hugo Harper:Um, and so that's sort of a nice like, you know, sort of join-up where we should be able to agree. I think that problems lie in the dosage of it, you know? What support's available, and how can you set up systems so that people don't need the support in the first place?
[28:31] Ravi Gurumurthy:Okay. [snorts] Let's move on to sort of physical activity. Um, because in—some people think physical activity is very important for tackling obesity. Um, I think you're less confident on that for various reasons, which we can get into, but physical activity in its own right is still really, really important and incredibly uh strong protective factor for—for people's health. It's just quite hard, isn't it, to shift that habit, particularly amongst those who really need it?
[28:57] Hugo Harper:Yeah. The phys—I mean, physical activity is great, like, don't get me wrong. Uh, it's got really interesting dosage effects, right? If you go from completely sedentary to walking a bit, you see big improvements in health, right? If you go from running 10k a week to 15k a week, me—doesn't, you know, it doesn't do so much. Um, and the issue particularly for weight is a couple of things: one, you don't burn that much energy doing exercise generally, like as—as much as—as much as you think; and then the problem is, anyone who's sort of put it onto calories on a treadmill when they're running in a gym can attest to this, like, it doesn't go up very quickly.
[29:34]Um, and then the problem is, particularly if you've done exercise of that nature, um, it's very effortful. You know, you've done it, and you maybe get some compensation effects. These can be psychological or physiological, right? So people either think like, "Ah, I was good. I'll go to—I went to the gym; I can have some dessert." Uh, or sort of less consciously, they are fatigued from that exercise and so they sort of move around less for the rest of the day. It's called non-exercise activity thermogenesis (NEAT). Um, and uh this is the idea that you get this sort of compensatory effect.
[30:05]And so when you look at this, like, broadly—broadly, the calories that people like would burn off in exercise, the weight loss that you see is something like half that. So the absolute number of calories you burn off initially isn't that big, and then the actual impact is about half of what you get for these compensatory measures. Um, and so it's really tricky because people are like putting in their effort into this thing, and it's, you know, it's not this bad thing, but if—if weight loss is the goal, it's perhaps not the easiest way.
[30:31]And then, you know, how do you—how do you increase it? A lot of the policies that are really effective in this kind of area can be quite expensive. You know, like cycle lanes are great, but they're quite expensive. They take—take a long time to build, and so it's not that those things shouldn't be pursued, but if you want sort of a change in national weight and you want it quickly, the—the rule of thumb that I use that is like broadly—broadly accepted by people if you push them to be specific would be like 80/20: so 80% energy uh energy in, 20% energy out.
[31:01]Um, now, of course, there's nuances to this, right? Like, physical activity is great, is important for mental health; physical activity is important to stop muscle wasting in elderly people, balance, preventing falls, all that sort of stuff.
[31:12] Ravi Gurumurthy:It'll be increasingly important with GLP-1 use as well, shouldn't we?
[31:18] Hugo Harper:Yeah, hugely. So, with the GLP-1 use, you get lots of weight loss. A lot of that weight loss comes from muscle loss. Um, and so you want to reduce that. And the greater your resistance activity, your exercise, you know, the stuff you do whilst you're in a large calorie deficit, the less muscle mass you use—you lose. Like, there's lots of um—there's interestingly lots of research on this in like strength and conditioning research. So like bodybuilding, like track and field athletics, like strength coaches for like American football, uh, where they want people to be like as lean as possible and as strong as possible. So they want like very low fat and very high muscle. And so, uh...
[31:49] Ravi Gurumurthy:Sounds exhausting.
[31:53] Hugo Harper:It's—yeah. And it's—but it's interesting when you like uh when you see very different like groups of people coming to the same recommendations. You like bodybuilders and like public health folk both being like, "Actually, this is sort of, you know, this is the—this is the way to go here." Um, it gives you greater confidence.
[32:16]Um, so um let me talk a bit now about—we've circled around obesity; I want to come back to it now. Um, let's start with actually GLP-1s because um I don't know what the penetration of GLP-1s is right now, but it could easily end up being pretty huge. What proportion of the 30% of people who are obese in this country do you think will end up having GLP-1s in 5-10 years, and—and—and what—what do you think is desirable?
[32:48] Hugo Harper:Yeah, it's a great question, and the—the big thing here is cost from public perspective. So at the moment they cost a lot, you know? It's thousands of pounds a year, uh, and lots of people don't have thousands of pounds a year. So when you look at the penetration rate for PE—and when particularly when you um account for people living with obesity across deprivation, Health Foundation have some lovely research on this, um, that you see much higher uptake in more affluent communities. Unsurprising.
[33:14]And, you know, with how easy it is for the private—on the private side of things to like claim you have, you know, sleep apnea or a higher BMI, like gut feel, a lot of those people aren't really on the clinical high need area. I know lots of people, you know, like you could—people will—people you probably know people who are on these drugs, uh, and whether that's conferring a huge public health benefit, you know... But to—to go back to the sort of specific point, like, some—by some research states that like maybe up to 9% of households might have someone on this drug at the moment. Um, but if you say people living with obesity is about 30% of people, so about one in three people, um, what would be—what would be a—a good case for this?
[33:57]Well, it depends a little on who's paying for it. So, you know, if people are funding these things privately and they've got plenty of money to do it, you can kind of see this going away in 10 years time—and this being like obesity. You can imagine the case that, you know, in high-income groups you basically do not see people living with obesity. Um, you know, if the drugs come down a bit in price and it's people—you know, it's already manageable in the budget if it becomes sort of like socially unacceptable now because you can kind of buy your way out of it, um, those things, you know, it's sort of like fancy teeth in America, um, or like wrinkles now don't really exist.
[34:34]Um, and so, you know, that maybe goes away. But several thousand pounds a year is still a lot of money for a lot of people.
[34:38] Ravi Gurumurthy:Well, it's a lot of money in general, but particularly...
[34:41] Hugo Harper:And so then the—the problem is you might get this massive social gradient, but you basically eliminate obesity in affluent communities and you see it sticking pretty much the same. Because the—from, you know, our research on the area, it's like 5 years, the price are not going to drop big time. Mhm. Like, when the p—15 years, probably quite a lot cheaper, you know, really difference there.
[35:01] Ravi Gurumurthy:And by "quite a lot," are you talk—talking about half the price, a quarter of the price?
[35:03] Hugo Harper:A quarter of the price, you know, meaningfully a lot cheaper. Um, there's some stuff that's saying like places in India are producing some generic versions for like 50 bucks a month, you know? That sort of like—it's not—it's not nothing, but it's sort of like—it's maybe like more like a bill, you know? Like, it's sort of like fancy phone contracts are about that. Um, so you can imagine people sort of going for it.
[35:26]The amount of people we can imagine being on it is—it also depends on when you mean. So right now you probably want more people on it than you want longer term. And that's because at the moment the food environment isn't conducive to weight loss. So we have lots of people who are living with this problem. So, you know, anybody living with sort of severe obesity, if you've got a BMI over sort of 40, over 35, it's probably a good thing if you have access to these drugs.
[35:52]And now the—this isn't just like my take on it. The NICE guidance originally recommended the access to these drugs on the NHS for about 3.6 million people. The current provision, uh, the sort of scaled provision of it, is for about 1.2, I think. But the problem is that 1.2 would occur—occur over 12 years.
[36:11] Ravi Gurumurthy:Yeah.
[36:12] Hugo Harper:And so in the next couple of years you're more getting like a couple hundred thousand people on it. That's nowhere near enough.
[36:17] Ravi Gurumurthy:Yeah, right. So just—let's just stop on that because that's massive. If—if—if NICE are saying 3.6 million should get it, and we're only going to get 200,000 people on it in the next year, what would we need to do to—it is cost effective and healthy, presumably, to get to that 3.6 million. How would we get to that, close to that target?
[36:34] Hugo Harper:So there's something about how can you deliver these things safely? And here you got this really interesting distinction between the private and the sort of NHS supply. A lot of the private uh market is essentially like, "Here are your drugs, off you go, check in in 3 months." Uh, whereas the wraparound care that's available on one of the NHS provision is like a high number of clinical appointments. Uh, I—I forget, I think some of the pathways is something like 20, you know, like a lot of clinician time. And that has cost, but it also has time constraints. And so maybe there aren't enough clinicians to be doing that, and then if there aren't enough clinicians you need to wait to train more clinicians, and that is not just a cost thing, it's a time thing.
[37:09]And so one of the things would be, as you scale the drugs to people with lower clinical need—so at the moment the people getting it on the NHS, probably sort of BMI of over 43, comorbidities, so people who are not well—um, it's plausible that it is appropriate to give a high amount of wraparound care to those people, you know? Um, as you sort of move down the intensity gradient, plausible that you draw out some of that wraparound care. The wraparound care is a substantial amount of the costs, and it can be a substantial amount of the operational constraints as well.
[37:41]So what's the sweet spot in terms of the delivery? It's probably not, "Here the drugs, off you go." Um, but it might not be, you know, very, very regular checkups on this. The interesting meta-analysis uh from Susan Jebb's group at Oxford found that whilst more behavioral support with the drugs improved outcomes a bit, effects weren't massive, you know? The drugs are doing the heavy lifting, and once you removed the—once people came off the thing, they all put the weight back on anyway.
[38:05] Ravi Gurumurthy:Yeah.
[38:05] Hugo Harper:And so that's the other problem, right? People don't want to sign up to a bill that's endless.
[38:09] Ravi Gurumurthy:Yeah.
[38:12] Hugo Harper:Um, and here's where—here's where we can sort of wrap—wrap it. Like, you don't want to have a situation where you're paying thousands of pounds a year for 30% of the population on these drugs. Um, but, you know, maybe at the moment we think 5—5% of the population, 10%, something like that, it would be helpful for them to be on these drugs. Maybe the long-term 3% of the population, something like that, you know, people with real genuine genetic predisposition to sort of excess weight. How can you help these people?
[38:39]Um, the idea, you know, that what we would posit is: you get your short-term benefit from the drugs now, you line up all your prevention policies, you enact them, and so you have all the benefits of your prevention policies hitting after, say, like 3 to 5 years, and then you can dampen down your drug costs.
[38:52] Ravi Gurumurthy:Yeah, okay. But if we—if—if someone said to you right now, "How do we get 3.6 million people that NICE suggest should be having this drug to have this drug in the next 5 years?" um, you'd basically have to hire quite a lot more people, put a lot more money into this, but it'd have to be a real sort of mission for the NHS, wouldn't it?
[39:14] Hugo Harper:Yeah, exactly. And the—there's always opportunity cost to that sort of stuff, right? You know, I think the reason this is particularly interesting...
[39:19] Ravi Gurumurthy:Or would you say it's r—a rational thing to do that, to distort the system to focus on that group, or are there more high priority health needs that should be focused on?
[39:29] Hugo Harper:Why we think it might be a rational priority is because it could be a short-term priority, which is not the case for a lot of treatment stuff. You know, uh the, you know, if you just have people on diabetes medication, they tend to be just on that for life. Um, here, the idea would be you, if you line up a sufficient activity on prevention policy, then you're focusing on this to get sort of a shock into the system to massively reduce the rates of obesity, and then you can sustain that with the prevention policy in a much lower dosage of the drugs.
[40:00] Ravi Gurumurthy:Okay. So on the prevention policy, what is the kind of high-dose version of this?
[40:04] Hugo Harper:Yeah, so everyone talks about prevention policy and then what actually ends up happening is like, "Here are some leaflets," or "Here's a bit of information." Um, which is just not sufficient, right? Um, the—what you actually need to do that, the sort of the three main learnings: we did this big thing called—we call the blueprint for halving obesity, reviewed thousands of papers, talked to a bunch of eminent academics in the UK to work out like, what—what's actually the cost, the benefit, and strength evidence of about 30 obesity policies?
[40:32]And the—the sort of the thing that came—comes out really, really, really clearly is:

1. You need meaningful incentives to change the behavior of the food industry to make food healthier for people.
   
2. You need to upscale treatment for the people who need it.
   
3. Education and information is totally insufficient to the scale of the problem at the moment.
   

They're not bad things to do, but they're not going to solve it.
[41:00]And so, what is that incentive that we're providing to the food industry? Because voluntary action hasn't worked; we've been trying voluntary action for a long, long time. And it's interesting because if you talk to the food industry people, they'll say sometimes, "We support regulation. You know, we think what we want is a level playing field." And that's exactly what we're trying to do, but a level playing field that brings health into the value equation for them.
[41:21] Ravi Gurumurthy:Okay. Do you want to set out just two options then? Because basically you only need to regulate, you need to tax. Set out the regulation option, and also let's talk tax with you as well.
[41:27] Hugo Harper:Yep. Uh, so the regulation option comes back to the scale of the problem. So, massive problem nationally, but individually could be quite a small change in calories. And so that's why regulation's—the other reason regulation's appealing is because a small number of businesses, about 11 large retailers, contribute the vast majority of what people eat. So it's sort of tractable; you can get—you can kind of get your hands around it.
[41:48]Um, and so here you could—the problem at the moment is, in our view, that regulation has focused on changing sort of practice, banning things. It's not—not a bad start, right? But what we've seen for like the end-of-aisle restrictions, you know, no chocolate bars at the checkout or at the end of the aisle—um, not just chocolate bars, sort of uh HFSS food, sort of junk food if you like—um, is that you just come up with alternative ways to get people's attention, right? You have spotlights in the middle of the aisle, you have these shelf wobblers come out, you can still put things on sort of price discounts.
[42:21]And so it's like the—and then the policy, you know, takes years to come in, is only updated every so often, and businesses have changed their practice in a month. Yeah, and so it's this cat-and-mouse game, but you're a really slow cat and it's a really quick mouse, maybe. Um, and so—and also businesses hate it because you—you're really micromanaging them. You know, you're like, "You—this product can't be within X feet of the entrance of this size store," and, you know, all of this sort of stuff.
[42:48]And so what we're—what we've been trying to push for is outcome-based regulation: say, "Look, you guys know how to sell stuff to people. That's your whole bit. You know how to make food. That's your whole bit. Um, just make it healthier." And being really specifically, healthier, right? We're not saying no crisps anymore, it's only carrots. We're saying like if you could switch to like if someone has a pack of Wotsits instead of a pack of Walkers, that's probably for the best.
[43:15]And so this is—this is really key: we're looking to incentivize regulation that's outcomes-based, that isn't too prescriptive, that gets to the changes that we want in a way that's good for people (their diets still look similarish to what they do now, they still have the joy of food) and works for business, you know? It's not sort of really hardline; it's changing people's tastes over a period of time. I've seen some improvements on this in salt, for example.
[43:35] Ravi Gurumurthy:Yeah. So, precisely what would you do if, you know, what exactly would you do when?
[43:39] Hugo Harper:Uh, so I—I am Andy Burnham uh and uh f—maybe not the first day at the first day in office, but certainly in the first sort of 10 days, first 100 days, you're looking at this uh regulation on s—on supermarkets. You're looking at implementing the Healthy Food Standard. This is already government sort of stated policy; they're saying they want to do this. It's part of the 10-year plan, so it shouldn't be controversial. Um, it was as of today, actually, from when we're recording this, uh, the like primary recommendation from the Health Select Committee coming out on on uh on weight.
[44:09]Uh, the—what this means is you would set an a target, an absolute target for the average health of what is sold in uh m—in large food businesses, and f—moving first on retailers or big supermarkets, and you say, "If you—you need to hit this, and if you uh don't, there'll be some—something bad will happen; there'll be a big, big fine." Could look at positive incentives as well: "If you do, maybe something really good, good will happen." But you need to change incentives in a way that matters for these massive businesses.
[44:35]Um, and the—the the sort of nerdy first step to this is you need to have the data to be able to make this regulation. If you want to know the average health of what people sell, you need to know how much stuff they sell and what the average health of that—and what the health of that stuff is. And that requires mandatory reporting. That's another aspect of it. That is data that many of these businesses already have. You know, some of these businesses publish their sales-weighted average Nutrient Profile Model score, which is like the score that underpins it, already online.
[45:02] Ravi Gurumurthy:Yeah.
[45:02] Hugo Harper:And so this is—this is doable, but you need to go—you need to step forward on that, so that you could plausibly do by next year.
[45:06] Ravi Gurumurthy:Okay. One other option, of course: there will be a fiscal event, probably there'll be a budget in the autumn. You could also go for a tax.
[45:10] Hugo Harper:Yeah, tax it. Um, it would work, right? Like, and it's not a new idea. So, uh, well, one, sugar tax—incredibly successful, but applied to a very small amount of uh what we eat. So soft drinks now have a lot less sugar in than they used to, but we don't consume that many soft drinks. Uh, also the salt and sugar tax as in the National Food Strategy that Henry Dimbleby did. Those things uh—they're effective; they have—and we've got a—we've got our own version, sort of a slightly more nuanced version on this NPM.
[45:43]The idea here would be you would only have a tax on unhealthy food. So anything that falls into the healthy category, totally the same as it is now. And the more unhealthy food is, the higher rate of tax would be.
[45:54] Ravi Gurumurthy:Okay, right.
[45:54] Hugo Harper:Uh, so if something's just on the wrong side, like it's a cereal bar with a little bit of chocolate in, uh, then maybe that's get—that's a little bit more expensive. If something's like, you know, chorizo or like uh um Lindt chocolate balls, that's probably quite a bit more expensive.
[46:06] Ravi Gurumurthy:Yeah, okay.
[46:10] Hugo Harper:We think that's also a plausible route here. Our modeling suggests that it would have a 1% increase in food prices, which isn't super palatable, right? 1% actually isn't that much. Um, uh, and could have like a roughly comparable, so 20% reduction in obesity.
[46:24] Ravi Gurumurthy:Okay. So you can get it either way: you can regulate, or—or you can tax. There are two ways that you could get a roughly 20% reduction in obesity, and you need a roughly 20% reduction in obesity or something comparable to that if you want to make a dent on this national health crisis.
[46:35]Yeah, okay. So you're Andy Burnham, first 100 days: what are the three things you're going to get done?
[46:40] Hugo Harper:Uh, so, firstly, I'd progress on the Healthy Food Standard—so this regulation of uh retail supermarkets to sort out obesity, get data reporting uh in.
[46:54]Second thing I'd do is try to come up with a plan to massively upscale the provision of GLP-1s on the NHS so the people living in high deprivation, people who can't afford the private supply, aren't left behind.
[47:05]Thirdly, I'd really get cracking on sort of finalizing the job on smoking. We've made great progress; the consultation's out on the Tobacco and Vapes Bill at the moment, and that could be a really nice early win. You want to reduce the amount of kids vaping, you want to increase the amount of people quitting smoking, and the very specific thing I'd prioritize is getting that prescription e-cigarette on so that—and increasing those stop smoking services for people.
[47:26] Ravi Gurumurthy:Hugo, thanks very much. That was great. We'll see what Andy does in the first 100 days.
[47:30] Hugo Harper:Very good. Thanks for having me.
[47:33] Ravi Gurumurthy:If you enjoyed this episode, please do like, share, and subscribe wherever you get your podcast. We've got more coming. For those of you who don't know us, Nesta is a research and innovation foundation based in the UK. We design, test, and scale solutions to the big challenges of our time. We're funded by a charity endowment and are politically neutral. For more, do visit www.nesta.org.uk.