That overweight person you’re judging might not be able to control the amount they eat. For ten years, Joshua Bell was part of a team that researched the causes and incidence of obesity in Britain. One of his many takeaways from the experience was just how complex and misunderstood body weight regulation really is.

“It's useful to begin by understanding that a big chunk of it is genetics and that it's not a willpower issue. It's not something that they've done wrong or failed at,” said Dr Bell, an epidemiologist who now works in the Obesity and Liver team within the Real World Evidence group of the Danish pharmaceutical company Novo Nordisk.

“There's just inbuilt biology [that some people have] more of a challenge with than others ― the way the genes would work is by making people more prone to crave food, or they feel fuller less quickly.

“The mechanisms behind why people over-consume, that would be controlled by genetics. So it's people battling their biology.”

Understanding those biological mechanisms was a central focus of his research.

“I looked a lot at body fat distribution ― so, waist measures; fat stored in the trunk area was a major driver ― and how it affects the bad kinds of blood lipids, which can be seen really early on in life, in children and actually even in people with lower BMIs,” he said.

“So it’s not exclusively a problem of obesity; nothing magic happens with a BMI of 30.”

As health information, it helps shift the blame away from individuals towards a better understanding of biology and environment.

On graduating from Mount Saint Agnes, Dr Bell earned a bachelor of science from McMaster University in Canada before moving to England to pursue a master’s of science in social epidemiology at University College London.

He then received a “studentship”, a scholarship that pays tuition and a small salary, from the UK Economic and Social Research Council to stay at UCL and do a PhD.

Through his work, Dr Bell has published 50 scientific papers in journals including the American Diabetes Association and American College of Cardiology.

He would love to bring his knowledge back home. A key motivation dates back to 2009 when he was a summer student at King Edward VII Memorial Hospital.

“The more time I spent there, I noticed [that] obesity, diabetes, heart disease, they're all massive issues and there was really no research in it.

“There was a real gap in expertise in it scientifically. So that was a motivation for going deeper into that,” he said.

“A lot has changed since that point in terms of research and that’s what keeps me interested, to see how I can help in the future.”

In his past role, Dr Bell was able to draw on birth cohort studies conducted in Britain over the past 80 years, which made him think about how something similar could be done on a global level and “how little was being done in Bermuda, and what could be done”.

“They've never really gone beyond descriptive work, things like, how common is diabetes, for example.

“There’s a lot you can do beyond that, which would be unpacking that and understanding why [the numbers] are so high and what are the causes, what risk markers can be used to help identify people,” he said.

“Research elsewhere is relevant, but you really need a local lens on things and that's really lacking so far.”

Novo Nordisk, a leader in weight loss and diabetes treatments, was a natural fit for Dr Bell, who had spent a decade working with some of the world’s most advanced cohort studies and wanted to shift towards more applied and impactful work that more directly benefits people with obesity”.

One of the cohort studies, Children of the 90s, identified 14,000 women who were pregnant in the early 1990s and has been tracking them and their babies ever since.

“It's how you get really detailed measures on how people grow and develop, and what causes ill health,” Dr Bell said. “I looked at a lot of obesity in childhood and adolescence, and the impact of that on health. But so far, there's nothing equivalent to that in Bermuda. That’s not to say it couldn't be done, there's just no investment yet.”

His analyses focused on metabolic health, specifically the links between different body fat measures and blood-based indicators such as cholesterol and glucose levels.

“The results are still relevant to Bermuda ― and really, anywhere ― but they don’t have that local lens,” he said, explaining why a study conducted here would be valuable.

“In the US, for example, there's massive data sets on over 100 million people. Some of them are updated almost daily and you get a really current picture of health.

Bermuda does a survey like every ten years or so. So there's definitely more that can be done in that way and maybe with the government looking at getting universal healthcare, that could be an opportunity to build data capture within that.”

Even if we only improved how existing information is formatted, it could be used to better understand people’s health and to provide more tailored health advice for the island’s population, he added.

“You’d think it'd be doable. You look at places like the UK and the US, and they've been active in it for many decades — Bermuda is only 60,000 people with one hospital.

“It should be possible to do something pretty comprehensive there, if there was the investment and the will for it.

“We're linking what's already there. We’re just really trying to make the most of opportunities to get a better picture of people's health.”

In Bermuda it is likely that genetics plays a huge role in about half of the people who are overweight.

“But what we can actually measure with genetics isn’t there yet. So far, less than ten per cent of risk is captured by measurable genetic factors — there's still a lot of missing heritability.

“That might improve as the tools get better and studies get larger, but for now, the genetic data just isn’t that useful for predicting risk. What we’ve seen so far appears to be more environmental — at least at the population level.”

The solution, he feels, “boils down to food environments” — the physical, economic, social, and political factors that influence what people eat and drink.

“You would think with Bermuda being so small, and with virtually everything imported, you would think there might be options to improve the food environment pretty drastically if they wanted to,” Dr Bell said. “But realistically, it's kind of where we are and that people have the biology of craving what's around them, and no one's figured it out beyond having medicines available that help control people's response to the environment and the cravings that come with being surrounded by food all the time.”

He does not know of any other Bermudian epidemiologists, but says the field is a good match for people who are “very analytical” and can communicate well.

“We're quite sceptical. We don't believe everything we see. We have to understand what else could be going on,” he said.

The beauty is there isn’t a single course of study that leads into it. Some people enter with an undergraduate degree in biology, Dr Bell studied psychology and neuroscience.

“It's kind of the science behind medicine and public health. You can come into it from any kind of science background — whether it's quantitative, analytical or otherwise.

“Essentially you just become an expert in evidence and knowing where evidence comes from; being able to scientifically critique something to understand bias and limitations in what you see.”

For real change to happen though, evidence alone isn’t enough — it needs to be backed by action.

“That would take a lot of political will [and] more social equality. People who are more socially disadvantaged, [people with] lower wealth, they have a higher burden of disease. So I think as long as that's there, these diseases will always be present.”