Select Committee on Public Accounts Minutes of Evidence

Memorandum submitted by The Obesity Awareness & Solutions Trust Limited (TOAST) (PAC 00-01/148)


  TOAST welcomes the publication of the National Audit Office Report on obesity and is glad that at last there is to be a joined up approach to tackling obesity. We support the Government's promotion of a healthy diet, containing adequate amounts of fruit and vegetables, coupled with good exercise as one means of preventing further increases in the levels of obesity. However, this advice has neither halted the increase nor resulted in a decline. Indeed, the problem has reached epidemic proportions according to the World Health Organisation. What must not happen is that the emphasis be put just into prevention, important as it is, there are still two thirds of men and half of women who are currently obese or overweight. Obesity is caused by a diversity of problems and needs a diversity of solutions.


  The Health of the Nation Report in 1992 identified the co-morbidities and therefore the financial costs of obesity and set targets to reduce the incidence from 12 per cent back to the 1980 level of 8 per cent. By 1999 it was obvious that the targets would not be met and so, with the obesity epidemic raging, "Saving Lives: Our Healthier Nation" dropped obesity, setting no strategy to reduce or limit it. There was a feeling amongst those living and working with obesity that the government hoped that if they ignored obesity and the obese then it and they would go away. TOAST is concerned that local and national schemes will fail to include effective programmes; leaving obesity and obese people labelled as hopeless and once again put on the back shelf of health care.


  There is no one single cause. At the simplest level obesity is caused by eating more than a body needs. However, the food choices of all human beings are made for a variety of reasons, ranging through appropriate "dinner-time" hunger, stress leading to undereating, stress leading to overeating, a scrumptious looking dessert trolley to celebratory meals. We have asked a variety of groups why they think obese people over eat; the following list is a typical example:

Because it's there
To celebrate
Pressure from other people
Going to start a diet tomorrow
It's Sunday
Not appreciated

  As well as looking at the observable behaviour such as how much is eaten, it's important to look at what drives food choices; the cognitions and emotions that lie behind food choices.

  For many types of obese there is a strong link to the problems of those with a drink problem. The alcoholic doesn't drink too much because they are thirsty. The alcoholic is not "cured" because they have not had a drink for weeks, months or even years. Treatment programmes use some form of counselling, recognising that alcohol is often used as a coping mechanism; to drown sorrows, for swallowing anger, blotting out the pain, to be part of the crowd. Many overeaters will recognise these behaviours and reasons for over consuming.

  "The worst health problems in our country will not be tackled without dealing with their fundamental causes." (NHS Plan, 2000). We have to stop treating obesity at the simplest level. The only direct statement in the Report that acknowledges, ". . . psychological problems may equally contribute to the type of behaviours, such as emotional and binge-eating, that can result in the onset of obesity" is in the appendices (NAO Report 2001—all italics refer to Report).


  One of the major failings of the Report and in obesity management in general is the focus on "Healthy Eating and Physical Activity" (HEPA) as the main (if not only) solutions to the obesity epidemic.

  The National Food Survey (1992) showed that energy intake has decreased since the 1970's; however, the Survey did not take into account that eating patterns have changed in the last 30 years; people eat away from home more frequently and this data is not included in daily consumption. The "Effective Healthcare Bulletin" (1995), although acknowledging that eating outside the home "may also contribute to this trend" states "This [the increase in obesity] has occurred despite a reduction in the total average energy consumption, suggesting that sedentary lifestyles are the most important factor." It is important that such errors are not perpetuated and the solution to obesity is not seen as just getting people to exercise more.

  Exercise can have a part to play. Because losing weight reduces the risk of coronary heart disease (CHD), obesity is mentioned in the National Service Framework for CHD (NSF, 2000). However, because the focus of this document is on reducing the risk of CHD, the levels of activity recommended are also focused on how much exercise an individual needs to do to reduce their risk. Unfortunately, the level of activity required to be fit and the level required for weight loss are different, but advisers are not putting this information across. Thirty minutes a day is for prevention of CHD; in order to lose weight this needs to be roughly trebled, and this is assuming no overeating is going on. To burn up one pound of fat a human being needs to walk or run 35 miles.

  Whilst recognising the importance of improving diet in this country, it is important that this is not confused with action to deal with the obesity problem. The healthy eating advice that is necessary for the average weight person is different from the advice that an obese person needs. The "Balance of Good Health" plate is an excellent way of putting across the healthy eating message. But this message has been around for decades. Education messages alone don't work; advice alone will not change behaviour.


  Most obese people have been on lots of diets and are dieting experts. "I know what I should eat—will somebody help me do it" is a common cry.

  Our research (Cox 2000) showed 90 per cent of obese people questioned thought that GPs did not, or only occasionally provided the right kind of support. Similarly, 90 per cent thought dieticians did not provide the right kind of support. Many tell us that they felt their doctor was not interested, did not understand and did not have time to listen.

    3.25  ". . . we found that almost all practices recorded the height and weight of all patients. In addition, about 95 per cent recorded the body mass index of all patients."

  In contrast, work by Nick Finer at the Luton and Dunstable Hospital highlighted poor GP referral letters to his obesity clinic. Many did not include the weight of these patients. This low quality may represent a negative attitude of the physician towards the obese.

  The National Service Framework for CHD gives milestones of April 2001 and 2002 for action on obesity management. Our concern is that many GPs as yet do not know of the milestones, let alone actioned them. It will be 2003 before anybody realises this. We would like to know the progress of the milestones and details of the budgets for putting these policies into action.


    3.17  ". . . A weight loss of 5kg (11 lbs) is equivalent to a loss of some six per cent in body weight for a man or woman of average height with a body mass index of 30"

  TOAST recognises the health benefits of a 5kg loss. However, we agree with the government's National Service Framework for CHD statement, ". . . but the goal which patients should be encouraged to aim is still a BMI in the average range".

  One of the disadvantages of only focusing on the benefits of a small weight loss is that it becomes the expected norm. We must continue to find ways of helping individuals to reach and maintain an even healthier weight. The health benefits increase as the weight loss increases.


  Identifying the overall cost of obesity is very different from identifying what is currently being spent. The Report itself acknowledges its underestimation of the costs of obesity. The cost is probably around 2 billion, yet the NHS is only spending £9.4 million.


Obesity! A complex problem

  With many routes to becoming obese it seems realistic to assume that "one size fits all" is not a useful approach for treatment. One obese person may, for example, simply need more knowledge about low fat eating, another may be a dieting expert full of facts and figures but be unable to motivate her/himself to put that knowledge into action. There are many influences on an individual's obesity development. A fundamental flaw in the government department system is the lack of attention paid to psychology and emotional well being.

Too big a problem for the NHS to cope with alone

  With 25 per cent of the population obese, Primary Care Teams cannot deal with the problem alone. Any effective public health strategy must recognise the wide range of factors that contribute to the problem and provide for a range of solutions open to individuals including, but not limited to:

    Conventional dietary advice

    Behavioural change, including exercise

    Counselling—eg cognitive behavioural therapy

    Self-help groups

    Slimming clubs

    Nutritionally assured formula foods including very low calorie diets and other meal replacement programmes

    Medical intervention—eg medication, surgery

  There is a need for a new type of health professional to specialise in obesity management.

What can we learn from others?

  Within geriatric care the NHS and the commercial sector work together; the NHS frequently treats medical symptoms and the commercial sector frequently provides other care.

  Treatment programmes for addictive behaviours provide motivation for change and long term support. Many work with groups, which have been shown to be effective, and are good use of the professional's time.

  Training programmes used by industry and the public sector aim to help people change attitudes, motivate themselves and work towards achieving their and their organisations goals. They are the culmination of decades of research into understanding these processes.

  The Health Education Authority's "Lifesaver" quit smoking programme has provided varied support for those wishing to stop smoking ranging from a screensaver—"Smoking: don't give up giving up" to a national media campaign.

  The "whole practice" approach is a good method of using skills and resources.

  There is a need to co-ordinate initiatives including NHS, policy makers, the food industry, slimming industry, Advertising Standards Authority and other campaigns.

  Promoting a healthy school environment, healthy travel to school, sport and physical recreation in schools and healthy eating in schools and, importantly, not forgetting bullying and the psychological well being of the already obese child.

  The message that the government puts out needs to be simple. There have been so many conflicting nutritional messages over recent decades that many are confused. One suggestion for getting across the health message; "Obesity leads to diseases which kill"

Recognise that the message on diet and exercise is important but not the whole solution

  There is a danger that Health Authorities providing "encouragement" for people to eat healthily and to do more physical activity will enable them to be seen as having an obesity management strategy. When this fails (again), overweight and obese people will be seen as too difficult to treat. We want to stop the government wasting money in thinking that obesity will be solved by continuing with more of the same policies that have blatantly not worked in the past.

Better information on food labels

  Government advice is that only 25 per cent of our Calorie intake should be from fat. Currently labels show fat weight, which does not easily allow people to make that choice. Most people would need a calculator to find the percentage of fat in the product.

  Clear, readable labels showing percentage from fat Calories would also stop X per cent fat free claims. Some products carry a banner on the front of the packaging declaring the product to be, for example, 85 per cent fat free. Most people interpret this as meaning only 15 per cent of the Calories in the product are from fat. In reality the percentage of Calories from fat can be nearer 30 per cent.

Prevention alone is not good enough

  Paragraph 3.13 of the Report suggests, ". . . A more realistic five year aim might be to keep the local prevalence of obesity constant. . . ."

  A consequence of this message is that it will be taken as a guideline to focus on prevention, ignoring the 10 million already obese in this country. This approach will also lead to an increase of the costs of obesity because the existing obese population is getting older. To simply focus on prevention is not good enough.

Put in place weight maintenance programmes

  Many obese have been successful at losing weight but only a small percentage of those are successful at staying at the lower weight. These two activities take place over different time frames and require different skills. Most of the solutions to obesity have only been solutions for losing weight and have not included a solution for the much more difficult problem of keeping the weight off once lost.

Set targets that reduce obesity

  Failing to plan is planning to fail! It is important to reinstate measurable targets for obesity reduction and identifying efficacious weight loss methods and best practice. Uncertainty over the aetiology of obesity remains one of the chief barriers to designing effective strategies for prevention and treatment. The report continues the common lack of understanding of the complexities of obesity and thereby contributes to the uncertainty of how to treat.


  Cox JSA., Hewlett B. (2000) Attitudes and opinions towards some weight related-issues. International Journal of Obesity, 24, (suppl. 1), pS58.

  Department of Health (1992). The Health of the Nation. HMSO.

  Department of Health (1999). Saving Lives: Our Healthier Nation, The Stationery Office.

  Department of Health (2000). National Service Framework for Coronary Heart Disease: Modern Standards and Service Models.

  Department of Health (2000). The NHS Plan: A Plan for Investment, A Plan for Reform. The Stationery Office.

  Ministry of Agriculture, Fisheries, and Food (1992). Household food consumption and expenditure. London: HMSO.

  NHS Centre for Reviews and Dissemination (1997). Effective Health Care: The Prevention and Treatment of Obesity, Vol 3, No. 2.


April 2001

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