Treatment of obesity
344. Dr Nick Finer, a consultant in obesity medicine
at Addenbrooke's Hospital, Cambridge, stressed to us that "even
the most successful prevention policies cannot address the current
burden of ill health related to obesity, nor obviate the need
now, or in the future, for appropriate medical care for the obese."[334]
However, when we asked about the provision of such services, we
were informed by the Department that the responsibility for ensuring
provision of obesity services rested exclusively with PCTs. Worryingly,
it was not only in strategic action to prevent obesity that PCTs,
and the NHS more broadly, appeared to be failing. The evidence
we received pointed repeatedly to the gross inadequacy of services
currently available to tackle obesity within the NHS, as articulated
by Dr Ian Campbell, a GP with a special interest in obesity:
Whilst no-one would disagree that it is important
to prevent obesity, particularly among children, I just find it
inconceivable that we should reach a situation where we are not
able to offer treatment to those who are already obese, which
is about 10 million people.[335]
345. Sally Hayes, of North West Leeds PCT, described
the current situation in even more stark terms, contending that
"at present most of the NHS has no systematic approach for
the management of obesity at any level of BMI."[336]
346. The problems appear to have originated with
a lack of prioritisation within PCTs, and to have filtered through
every level of service provision. TOAST argued that the vast majority
of PCT teams were unaware of their obese patients and "frankly
uninterested and unaware of the aetiology of the problem."[337]
This view was supported by Roche, who maintained that there was
"little motivation within PCTs to ensure that weight management
is offered to patients" since obesity is seen as a "lifestyle"
not a medical issue.[338]
The Dr Foster research showed that over half of primary care organisations
in the UK did not have organised weight-management clinics within
their local areas, and even in those areas that did, such clinics
were available on average through only a quarter of GP practices.
According to Roche, "obesity does not rank very highly as
an area of interest to GPs", a view which was re-emphasised
by Sally Hayes:
At present, primary care professionals are offering
short term support to people who are obese within current resources
which may include diet, activity and behavioural strategies. Unfortunately
this is often on an ad hoc basis with little structure to these
key interactions.[339]
347. Obesity is a complex medical problem, and it
is clear that superficial interventions, such as the distribution
of a diet sheet to an obese patient, are unlikely to work. Specialist
skills and knowledge are needed fully to engage with obesity as
a psychological and behavioural as well as a physiological problem.
It has been likened by some to alcoholism, and requires similarly
holistic treatment programmes.
348. Professor John Baxter, a consultant bariatric
surgeon, described his constant amazement at the fact that other
doctors referring patients to him for bariatric surgery appeared
to know so little about obesity, and evidence from those actually
working in primary care supported this view. Louise Mann, a practice
nurse at the Gable House Surgery in Wiltshire, told us that "as
nurses, we do not get any training at all in weight management
in our training. In primary care and with our practice, we did
weight management, but very much in an ad hoc way,
with no instruction at all."[340]
349. This is perhaps particularly concerning given
that many of our witnesses were in agreement that primary care
was the best level at which to tackle obesity. The National Obesity
Forum argued that the "vast majority of overweight and obese
people are encountered within primary care, either seeking help
directly for their weight problem, or indirectly because of a
related medical condition", and maintained that primary care
was the best place to offer intervention and concentrate funds
and efforts.[341] And
according to Colin Waine, Visiting Professor of Primary Care at
the University of Sunderland, "about 75% of the population
see their general practitioner in one year and approximately 90%
over a five-year period. Thus the opportunities exist to identify
opportunistically people at high risk and likely to benefit"
from treatment. Dr Waine went on to argue that this was in fact
one of the great strengths of the British system of primary care.[342]
Research commissioned by Roche suggested that patients were reluctant
to discuss their weight pro-actively, and would prefer their health
care professional to raise the issue. However, further research
found that general practitioners were unlikely to raise the issue
of obesity during a health consultation.[343]
350. The Counterweight project, a pilot obesity management
study being trialled in 80 general practices, is attempting to
evaluate the usefulness of setting up specialised obesity-management
clinics within a general practice setting, following specialised
training and using tailored protocols. The clinicians, who do
not necessarily need to be GPs, follow protocols setting out different
evidence-based 'lifestyle approaches' to obesity management. The
programme will be fully audited in each practice after two years,
and will measure changes in clinician knowledge, attitudes, perceived
confidence and willingness to treat obesity, as well as changes
in practice approaches to obesity management and weight-screening
rates. The primary end point for the patient intervention programme
will be the percentage of patients achieving >5% and
> 10 % weight loss. While the final conclusions of the
programme will not be known for some time, the preliminary results
from the intervention programme indicate that clinically beneficial
weight loss can be achieved in high-risk obese patients in the
primary care setting.[344]
351. However, service providers maintained that resources
to provide structured, long-term interventions to tackle obesity
in primary care were simply not available. Dr Campbell felt that
GPs would be "up in arms" if they were instructed to
institute routine measurement of BMI, and stated categorically
that there was no point in measuring BMI without sufficient resources
to address obesity where it is identified:
To try to put this into context, my own practice
is 4,500 patients, and we have identified 483 who are clinically
obese. I could not start to treat all of those tomorrow, so just
measuring it is one thing. You need therefore the resources to
do something about it.[345]
352. The Counterweight Project told us that it deliberately
did not give practices extra funding, relying, in the words of
a practice nurse, "on the good will of GPs".[346]
We also heard how a 15-month project to develop a service for
weight management within four GP practices in the Leeds North
West area also risked being abandoned as it could not secure ongoing
funding.[347]
353. In contradiction of the Public Health Minister's
argument that the new GP contract provided sufficient incentives
for health promotion, Dr Campbell told us that out of a possible
1,000 quality points GPs could gain, only three could be acquired
by measuring body mass index.[348]
None related purely to the treatment of obesity. Dr Campbell characterised
this failure of the new GP contract to incentivise GPs to treat
obesity as a significant mistake.
354. Our witnesses argued compellingly that improving
obesity services within primary care was not an aspiration that
was entirely out of reach. Dr Campbell suggested that programmes
to train primary care clinicians in obesity management, like the
Counterweight project and that being undertaken by Leeds North
West PCT, would not need to be extended to all primary care practices,
but that targeted training need only be offered to interested
GPs. Trained GPs with a specialist interest in obesity could then
provide specialist obesity services within their own practices,
and other practices could also refer to them, as an intermediary
between primary and secondary care.
355. We feel that this country's well developed
network of primary care providers, local GPs, provides a unique
resource for health promotion and for the identification and management
of patients who are overweight or obese. However, managing weight
problems sensitively and successfully requires specialist skills,
and we are concerned by suggestions that obesity is viewed by
many clinicians as a lifestyle issue rather than a serious health
problem requiring active management to prevent dire health consequences.
We deplore the low priority given to obesity by the new GP contract.
We hope that NICE guidance on the prevention, identification,
evaluation, treatment and weight maintenance of overweight and
obesity, currently expected in Summer 2006, will go some way towards
increasing the priority of obesity within general practice, as
well as helping primary care practitioners develop and improve
the services they provide in this difficult area. The Government
should also ensure that within each PCT area there is at least
one specialist primary care obesity clinic, probably supported
by a range of different health professionals, to which GPs can
refer any patients they identify as needing specialist support
to address a developing or existing weight problem.
356. Weight management within primary care may not
necessarily need to take place in traditional primary care settings
such as the GP surgery, or even be carried out by GPs. The majority
of practices in the Counterweight project, for example, ran nurse-led
clinics under the supervision of a GP. Community dieticians can
also play an important part, and organisations representing community
pharmacists have submitted evidence stating that they are keen
to play an increased role in dealing with obesity; and that they
have developed thinking in this area, building on an existing
scheme for diabetes testing.[349]
In Finland we noted moves to make testing for diabetes available
in a much wider range of settings. We recommend that, in establishing
primary care obesity clinics, PCTs should fully explore the possibilities
of using less traditional models of service delivery, involving
clinicians from across the professional spectrum, from nurses
to pharmacists to dieticians. The full range of interventions
available to treat obesity includes diet, lifestyle, medical treatment
and surgical treatment.
357. We also took some interesting evidence from
commercial slimming organisations. We recommend that the NHS examines
whether their expertise can be brought to bear in devising strategies
to combat obesity holistically.
358. Although primary care provides the best starting
point for treating people with weight problems, more specialist
care is clearly necessary for some patients, particularly those
with severe and complex problems relating to their obesity, including,
amongst others, patients with metabolic and cardiovascular disease
whose treatment will need to involve an holistic approach to their
medical needs; those suffering from sleep apnoea syndrome; those
requiring peri-operative care where weight loss may be needed
to minimise risk and optimise outcome; and those with life-threatening
morbid obesity.
359. The evidence we received universally pointed
to a dire lack of specialist obesity care provision in the NHS.
Sally Hayes, of North West Leeds PCT, stated that currently "the
secondary care service for morbid obesity has a closed waiting
list."[350] Dr
Nick Finer, a consultant obesity physician, argued that "secondary
care cannot effectively contribute to the management of obesity
since it hardly exists."[351]
Interestingly, we heard that there have in fact recently been
specific directives aimed at the treatment of obesity in secondary
and tertiary care. Services for morbid obesity were defined in
the Specialised Services National Definitions Set (2nd Edition)
No. 35, released by the Department in December 2002. These identified
specialised treatment activity that should be subject to collaborative
commissioning arrangements including: "an integral management
approach … aimed at weight loss and weight maintenance …
drawn up by a multi-disciplinary team to meet the needs and requirements
of each individual patient." However, Dr Finer argued that
in his own area of Anglia, as well as elsewhere in the UK, "these
services remain unimplemented, with no process or individual responsible
for their implementation as yet operational."[352]
360. Dr Finer reported that the existence of both
of the clinics he ran had always been dependent upon research
funding, and that both clinics struggled "to receive explicit
funding from Primary Care Trusts."[353]
He also described the significant mismatch between demand and
capacity. At his Luton clinic, he could see about 250 new patients
a year. At Addenbrooke's the capacity was only 80 new patients
a year. However, the clinics regularly received five times as
many referrals as this, and even this figure did not take account
of a vast amount of untapped demand. Dr Finer estimated that the
current prevalence of obesity meant that within the catchment
area of a typical hospital serving a population of 300,000, about
130,000 adults would be overweight or obese, 53,000 obese (BMI>30),
and about 3,500 morbidly obese (BMI>40). This means that even
if specialist obesity treatment were only to be offered to all
patients with morbid obesity, Dr Finer's clinic would require
a 14-fold increase in capacity.[354]
361. Oversubscription to the clinic recently forced
Dr Finer to run 'group' consultations, which were not well received
by patients, and also, more worryingly, to close his clinics to
new patients when waiting lists got too long:
The problem has always been how to meet the demand
which is there, with the lack of resources. At Luton … over
the last seven or eight years the only way of managing referrals
was to shut the clinic to referrals. I have been at Addenbrooke's
now full-time for a year, and I run a clinic that is primarily
resourced from my appointment as a university appointment. Without
my doing a large number of extra clinics to see these new patients,
I would have lost Addenbrooke's Hospital its third star probably
six months ago.[355]
362. The Department told us that there were only
ten obesity clinics in England, and that these were not evenly
distributed.[356] According
to Dr Finer, all of these clinics had waiting lists of "at
least 12 months".[357]
To put this in context it is worth noting that the Government
aims to achieve a maximum wait of three months for an outpatient
appointment in any specialty by 2005, and interim targets for
March 2004 were set at no more than four months for an outpatient
appointment.[358] However,
when discussing with us the number and availability of specialist
obesity clinics, Department of Health officials did not seem concerned
about the low numbers, and stated that "whether there should
be more is a decision that needs to be taken through PCTs in consultation
with other local commissioners as to the need."[359]
363. Obesity is a serious medical problem. Although
in common with other illnesses, its prevention and some first-line
management can be delivered within a primary care setting, patients
with more entrenched or complex problems need prompt access to
specialist medical care. Childhood obesity is a worrying and increasingly
common subset of this illness, and children in particular need
specialist care. Yet specialist obesity services seem to be an
almost entirely neglected area of the NHS, apparently exempt from
Government initiatives to push down waiting times despite their
obvious importance in preventing a large range of other debilitating
and costly diseases. We therefore recommend that the Government
provides funding for the large scale expansion of obesity services
in secondary care, underpinned by careful management to ensure
that the service provision is matched to need. The Government's
maximum waiting time targets must apply to all of these services.
364. The treatment of children with obesity is, if
anything, more important than that for adults, as habits set down
in childhood are likely to form the pattern for the rest of a
person's life. However, Dr Finer told us that specialist services
for obese children were "even patchier" than the virtually
non-existent provision for adults, a view endorsed by Dr Mary
Rudolf, a consultant paediatrician with a specialist interest
in obesity:
There is a dire lack of services within the NHS for
the management of childhood obesity. Our experience in Leeds is
likely to be typical of the rest of the country. There is no specialist
service even for the grossly obese. A minority of these children
are seen in the Regional Endocrinology Service (and only if they
are likely to have medical problems resulting from their obesity).
They are seen briefly and only very periodically for a "medical
check" but no real intervention. The hospital paediatric
dietetic department is so limited that there is a ruling that
no child may receive dietetic advice about their obesity even
if they are on medication for the problem. [360]
365. In June 2003 the waiting list for the specialist
obesity service for children at Bart's and the London Trust stood
at 11 months and rising.[361]
366. We were appalled to learn of the desperate
inadequacy of treatment and support services for obese children.
Steps must be taken to ensure that obese children and young people
have prompt access to specialist treatment wherever they live.
367. Recent research carried out by the Peninsula
Medical School has suggested that overweight and obesity are now
becoming so commonplace amongst children that even parents are
failing to notice when their own children become overweight or
obese. In a survey of 300 British families, only 25% of parents
with overweight children recognised that their children were overweight.
No fathers identified their sons as overweight, even when they
were, and, perhaps even more disturbingly, 33% of mothers and
57% of fathers described their children as 'normal' when in fact
they were obese.[362]
As treatment is only possible once a problem has been identified,
this represents a worrying trend. We were also told by Professor
Jane Wardle, of the Health Behaviour Unit at University College
London, that parental concern about children developing eating
problems may be overly biased towards eating disorders such as
anorexia and bulimia:
I think parents feel exceptionally responsible if
their children develop eating disorders. I think probably they
feel slightly less responsible if their children develop obesity,
even though that may not be the justifiable allocation of responsibility.[363]
368. We feel that the school nursing system offers
a valuable opportunity to correct this through a programme of
routine measurement of BMI throughout a child's school career.
The Children's Minister, Margaret Hodge, expressed reservations
about the possibility that such a measure could stigmatise overweight
and obese children. We are confident that this could be overcome,
through the adoption of a sensitive approach whereby rather than
singling out individuals, all school children are weighed and
measured once a year, and their BMI results sent in confidence
to their parents together with, if appropriate, advice on how
to modify diet and exercise patterns. Not only would this system
identify children who are already overweight or obese, but it
could target those at the top end of the 'normal' range of BMI
to prevent further weight gain. As the Public Health Minister
reassured us that every school now had access to a school nurse,
we are confident that such a scheme could be administered within
existing resources.
369. We recommend that throughout their time at
school, children should have their Body Mass Index measured annually
at school, perhaps by the school nurse, a health visitor, or other
appropriate health professional. The results should be sent home
in confidence to their parents, together with, where appropriate,
advice on lifestyle, follow-up, and referral to more specialised
services. Where appropriate, BMI measurement could be carried
out alongside other health care interventions which are delivered
at school, for example inoculation programmes. Care will need
to be taken to avoid stigmatising children who are overweight
or obese, but given that research indicates that many parents
are no longer even able to identify whether their children are
overweight or not, this seems to us a vital step in tackling obesity.
370. The National Institute for Clinical Excellence
(NICE) has published guidance supporting the use of the obesity
drugs orlistat and sibutramine in certain, limited circumstances.[364]
These drugs in no way represent a 'cure' for obesity, their success
rate averaging a maximum of 5kg of weight loss per year of treatment,
weight loss which is usually regained once treatment has stopped.
For this reason, the conditions attached by NICE to use of these
treatments stipulate that they must be supported by dietary and
lifestyle changes. According to the Department's memorandum, estimated
costs since the two products became available on the NHS are now
approximately £31 million.[365]
371. Research carried out by Dr Foster concluded
that 96% of PCTs were prepared to provide funding for drugs for
the treatment of obesity, although 4% were not, despite the NICE
guidelines. However, this does not necessarily provide a true
picture of whether all patients who could potentially benefit
from drug treatment are obtaining it, as this will depend on whether
GPs are knowledgeable and confident enough to prescribe it, or
whether patients are able to secure a referral to vastly over-subscribed
specialist obesity clinics. Equally, although PCTs may have an
official policy of funding the drugs, GPs may come under pressure
to curtail their prescribing of obesity drugs to stay within cost
limits, a situation described to us by Dr Campbell:
Two days ago I received a letter from my own primary
care trust saying that as a PCT we were quite high in our use
of weight-loss medication, and we were to reconsider our practice
policies. I cannot recall, in 15 years in general practice, receiving
a letter questioning our prescribing of heart disease medication
or diabetic medication; and this really typifies the prevailing
attitude at the moment.[366]
372. We were dismayed to hear that a specialist
GP who devoted much of his time to trying to tackle obesity in
his local population was being put under pressure from his local
PCT to reduce his prescribing of drugs to tackle obesity, despite
these drugs having received approval from NICE, with the corresponding
obligation on PCTs to provide funding for them. We were told by
the same doctor that in 15 years of practice he had never received
communications questioning his prescribing rates for drugs to
treat heart disease or diabetes, two illnesses frequently caused
by obesity. This provides a telling exposé of current attitudes
towards obesity, whereby it is regarded by NHS decision-makers
as a lifestyle problem for which treatment is an optional extra.
We recommend that the Government takes urgent steps to tackle
this subtle deprioritisation of obesity wherever it occurs in
the NHS.
373. A more drastic option for treating obesity is
through surgery. Obesity surgery, also described as bariatric
surgery, can be either 'malabsorptive' or 'restrictive'. Malabsorptive
surgery works by shortening the length of the digestive tract
(gut) so that the amount of food absorbed by the body is reduced.
This type of surgery involves creating a bypass by joining one
part of the intestine to another. Restrictive surgery limits the
size of the stomach so the person feels full after eating a small
amount of food. This type of surgery can involve 'stapling' parts
of the stomach together or fitting a tight band to make a small
pouch for food to enter.[367]
Currently, four types of obesity surgery are available: vertical
banded gastroplasty, the Lap-Band system, Roux-en Y gastric bypass,
or biliopancreatic diversion with a duodenal switch.
374. NICE have also given their approval for obesity
surgery to be funded for NHS patients. Having reviewed 19 clinical
trials and other evidence, NICE concluded that:
surgery for people with morbid obesity is associated
with significant weight loss that is maintained for at least 8
years, whereas there is little sustained weight loss with conventional
treatment in this group of patients. Surgery is also associated
with improved quality of life and reduced co-morbidities. There
are significant risks attached to surgery, although these are
thought to be outweighed by the benefits.[368]
However, Professor John Baxter, a consultant bariatric
surgeon, told us that despite this recommendation obesity surgery
services in the UK were 'third world' when compared with other
developed countries. NICE's guidance suggested that the NHS should
aim to build bariatric services up over the next eight years to
around 4,000 procedures per year, from the 200-300 procedures
performed in the UK at present. Professor Baxter felt this target
number to be "manifestly too low".[369]
375. Based on the assumption that in the UK around
0.8% of males and 2% of females are morbidly obese, Professor
Baxter argued that there were currently around 228,000 men and
570,000 women potentially suitable for surgery. If this were expanded
to include all patients who had a BMI between 35 and 40 who had
a co-morbid condition, this would push the target population up
to 1.2 million. On top of this, Professor Baxter estimated that
a further 5,000-8,000 patients would become morbidly obese each
year. Even if only 5% of suitable patients opted for surgery,
in his view a very conservative estimate, this would mean a current
"backlog" of around 60,000 patients needing surgery
immediately. Professor Baxter told us that the Swedish health
service worked on the assumption that to maintain a "steady
state", 500-1,000 procedures are needed per year per 500,000
population. Extrapolating this using UK data, around 25,000 procedures
would be needed per year in this country, over six times the number
recommended by NICE.[370]
376. Dr Finer supported Professor Baxter's view about
the problems with obesity surgery:
Obesity surgery remains virtually unfunded and unavailable
to most eligible patients through the failure of district Health
Authorities and now Primary Care Trusts to implement NICE guidance.[371]
377. Professor Baxter described provision of bariatric
surgery as a "postcode service" and warned that Strategic
Health Authorities were now "starting to panic about how
to provide this service."[372]
He told us that waiting lists were very long in all centres. For
his service, in Swansea, the waiting list was one year for an
outpatients appointment, followed by three years' wait for surgery,
giving a total wait of four years. Another impediment to access
was that many suitable patients were not being referred simply
because their GPs were ignorant about bariatric surgery. The huge
mismatch between capacity and need was shown by Professor Baxter's
estimate that at least 300 obesity surgeons were needed, compared
with the 13 or 14 currently practising.
378. In the United States, we met with two bariatric
surgeons who explained that bariatric surgery was a rapidly increasing
speciality there. Last year there were 103,000 bariatric operations
performed in the US and this figure is projected to rise to 126,000
this year. While up until two years ago, these operations were
only carried out in large specialist university hospitals, now
almost every private hospital, both large and small, performs
the operations.
379. Bariatric surgery is in no way a panacea
for the current obesity epidemic. Rather it is a high-risk, invasive
surgical procedure that represents a last line of defence for
people with life-threatening morbid obesity. However as the number
of people suffering from morbid obesity in England looks set to
increase, it is an option that needs to be made available to all
those who need it, and it is unacceptable that in some parts of
the UK patients with a life-threatening condition are having to
wait as long as four years for bariatric surgery. We hope that
the measures we have recommended to improve provision of specialist
obesity services in both primary and secondary care will help
to address the problem that many patients are not referred for
bariatric surgery simply because their local doctors are not aware
that it is an option. However, the NHS needs also to ensure that
adequate service capacity is in place fully to meet need, which
is patently not the case at present. The Government must devote
protected resources to ensuring that bariatric surgery is available
to all those who need it, and should issue guidelines for the
strategic development of services across the country, to eliminate
the current postcode provision of obesity surgery.
380. As well as medical and surgical approaches,
it is vital that the psychological and behavioural aspects of
obesity are addressed. As TOAST pointed out in their written evidence,
there are a multitude of reasons why people may overeat, many
of them linked to underlying psychological factors:
We have asked a variety of groups why they think
obese people overeat. The following list is typical of the answers
given:
Boredom Guilt
Anger Shame
Stress Because it's there
Loneliness Pressure from other people
Happiness Going to start a diet tomorrow
Revenge Frustration
Depression It's Sunday
Addiction Pleasure
Habit Unloved
Not appreciated Unfulfilled
Tired Unsatisfied
Unhappy To celebrate
Comfort Holidays[373]
381. TOAST argued that amongst some groups, obesity
was comparable to addictive habits such as smoking or alcohol
dependence:
For many types of obese [people] there is a strong
link to the problems of those with a drink problem; many talk
of sometimes feeling out of control around food … All the
alcohol treatment programmes we know of use some form of counselling
within their treatment profile. They recognise that the 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.
Alcohol treatment programmes help people to recognise why they
have been over consuming and to find other coping mechanisms,
helping clients build belief in them.[374]
382. TOAST and the Royal College of Psychiatrists
both argued strongly that multidisciplinary teams to treat obesity
must involve a range of professionals properly equipped to address
the psychological and behavioural aspects of obesity, including
counsellors, psychiatrists, psychotherapists, psychologists and
family therapists.[375]
We feel it is vital that advances in medical and surgical treatment
of obesity should be supported by equivalent development of services
to address the psychological and behavioural aspects of obesity.
All those receiving treatment for obesity, whether in a primary
or in secondary care setting, should have access to psychological
support provided by an appropriate professional, whether this
is a psychiatrist, psychologist, psychotherapist, counsellor,
or family therapist.
Prioritisation within the NHS
383. While we agree that the obesity epidemic has,
in contrast to other public health concerns which may come to
prominence very rapidly, manifested itself gradually and insidiously
over a number of years, we were a little surprised to hear the
Public Health Minister, Melanie Johnson, argue that it had "caught
us all slightly unawares."[376]
While it is clear that the Government and the NHS are at present
unprepared to deal with this problem on the scale at which it
now presents itself, obesity has been recognised as a serious
threat to the nation's public health by experts and governments
alike for several decades. In 1976, nearly 30 years ago, a report
by a joint Department of Health and Social Security and Medical
Research Council group highlighted the problem in unequivocal
terms:
We are unanimous in our belief that obesity is a
hazard to health and a detriment to well being. It is common enough
to constitute one of the most important medical and public health
problems of our time, whether we judge importance by shorter expectation
of life, increased morbidity, or cost to the community in terms
of both money and anxiety.[377]
384. Twelve years ago, the 1992 White Paper The
Health of the Nation identified targets for obesity reduction.
These targets were not met, and obesity increased rather than
decreased during this period. However, there were no obesity targets
in the 1999 public health White Paper Saving Lives, an
omission regarded by TOAST as deplorable: "With the obesity
epidemic raging, obesity had been dropped, with no strategy being
pursued to reduce or limit it."[378]
When questioned about why this had happened, Department of Health
officials responded that the issue of targets was a question for
Ministers. In its memorandum, the Department argued that service-based
targets within existing NSFs were sufficient:
The Priorities and Planning Framework for 2003-06
includes targets for reducing CHD. One of these targets requires
practice-based registers and systematic treatment regimes, including
appropriate advice on diet, physical activity and smoking. This
also covers the majority of patients at high risk of CHD, particularly
those with hypertension, diabetes and a BMI greater than 30. In
order to tackle health inequalities, the Priorities and Planning
Framework also sets a target to contribute to a national reduction
in death rates from CHD focusing on the 20% of areas with the
highest rates of CHD, and this should encourage action on obesity
in disadvantaged areas. The Priorities and Planning Framework
has also set a target to increase breastfeeding initiation rates
by 2 percentage points each year, particularly among disadvantaged
groups.
Standard One of the NSF for CHD relates to the reduction
of coronary risk factors in the population and requires that all
NHS bodies will have agreed and be contributing to the delivery
of a local programme of effective policies on promoting healthy
eating, increasing physical activity and reducing overweight and
obesity and have quantified data on the programme by April 2002.[379]
385. Speaking to the Health Service Journal,
Melanie Johnson, the Public Health Minister, expressed her view
that the current package of measures to tackle obesity,—which
she listed as the school fruit scheme, the Five-a-day fruit and
vegetable initiative, and the as yet unpublished Food and Health
Action Plan—when taken together "amounted to a strategy"
to tackle obesity.[380]
386. However, none of these things has any direct
connection to NHS services to prevent and treat obesity. And although
the Government has often cited a reluctance within the health
service for more targets and central directives, we in fact received
a substantial body of evidence from those working within the NHS
who argued strongly in support of a national service framework
specifically addressing obesity. Significantly, this call has
come both from clinicians and from those involved in NHS management.
Dr Ian Campbell, a GP, told us that:
The impact of a national service framework should
not be underestimated within the world of general practice. The
National Institute for Clinical Excellence has made many pronouncements
on weight management and the use of drugs for surgery, but they
are only accepted at a distance by health authorities and not
always acted upon; whereas national service frameworks are accepted
as being directives that must be done, by which primary care services
are judged; so it would have a huge impact on the service that
followed.[381]
387. Sally Hayes, the CHD Lead at Leeds North West
PCT supported this view, stating that an NSF in obesity "would
help greatly" as "the setting of standards and targets
does wake us up, as organisations".[382]
She described her current means of securing one-off funding for
obesity as "a mad scramble to try and bid for this and that",
and told us that funding uncertainties prevented her project from
being developed further, leading to de-motivation amongst staff
involved in tackling obesity.[383]
388. According to the Institute of Human Nutrition
at the University of Southampton, a key problem with the UK health
system in relation to obesity was that there was "a notable
absence of well-structured and validated care pathways" and
that furthermore, "there is no formal budgetary responsibility
at any level of care—community, primary, secondary or tertiary—for
the identification of the overweight and the support and management
of those identified as being at special risk."[384]
389. Although the Department argued that the references
to obesity within the NSFs for CHD and diabetes were sufficient
to address obesity, we were told by the Counterweight Project
that, ironically, those NSFs were in fact drawing resources away
from the prevention and treatment of obesity, despite the indisputable
link between obesity and both CHD and diabetes:
The main barriers to continued provision of a structured
approach to obesity management have been competing priorities
and a lack of dedicated nurse time. Many practices however claim
to be prioritising nurse and GP time to meet the national service
frameworks for conditions such as diabetes and coronary heart
disease. Ironically, many of these competing disease areas can
be directly improved by obesity management.[385]
390. Dr Nick Finer, a consultant obesity physician,
argued that the references to obesity within two NSFs were scant
and ineffectual:
Although there are odd little lines in the existing
NSF to cardiology and diabetes, the fact that they are right down
in the sub-sub-sections, means that to all intents and purposes
they are ignored.[386]
391. Sally Hayes supported this view:
Obesity is not specified enough within those standards
and milestones. There are other things based on medication, on
lifestyle. It is not specific enough really, and the targets are
not specific enough.[387]
392. Dr Ian Campbell, in his capacity as Chairman
of the National Obesity Forum, was one of many to recommend the
appointment of a 'Fat Czar' to develop a central government strategy
to tackle obesity on all fronts, in addition to the development
of an Obesity National Service Framework and obesity targets for
the NHS.
393. The evidence we received during the course
of this inquiry has convinced us that despite its overwhelming
importance, obesity remains a low priority for the majority of
service commissioners and providers in the NHS. The National Health
Service has a responsibility both to take strategic action to
prevent obesity, as part of its public health remit, and to provide
adequate treatment for those already suffering from overweight
or obesity, as it would for those suffering from any other medical
condition. It appears to us to be failing in both of these areas,
and this needs to change as a matter of urgency.
394. We are fully aware that obesity is mentioned
in existing NSFs, but we believe that these scant mentions are
woefully inadequate to provide a strategic framework through which
to tackle what has been described as 'the biggest public health
threat of the twenty-first century'. We also understand that a
public health White Paper will be published in the summer, but
again we fear that the extent and seriousness of the obesity problem
will be lost by including obesity only as part of a wider umbrella
of general public health initiatives.
395. We note the Government's reservations about
committing to further National Service Frameworks, which they
voiced in response to our report on Sexual Health. However,
the current structure of the National Service Framework programme
places too great an emphasis on tackling discrete disease areas,
focusing on downstream consequences at the expense of the upstream
contributors to these diseases, including obesity. Indeed, we
heard compelling evidence that many general practices are unable
to devote time to tackling obesity because of their obligation
to meet targets in the Coronary Heart Disease and Diabetes NSFs,
even though, ironically, many of these 'competing' disease areas
can be directly improved by tackling obesity. And while it is
clear that general public health problems, such as smoking, can
be addressed within disease-based NSFs, the lack of obesity targets
has led to this area being systematically neglected.
396. It is essential that, as part of the Government's
wider strategy to tackle obesity, a dedicated framework document
is produced to emphasise to a largely sceptical NHS the full scale
and seriousness of this problem. The complexity of the challenge
facing the NHS in this area, including the need to develop services
and care pathways across all tiers of service delivery in a rapidly
changing area of medicine, as well as to take the lead on prevention
and health promotion, makes a detailed strategic framework vital.
This document should build on existing work in this area, drawing
together and emphasising the obesity measures already set out
in the National Service Frameworks, and linking in with the ongoing
work of NICE. Crucially, it must re-introduce realistic but stretching
targets for reducing the prevalence of obesity and overweight
over the next ten years, underpinned by more detailed, service-based
targets, in particular bringing waiting times for specialist medical
and surgical obesity services in line with all other NHS specialties.
PCTs should be stringently performance-managed on their delivery
of these targets.
182 Health Service Journal, 6 November 2003,
pp 26-27 Back
183
Q315 Back
184
Q256 Back
185
Storing up problems, p xii Back
186
Derek Wanless, Securing Good Health for the Population,
Final Report, February 2004, p 5 Back
187
Ibid, p 121 Back
188
Ev 109 Back
189
Q14 Back
190
Q357 Back
191
Q294 Back
192
Q1304; Q1306 Back
193
http://news.bbc.co.uk/1/hi/health/3579313.stm Back
194
Department of Health, press release 2002/0499, 28 November 2002 Back
195
Health Committee, Third Report of Session 2002-03, Sexual Health,
HC 69 Back
196
Department of Health, Memorandum OB 8C (not printed) Back
197
Move4Health is a co-ordinating body representing interested parties
seeking to tackle physical inactivity. More information can be
found at www.Move4Health.org.uk. Back
198
Appendix 34 (Focus on Food) Back
199
Q1509 Back
200
Ibid Back
201
Department for Education and Skills, http://www.dfes.gov.uk Back
202
Ev 81 Back
203
Ev 9 Back
204
For example, "All talk and no action on obesity",
The Guardian, 7 May 2004 Back
205
Q1109 Back
206
Q312 Back
207
Q302 Back
208
BBC Radio 4, The Today Programme, 3 March 2004 Back
209
FSA Paper 04/03/02, 11 March 2004, pp 8-9, www.food.gov.uk Back
210
Co-op, Blackmail, p3 Back
211
International Association of Consumer Food Organisations, Broadcasting
Bad Health, July 2003, p24 and http://www.childrensprogramme.org/regulate.html Back
212
See www.irishhealth.com Back
213
See, for example, Q864. Back
214
See eg Health Committee, Fourth Report of Session 2000-01, The
Provision of Information by the Government Relating to the Safety
of Breast Implants, HC 308, para 31. Back
215
Q1487; Q1493 Back
216
Food Standards Agency, A feasibility study into healthier drinks
vending in schools, Health Education Trust, March 2004, www.food.gov.uk. Back
217
'Ban Junk Food from Schools, says poll', The Guardian,
22 October 2003 Back
218
The 'Big 8' are defined as: energy, protein, carbohydrate with
declaration of sugars, fat with declaration of saturates, dietary
fibre, and sodium. Back
219
Q1166 Back
220
Q1151 Back
221
Q1148 Back
222
Q1143 Back
223
Q1153 Back
224
Q791 Back
225
Q897 (Andrew Coslett) Back
226
Q726, Q738, Q920 Back
227
Q535 Back
228
Q1170 Back
229
Q1386 Back
230
Q1168 Back
231
Q1179 Back
232
Q1168 Back
233
Q1179 Back
234
Swedish National Food Administration, http://www.slv.se/engdefault.asp
Back
235
Q1258 Back
236
Q1259 Back
237
Q1273 Back
238
Q1148 Back
239
Q1160 Back
240
Ev 18 Back
241
"From sick care to health care: meeting the challenge of
chronic disease", speech to Oxford Vision 2020 Conference,
3 December 2003 Back
242
Q291 Back
243
Q303; FSA Survey, 2001 Back
244
Q127 Back
245
"Government unit urges fat tax", BBC online news, 19
February 2004 Back
246
T Marshall "Exploring a fiscal food policy: the case of
diet and ischaemic heart disease", British Medical Journal
320 (2000), pp 301-304 Back
247
http://news.bbc.co.uk/1/hi/health/3502053.stm Back
248
Ev 230 Back
249
WHO, Global Strategy on diet, physical activity and health A57/9,
17 April 2004 Back
250
www.foe.co.uk Back
251
Ibid Back
252
"Setting aside the CAP - the future for food production",
Consumers' Association, 2001, p 13 Back
253
WHO global strategy on diet, physical activity and health: European
regional consultation meeting report, p. 11, Copenhagen, Denmark,
2-4 April 2003. Back
254
"Setting aside the CAP", p 48 Back
255
Q1195 Back
256
Q1196 Back
257
Q1201 Back
258
Q1206 Back
259
Appendix 59 Back
260
L S Elinde et al (2003), Public health aspects of the EU Common
Agricultural Policy, Stockholm: National Institute of Public
Health Back
261
Q977 Back
262
Ev 391 Back
263
Scottish Nutrient Standards, Section 1.2 and Section 1,
tables 1 and 2; England Primary School Guidance, Annex Cii;
England Secondary School Guidance, Annex Cii Back
264
Scottish Nutrient Standards, Section 1.5 Back
265
Scottish Nutrient Standards, Section 1.4 Back
266
England Guidance, Section 4 Back
267
England Primary and Secondary Guidance, Annex Cii Back
268
Scottish Nutrient Standards, Section 2, "Menu Planning"
table, Group 5 Back
269
Scottish Nutrient Standards, Section 2, "Menu Planning"
table, Group 5 Back
270
Q1497 Back
271
Q1501 Back
272
Q1028 Back
273
Appendix 19 Back
274
At least five a week, p 9 Back
275
However, a European Commission Survey conducted in December 2002,
which relied on self-reported evidence, placed the UK roughly
in the middle of EU countries for physical activity. See europa.eu.int. Back
276
Q492 Back
277
Appendix 24 Back
278
Appendix 44 (DfES) Back
279
See DfES website at www.dfes.gov.uk. Back
280
See DCMS website at dcms.gov.uk. Back
281
Committee of Public Accounts, Ninth Report of Session 2001-02,
Tackling Obesity in England, HC 421, p 7 Back
282
Q1022 Back
283
Ev 300 Back
284
Q1025 Back
285
Q1033 Back
286
Ev 163 Back
287
BMA Board of Science and Education, Road Transport and Health Back
288
Ev 164 (Living Streets) Back
289
Ev 163 Back
290
A C Cooper, et al, "Commuting to school: Are children who
walk more physically active?", American Journal of Preventative
Medicine, vol 25,4 (2003), pp 273-76 and K R Fox "Childhood
obesity and the role of physical activity", Journal of
the Royal Society for the Promotion of Health 124 (2004),
pp 34-39. Back
291
Environment, Transport and Regional Affairs Committee, Eleventh
Report of Session 2000-2001, Walking in Towns and Cities,
HC 167, Summary of Recommendations Back
292
Q499 Back
293
Q499 Back
294
www.transport2000.org.uk/news Back
295
Q503; the 'Silly Walks 'sketch was actually broadcast on 15 September
1970. Back
296
Qq144-48 Back
297
Ev 15 Back
298
Q503 Back
299
Information in this section is sourced from Colorado Department
of Public Health and Environment, Colorado Physical Activity
and Nutrition State Plan 2010. Back
300
Q877 Back
301
The Daily Telegraph, 23 April 2004 Back
302
Appendix 60 Back
303
Ev 161 Back
304
Department for Transport, Cycling to Work, 2001 Back
305
Transport, Local Government and Regions Committee, Eight Report
of Session 2001-02, 10 Year Plan for Transport, HC 558,
para 104 Back
306
Appendix 8 Back
307
Appendix 60 Back
308
Q502; 509 Back
309
Q563 (John Grimshaw) Back
310
Department for Transport News Release 2003/0172 Back
311
Ev 111 Back
312
Ev 111 Back
313
Ev 164 (Living Streets) Back
314
Health Committee, Second Report of Session 2000-01, Public
Health, HC 30, para 21 Back
315
Appendix 19 Back
316
Tackling Obesity in England, p 35 Back
317
"Architects join fight against the flab", BBC News website,
27 March 2003. Back
318
Ev 106 Back
319
Ev 103 Back
320
HC Deb, 30 March 2004, col. 131 W Back
321
www.culture.gov.uk Back
322
For example, see Appendix 33 (Dr Sheila McKenzie). Back
323
Ev 113 Back
324
Including Primary Care Trusts, Local Health Boards in Wales and
Scotland, and Health and Social Services Boards in Northern Ireland. Back
325
Dr Foster, Obesity Management in the UK, available at www.drfoster.co.uk. Back
326
Ev 351 Back
327
Q 1101 Back
328
Q1299 Back
329
Derek Wanless, Securing Good Health for the Whole Population,
Final Report, HM Treasury, February 2004 Back
330
Ibid, p 45 Back
331
Ibid, p 45 Back
332
Ibid, p 49 Back
333
Ibid, p 50 Back
334
Ev 329 Back
335
Q1046 Back
336
Ev 354 Back
337
Ev 372 Back
338
Appendix 6 Back
339
Ev 354 Back
340
Q1082 Back
341
Ev 318 Back
342
Q1063 Back
343
Appendices 6 and 7 Back
344
Ev 344-46 Back
345
Q1064 Back
346
Q1077 Back
347
Q1084 Back
348
Q1066 Back
349
Appendix 26 (The Pharmaceutical Services Negotiating Committee);
Appendix 31 (Lloydspharmacy) Back
350
Ev 354 Back
351
Ev 329 Back
352
Ev 329 Back
353
Ev 328 Back
354
Ev 329 Back
355
Q1047 Back
356
Q60 Back
357
Q1051 Back
358
Improvement, Expansion and Reform - the next three years -
Priorities and Planning Framework 2003-2006, Department of
Health Back
359
Q60 Back
360
Ev 329; Appendix 4 Back
361
Appendix 33 Back
362
The Observer, 14 March 2004 Back
363
Q205 Back
364
Nice Guidance No 22, Orlistat for the treatment of obesity in
adults, 9 March 2001. Nice Guidance No 31, Sibutramine for the
treatment of obesity in adults, 26 October 2001. Back
365
Ev 2 Back
366
Q1036 Back
367
Nice Technology Appraisal Guidance - No 46, Obesity Surgery, p
3, 19, July 2002 Back
368
Ibid Back
369
Ev 332 Back
370
Ibid Back
371
Ev 329 Back
372
Q1058 Back
373
Ev 372 Back
374
Ev 372 Back
375
Appendix 40 Back
376
Q1301 Back
377
Cited in Appendix 18 (Royal College of General Practitioners) Back
378
Ev 369 Back
379
Ev 15-16 Back
380
Health Service Journal, 6 November 2003, pp 26-27 Back
381
Q1041 Back
382
Q1075 Back
383
Q1084 Back
384
Appendix 32 Back
385
Ev 346 Back
386
Q1040 Back
387
Q1075 Back
