APPENDIX 3
Memorandum by Professor A H Barnett (OB
5)
SUMMARY
Obesity has reached epidemic proportions in
the UK, both in the childhood and adult population, and is predicted
to increase significantly over the next few decades. It is associated
with major co-morbidities, including type 2 diabetes, cardiovascular
disease and cancer and there is now an excellent evidence base
which demonstrates unequivocally the value of maintained weight
loss in the obese population.
Prevention of obesity is even more important
with the requirement for major educational programmes starting
in childhood and continuing into adulthood. Encouragement of healthy
eating, increased physical activity and a host of measures which
include changes in food labelling and advertising, support in
schools and in the community, is urgently required. The costs
of obesity are enormous and the costs of the co-morbidities associated
with obesity are even higher. The Government needs to ask itself
whether we as a Nation can afford not to take this problem seriously.
The costs of inaction will, in the long run, be much higher than
the costs of doing something about the problem.
1. I am currently Professor of Medicine
at the University of Birmingham and Consultant Physician/Clinical
Director for Diabetes and Endocrine Services at the Birmingham
Heartlands and Solihull NHS Trust (Teaching). I have many years
experience in diabetes management and in related research and
education. I have a particular clinical interest in diabetes and
cardiovascular disease and the inter-relationships between the
two. For this reason I have developed a significant interest in
obesity, particularly in relation to its co-morbidities which
include type 2 diabetes and cardiovascular disease. I submit evidence
to the House of Commons Health Committee based on my expertise
in this area, with particular emphasis on the relationship between
obesity, type 2 diabetes and cardiovascular disease.
The health implications of obesity
2. Obesity rates in many parts of the world
have increased dramatically in recent decades. This is the main
reason why the numbers of people with type two diabetes world-wide
have also increased exponentially in recent years. Numbers are
now around 200 million people, with predictions that this will
reach 300 million by 2020. In the UK alone it is thought that
there is in excess of two million people with type two diabetes
and that these numbers will reach three million by 2010.
3. Diabetes is itself a cardiovascular disease
and around 80% of all patients with type 2 diabetes will die from
this complication, many prematurely. Diabetes now costs the Exchequer
around 9% of the total healthcare budget of the UK, with projections
that by 2025 that this could reach 25% of the total healthcare
budget! Around 80% of the costs of diabetes relate to the long
term complications mainly cardiovascular.
4. Obesity is not only a major cause of
type 2 diabetes and indeed the most important modifiable cause,
but is also a significant and independent risk factor for cardiovascular
disease per se. The relationship between obesity and cardiovascular
disease is independent of age, sex, blood pressure, cholesterol
levels, heart enlargement and indeed diabetes.
5. Less well appreciated is the fact that
obesity is also associated with around a 40% increased risk of
certain malignancies, particularly gynaecological cancers, prostatic
cancer and carcinoma of the colon.
Trends in obesity
6. Obesity rates have trebled in the UK
over the past 20 years. This is in large part due to inactivity
ie lack of exercise, but in addition the amount of food consumed
which is high in fat and refined sugars has continued to increased
as a proportion of the total diet. Obesity rates have increased
dramatically in many parts of the world, led by the USA where
over 30% of the population is now clinically obese. Rates in the
UK have now reached around 20% and even more worrying is the fact
that around 20% of teenage children are also now clinically obese.
The first cases of type 2 diabetes (which normally presents in
later life) are now being recorded in children and figures from
the USA (where this problem has been around for much longer) indicate
a very serious long term outlook for these children, with significant
numbers dying from heart attack or being on kidney dialysis and/or
blind before the age of 40 years.
7. Obesity rates have increased most dramatically
in lower social classes in the United Kingdom and indeed there
is now a social class divide which is becoming more significant
in rates of type 2 diabetes and cardiovascular disease.
Causes of the rise in obesity in recent decades
8. These mainly relate to sedentary lifestyle.
Indeed, this is probably the major contributor although dietary
factors with increasing emphasis in diets high in fat and refined
sugars make a significant contribution.
What can be done about it?
9. The Government must take significant
responsibility in counteracting increasing obesity rates and hopefully
affect a reversal. This will require significant investment in
a major public health campaign which should be Government-led
and public health initiated—this is not just a problem for
primary care!
10. The food industry must take a significant
role and most not be allowed to continue with misleading information
in advertising and food labelling (see later). The food industry
needs to change its marketing strategy and the media must use
its powers in a more positive way to support healthy eating and
appropriate changes in lifestyle, particularly increased physical
activity.
11. As stated, Government both at central
and local level must play a leading role in the above and I presently
detect little coherence in national or local strategies. To look
at International best practice one can perhaps study the way that
the Scandinavian countries have introduced their public health
programmes. In Finland, which at one time had the highest rates
of cardiovascular disease in the World, there has been a dramatic
fall in recent years—now below the levels in the UK. Scandinavian
countries have encouraged, through public health measures, a more
healthy lifestyle, particular increased physical activity. At
the same time, our own Government's practice of allowing schools
to sell off playing fields has been a disgrace!
12. More resource needs to be put into Public
Health advertising, encouraging Primary Care Trusts to take obesity
seriously, encouragement of weight management programmes and,where
indicated, anti-obesity drugs (which can be extremely effective
as part of a weight management programme in appropriate cases).
13. It is also important to recognise that
childhood obesity is a "timebomb waiting to explode"
and considerably more resource needs to be invested in school
education programmes.
Are the institutional structures in place to deliver
an improvement?
14. The Government needs to lead on this
one! The Department of Health and the NHS generally has an important
role to play, but it is ludicrous in the extreme to expect that
these problems can be tackled by primary care alone and indeed
hospital and specialist clinics. I have my doubts as to whether
health promotion can alone compete with the huge food sector advertising
budgets and I believe that there must be some form of compulsion
on the food sector to be much more honest in the way they advertise
their products. There should also be encouragement of true healthy
eating products and labelling which properly reflects food content.
Given the amount of tax that Government collects from cigarettes
perhaps one might think about punitive taxes on unhealthy foods!
15. The role of schools in preventing obesity
in children is extremely important and there are a host of measures
which could be taken which would be extremely helpful.
16. It is clear to me that there is a lack
of appropriate institutional structures, certainly not enough
cash, and that the Government (at least until now) has not seen
obesity as a high priority.
Recommendations for National and local strategy
17. I would suggest the following:
— There should be a National Service
Framework for Obesity.
— Much more resource needs to be put
in at Government level from the point of view of health promotion,
including healthy eating, encouraging physical activity and so
on.
— The Government needs to come down
hard on the food industry and outlaw the kind of misinformation
which is so common. A good example of this is goods labelled as
"80% fat free". Given that fat is twice as energy dense
as carbohydrate this means that such "healthy food"
actually provide around 40% of its caloric value as fat and almost
by definition also contains a lot of sugar. It is scandalous that
this kind of advertising is allowed to continue. It is also scandalous
that supermarkets should be allowed to have so-called "healthy
eating" sections where because foods are low in fat one immediately
is led to believe that they are healthy eating options. Again,
commonly these foods are very high in refined sugars. Organic
labelling also is a source of mis-information in that one automatically
assumes that because a product is labelled "organic"
it is healthy. This is often not the case as commonly they contain
high levels of sugar and/or fat.
— Schools should be discouraged from
having soft drinks machines and should be encouraged to provide
pupils with more balanced diets—a reduction in saturated
fat and refined sugars would be particularly welcomed.
— Schools should not be allowed to
sell off "excess" land unless they can demonstrate that
a full range of sporting facilities will still be available to
its pupils.
— Obesity in children must be particularly
targeted with help and support in schools and similar help to
parents.
— Public health measures must be set
in place to provide the necessary information and to also support
weight management services within the community.
I am willing to give oral evidence to the Committee.
This evidence is submitted on an individual basis.
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