APPENDIX 36
Memorandum by Dr David Ashton (OB 66)
SUMMARY
— As a result of a longstanding interest
in obesity and its co-morbidities, I* have developed an innovative,
evidence-based treatment programme, the primary focus of which
is the reduction of obesity-associated health risks. The experience
acquired from this work has a national resonance and, in my view,
points the way forward to addressing an increasing national problem.
— The treatment model I have developed
is relatively inexpensive, has excellent outcomes and could be
replicated. Whilst more data are needed, there is considerable
potential to adopt such a model as a standard approach to the
treatment of obesity and its co-morbidities.
— There has been an alarming increase
in the prevalence of obesity in the UK population and this is
likely to continue for the foreseeable future. Between 1980-1998
there was a three-fold increase in obese males and a 2.5-fold
increase in obese females. Currently, more than half the UK population
is overweight or obese. Similar trends are observable in many
European countries.
— Obesity causes much human suffering
and is an important risk factor for a number of serious diseases
which constitute the principal causes of death in the UK. These
include heart disease, stroke, certain forms of cancer and, in
particular, type II diabetes. Indeed, the looming epidemic of
diabetes is a potential public health catastrophe which threatens
to destabilise existing healthcare budgets.
— Estimates suggest that obesity accounts
for 30,000 deaths per year in the UK and a shortening of life
by nine years on average, at an annual cost to the nation of some
£2.6 billion.
— The growing prevalence of obesity
amongst children is also of major concern. Recent studies suggest
that obese children and teenagers have a health-related quality
of life as low as that reported by some young cancer patients.
— Evidence suggests that the marked
decline in physical activity levels in the UK population may be
the most important single factor underpinning the current epidemic
of obesity.
— Despite a plethora of mass-market
weight loss programmes and gimmicks, there is a growing awareness
on the part of both public health specialists and politicians,
that what is now needed is an approach to the management of obesity
that reflects its importance as an individual well-being and a
public health issue, rather than simply as a cosmetic problem.
With the above observations in mind, and as
a physician with an active practice and front-line experience
of managing obese patients, I recommend that:
— Careful patient selection is essential
if optimal outcomes are to be achieved. Individuals who are not
ready for change should not be recruited into active weight-loss
programmes and should not be prescribed anti-obesity drugs.
— Government policy to tackle obesity
must place much greater emphasis on physical inactivity as a key
determinant of weight gain. Simple, inexpensive forms of activity
should be promoted. More attention should be paid to achieving
moderate levels of activity across the whole population (young
and old), than to the sporting achievements of a tiny minority
of elite, competitive athletes.
— Individuals who undertake courses
in sports science and leisure studies should be trained in exercise
prescription for obese patients and for those with pre-existing
co-morbidities such as angina and diabetes. Individuals with appropriate
training could then be attached to GP practices.
— No drug currently available, can
overcome the obesogenic effects of the environment. Prescribing
expensive anti-obesity drugs should be limited to those patients
who are genuinely committed to long-term lifestyle and behavioural
change.
— The media and fashion industry should
be encouraged to adopt a more responsible approach to the problem
of obesity and eating disorders, by recognising that many of the
images they present in their promotional advertising could be
harmful.
— The government should try to do more
to curb the activities of the growing number of operators and
organisations making completely unsubstantiated claims about "miracle"
slimming aids and gadgets. Obese patients are vulnerable to such
claims and deserve better protection.
— Schools should be more actively engaged
in teaching the skills required to achieve and maintain a healthy
weight. These skills should be a core part of the curriculum—not
an optional add-on.
— Food manufacturers should be encouraged
to develop a standardised approach to food labelling which can
be easily understood by all.
— Surgery for obesity should be made
more widely available than at present and should be used much
earlier in the natural history of the disease.
— The independent sector can meet a
significant proportion of the future need for bariatric procedures
in the UK.
1. INTRODUCTION
1.1 Definition
Obesity can be defined as a disease in which
excess body fat has accumulated such that health may be adversely
affected1. The measure of obesity most commonly used in clinical
practice is that of relative weight, or Body Mass Index (BMI),
defined as weight (kg)/height (m2).
Commonly used cut-points for BMI and the risk
of associated diseases are:
2. TRENDS IN
OBESITY
2.1 World Trends
In 1998 the World Health Organisation designated
obesity as a global epidemic2. Indeed, obesity is one of today's
most blatantly visible—yet most neglected—public health
problems. Paradoxically coexisting with undernutrition, an escalating
global epidemic of overweight and obesity—"globesity"—is
taking over many parts of the world. In 1995, there were an estimated
200 million obese adults worldwide and another 18 million children
under five classified as overweight. From 2000, the number of
obese adults has increased to over 300 million3. Contrary to conventional
wisdom, the obesity epidemic is not restricted to industrialised
societies; in developing countries, it is estimated that over
115 million people suffer from obesity-related problems. If concerted
action is not taken, millions will suffer from an array of serious
health disorders.
2.2 US Trends
In the US, results from the 1999-2000 National
Health and Nutrition Examination Survey (NHANES), show that 31%
of U.S. adults 20 years and over—nearly 59 million people—are
obese and an estimated 64% are either overweight or obese4,5.
Meanwhile, the percent of children who are overweight (defined
as BMI-for-age at or above the 95th percentile of the CDC Growth
Charts) also continues to increase. Among children and teens ages
6-19, 15% (almost 9 million) are overweight according to the 1999-2000
data, or triple what the proportion was in 19804,5. Estimates
suggest that 300,000 deaths each year in the U.S. are attributed
to obesity (compared with around 400,000 deaths attributable to
smoking)6. The economic cost of obesity in the U.S. in 2000 was
some $117 billion7.
2.3 UK and European Trends
In the UK there has been a rapid increase in
the prevalence of obesity in the population, such that between
1980-98 there was a three-fold increase in obese males and a 2.5-fold
increase in obese females. The most recent data show that around
one fifth of all adults in England are obese (21% men and 21.4%
women), while 66.5% of men and 55.2% of women are either overweight
or obese—around 27 million adults8. Indeed, in the UK we
have some of the highest rates in Europe and recent estimates
suggest that the prevalence in the UK by the year 2020 may be
as high as 30—40%9. In Europe overall, around 10 to 20%
of men and 10 to 25% of women are obese10.
2.4 Trends in Childhood Obesity
The growing prevalence of obesity amongst children
and adolescents in the UK is also a major concern11. Data from
a recently published nationally representative sample of 2,630
English children show that the frequency of overweight ranged
from 22% at age six years to 31% at age 15 and that obesity ranged
from 10% at age six to 17% at age 15 years12. Other studies have
shown a similarly worrying increase in children under the age
of four13.
The stark reality is that overweight children
are twice as likely as normal children to be obese as adults14.
In addition, obesity in childhood is associated with a variety
of health problems and co-morbidities that may persist into adulthood
(see below).
3. THE HEALTH
CONSEQUENCES OF
OBESITY
3.1 Obesity and Disease
Obesity causes much human suffering. It is an
important factor in a number of serious diseases that constitute
the principal causes of death in the UK. These include heart disease,
stroke, certain forms of cancer and type II diabetes. Obesity
is also associated with an increased incidence of respiratory
complications (obstructive sleep apnoea and asthma), back pain
and premature osteoarthritis of large and small joints9,15-17.
3.2 Obesity and Diabetes
The strong association between obesity and diabetes
("diabesity") is of enormous public health importance18.
There are around 2.4 million diabetics in the UK—one million
of whom are undiagnosed—and the diabetic population is projected
to double in the next 10 years. This looming epidemic of diabetes
threatens to destabilise healthcare budgets, by increasing the
prevalence of blindness, end-stage kidney failure, cardiovascular
disease and amputation. The impending catastrophe is made all
the worse by the appearance of type II diabetes among adolescents,
a phenomenon not seen a decade ago. In some adolescent clinics,
type II diabetes now represents up to one half of the new cases
of diabetes19.
3.3 Obesity and Mortality
Overall, estimates suggest that obesity accounts
for 30,000 deaths per year in the UK and a shortening of life
by 9 years on average20. Furthermore, the adverse effects of excess
weight tend to be delayed, sometimes for ten years or longer21.
3.4 Psychosocial Consequences
In addition to physical symptoms, the psychological
and social burdens of obesity can be significant: social stigma,
low-self-esteem, reduced mobility, unemployment and a generally
poorer quality of life are common experiences for many obese people2.
Adolescents and children may experience social isolation, depression
and under-achievement at school. Indeed, a recent report suggests
that some obese children and teenagers have a health-related quality
of life as low as that reported by young cancer patients22.
4. ECONOMIC
CONSEQUENCES OF
OBESITY
The health risks associated with obesity also
have an important economic impact. Conservative estimates suggest
that obesity in developed countries accounts for 2-7% of total
healthcare costs, which represents a significant expenditure of
national healthcare budgets23. In England in 1998, obesity accounted
for 18 million days of sickness absence and 40,000 lost years
of working life. The combined direct and indirect (represented
by loss of earnings) costs of obesity were £2.6 billion or
0.3% of the UK Gross Domestic Product20.
5. THE CAUSES
OF OBESITY
At the population level, the current epidemic
of obesity is attributable to an obesogenic environment that promotes
excessive food intake and discourages physical activity24. At
the individual level, obesity results from a complex interaction
between genetic, environmental and psychosocial factors, mediated
by a variety of chemical neurotransmitters which influence appetite
regulation. Whilst genes determine individual susceptibility to
weight gain, the obesity epidemic is not attributable to genetic
factors, since the increase in the prevalence of obesity has occurred
over too short a period for the gene pool of the population to
have changed substantially25.
There is a widespread assumption that obesity
in affluent societies is largely a matter of greed, encouraged
by a highly palatable diet backed by persuasive advertising and
available at ever diminishing cost relative to average income.
Clearly, the food intake of obese people must have been excessive
relative to their energy needs during the dynamic phase of weight
gain. However, survey data suggest that average energy (calorie)
intake has actually been declining during the last two decades.
We, therefore, have an apparently paradoxical situation in which
the proportion of overweight and obese individuals continues to
rise at an alarming rate, against a background of a reduction
in average calorie intake. This strongly suggests that it is the
decline in energy expenditure through physical activity which
has played the dominant role in the current obesity epidemic26.
This observation clearly has implications for public health strategies
aimed at reversing the current trends in overweight and obesity
in the UK. It may, however, also indicate that the remedy is simpler
and more affordable than originally anticipated.
6. TACKLING
OBESITY—KEY
ISSUES
6.1 An Integrated Approach
The most effective population based interventions
are likely to adopt an integrated, multidisciplinary, and comprehensive
approach and involve a complementary range of actions that work
at the individual, community, environmental, and policy level.
These various elements have been extensively reviewed in the recent
literature and do not require detailed examination here17, 27.
The following are meant to provide specific additional comments
in relation to a number of well recognised strategies.
6.2 Patient Selection
It is essential to recognise that those who
are overweight or obese, may not yet be ready or willing to make
changes. This seems such an obvious point, yet it is so often
overlooked when planning health education and treatment programmes,
which tend to assume that behavioural change is a defined event
which happens at a given point in time. This is incorrect. Behavioural
change is a process which evolves gradually through five well
recognised stages28 (see Fig 1).
Therefore the correct approach to management
will vary, depending upon where the individual happens to be in
terms of his or her readiness to change. If these stages are disregarded,
it will result in the patient actually becoming more resistant
to change rather than the reverse. There is, for example, little
point in talking about what action is required to lose weight,
in a setting where the patient is still in pre-contemplation or
contemplation. Failure to recognise the need for flexible approaches
to management depending upon the individual's readiness to change,
is the source of much frustration on the part of health professionals
and patients alike.
Figure 1 STAGES
OF CHANGE
More importantly, it can lead to inappropriate
deployment of expensive resources to individuals who are unlikely
to succeed. There is good evidence to suggest that patients in
contemplation, do not do well in weight-management initiatives,
because they have not sufficiently overcome their ambivalence
to making behavioural changes—even though they can, at a
rational level, appreciate the benefits. Moreover, many patients
will stay in contemplation for a long time—in some cases
years. They should not be recruited into weight loss programmes
and they should not be prescribed weight loss drugs. Only when
they have progressed to the point where they are ready for change
and willing to engage in a therapeutic process, should they be
considered for treatment. At our treatment unit, we do not accept
patients onto our programme who are in Stages 1 or 2, because
we know they will not succeed. Our strategy with such individuals
is to practice "watchful waiting" by remaining in contact
and providing information and support at a distance, until we
are satisfied that the individual has progressed beyond Stage
2.
Accordingly, in my view, only patients who are
in Stages 3 or 4 should be offered treatment for obesity—including
pharmacotherapy. This is not just an issue of scarce resources.
It is because recruiting patients into a weight-loss programme
when they are simply not ready for it, will result in failure.
And repeated failure actually makes it less likely that they will
succeed in future.
6.3 The Role of Physical Activity
There is good evidence that physical inactivity
is a key factor—perhaps the defining factor—underlying
the obesity epidemic. We are more sedentary now than at any other
time in our evolutionary history. Studies suggest that in order
to equate our daily physical activity with that of our ancestors,
we would need to be walking an additional 12 miles per day29.
The Department of Health (DoH) recently issued
guidelines to all GPs in England, encouraging them to refer patients
to a fitness instructor at a local leisure centre or gym. However,
experience suggests that whilst instructors in most health clubs
are very good at prescribing exercise to improve fitness and sporting
performance, they know very little about exercise prescription
in older individuals who may be limited because of obesity, arthritis
or some other medical problem, or by taking medication. About
40% of men and 50% of all women in this country are taking prescribed
medication of one form or another and there is a steep rise in
drug use from the age of 45 years onwards. The obvious danger
is that some patients may be recommended forms of activity which
are at best inappropriate and at worst frankly dangerous, by fitness
instructors who have not had the relevant training. A further
complication is that obese patients are often much too self-conscious
and embarrassed to attend health clubs which are populated by
younger, slimmer people.
A practical approach to solving this problem
would be to make exercise prescription to older patients—with
pre-existing medical conditions—part of the university syllabus
for those studying sports science who are intent on pursuing a
career in the leisure industry. Appropriately trained graduates
with expertise in prescribing exercise to obese and overweight
people and others with recognised risk factors, could then be
attached to GP surgeries to receive "in-house" referrals.
Of course attending a gym is not the only—or
necessarily the best—form of exercise for weight control.
Walking is an extraordinarily effective and much under-valued
exercise, which is safe and does not require expensive equipment
or membership fees. If the government were to spend money on promoting
this sort of activity across the whole population, it would have
an enormous return on its investment in terms of health gain.
Unfortunately, the government seems more concerned
to foster sporting excellence among a small group of elite athletes,
rather than promote moderate physical activity for all. The decision
to bid for the 2012 Olympics may be an excellent PR ploy, but
it is obscenely irrelevant to the public health of an increasingly
sedentary UK population.
6.4 Pharmacotherapy
Newer drugs such as sibutramine (Reductil) and
orlistat (Xenical) have an important adjunctive role to play in
the treatment of obesity and have been approved for use by the
National Institute for Clinical Excellence (NICE). However, experience
suggests that these drugs are frequently regarded by patients
as a "magic bullet" and are too often prescribed by
GPs as a first-line treatment, without the requirement for sustained
behavioural and lifestyle modification. This has important implications
for scarce healthcare resources and—in the longer term—may
result in such drugs being less readily available to those who
will genuinely benefit from them. No anti-obesity drug currently
available can override the influence of the external environment.
This means that, unless the drug prescription is provided in parallel
with sustained changes in behaviour and lifestyle, weight loss
will be short-lived. Furthermore, a history of failure is likely
to make patients less willing to attempt weight loss in future,
hence (indirectly) reinforcing negative health behaviours.
6.5 Media and Advertising
Historically, the obesity issue has been largely
dominated by a media and fashion industry whose agenda emphasises
the cosmetic rather than the health benefits of weight loss. The
situation is made more complex because society gives us powerful
but conflicting messages. One the one hand, super-size servings
of fattening (energy-dense) food are more abundant than ever and
the explosion of TV programmes about food and cooking help to
fuel our national obsession with food. On the other hand, celebrities
and fashion models continue to shrink, promoting what many experts
say are unrealistic body images. Industry pressure means that
fashion designers are not interested in the plus-size market because
it would stray from the idealised beauty image. These pressures
to conform can lead some women to take extreme measures in attempting
to lose weight, thus making them prey to a burgeoning and unregulated
slimming industry (now worth billions) and possibly placing their
health at risk.
This is an important public health message.
Many overweight or obese people have abandoned weight loss efforts
because they have tried, and repeatedly failed, to reach what
they have been told is a "desirable" weight, when a
more modest but achievable weight loss goal could reduce their
risk of heart disease and other obesity associated conditions30,31.
Accordingly, the first goal of our treatment programme is to reduce
health risks, ie to encourage the patient to achieve a healthier
weight.
The fashion industry could do far more to foster
a healthier perspective on body image and weight, by recognising
that promoting a particular "image" to which many women
will aspire, is potentially harmful. The initiative provided by
government several years ago, in which an attempt was made to
encourage fashion and magazine editors to adopt a more responsible
stance, seems to have come to nothing. This should be revived
with a more clearly defined agenda for change.
6.6 The Problem of "Junk-Science"
Obese patients are vulnerable to exploitation
by any number of unscrupulous operators making completely unsubstantiated
claims about "miracle" slimming aids and a bewildering
array of gadgets and alternative remedies. These include weight-loss
earrings; slimming slippers; weight-loss patches; weight-loss
body cream; various pills and potions and even weight loss soap.
Such advertising on the internet is, of course, completely unregulated,
but there is also a lack of effective control of advertisements
in the popular press and media. Whilst it is understandable that
patients want to find the easy solution to their problem, they
can often spend hundreds of pounds on products which do not work.
I would like to see the government become much more active in
curbing the activities of such organisations, by insisting that
they produce proper evidence to substantiate their claims.
6.7 The Role of Schools
The potentially important role of schools in
promoting a healthy lifestyle is clearly set out in the recent
National Audit Office publication "Tackling Obesity in England"17.
I welcome this and endorse the wide ranging recommendations which
are detailed in that document. The stated objective of personal,
social and health education is to provide a foundation for the
personal development of young people in preparing them for adult
life. This subject became part of the core curriculum in September
2000.
However, whilst the curriculum includes the
various elements of a healthy lifestyle, such as diet and physical
activity, it does not specifically address the skills required
in the context of weight management. Experience suggests that
children are not merely able to learn these skills, but actively
enjoy doing so. By emphasising that maintaining a healthy weight
in today's environment is a skill to be learned and teaching some
of these skills, schools could do a great deal to encourage behaviours
that will hopefully be lifelong.
6.8 Food Labelling—"At a Glance"
Several of the larger supermarket chains have
attempted to introduce some form of food labelling, in an attempt
to support customers who would like more help in making healthier
food choices. Whilst this is clearly a positive step forward,
because the systems used vary, many people still find making sense
of food labels a difficult process. It would be helpful if food
manufacturers could agree amongst themselves as to the clearest
and simplest way to label foods according to calorific value,
fat content etc. A simply grading system is required, since even
the most determined among us may find talk of mono-unsaturates,
trans fatty acids and glycaemic index confusing. One system—applied
across the board as a legal requirement—would make an enormous
difference to those who wish to choose healthier options.
7. OBESITY SURGERY
In recent years there have been remarkable developments
in obesity (bariatric) surgery and this now offers an alternative
intervention for patients who are morbidly obese (BMI >40 kg/m2).
It important to remember that, if left untreated, patients who
have a BMI >40 kg/m2, have only a one in seven chance of reaching
their normal life expectancy32.
Since the advent of obesity surgery in the 1950s,
techniques have been developed and refined, whilst others have
been discarded entirely. Today, data from more than 14,000 patients
on the International Bariatric Surgery Register, show that at
12-months vertical banded gastroplasty and gastric bypass result
in a mean loss of 53% and 72% of excess weight respectively, with
operative mortality of 0.17%. Moreover, 93% of patients experience
no morbidity33.
New technology has increased the range of procedures;
the latest technique, laparoscopic gastric banding (LGB), results
in patients losing some 50-60% of their excess weight and maintaining
that loss for at least 6 years34. Two recent studies involving
500 and 625 severely obese patients respectively, reported a very
low (1%) risk of peri-operative complications and no deaths. These
data show that LGB is a safe and effective intervention in the
morbidly obese35-37.
Thus, if the patient is well motivated and given
lifelong support, surgery is a highly effective intervention resulting
in permanent weight loss. As a consequence of this weight reduction,
patients experience an enormous improvement in their quality of
life, with better control of hypertension, reduced risks of diabetes
and heart disease, together with increased mobility, less joint
pain and improved respiratory function38. The risks of surgery
are, in general, orders of magnitude less than the risks entailed
by morbid obesity. It is, therefore, clear that —in (but
only in) carefully selected patients, obesity surgery is both
life-transforming and life-saving. Moreover, there is good evidence
to suggest that surgery provides a cost-effective approach to
the management of severe obesity39, 40. In the next decade, there
will be a significant growth in demand for bariatric surgery and,
with excellent long-term results now available, the intervention
will be used earlier in the natural history of the disease.
The National Institute of Clinical Excellence
(NICE) has published recommendations on the use of surgery in
the seriously obese38. The problem is that the sheer numbers involved
make service provision within the NHS a formidable problem. The
NICE report estimates that there are 1.2 million people in the
UK who are eligible—at least theoretically—for some
form of surgical intervention. However, this number is currently
growing at an estimated 5% (60,000) per year. At present there
are around 200 bariatric procedures performed in the UK each year,
many of them in the private sector. The NICE report recommends
that the NHS should develop surgical capacity over the next eight
years, towards a goal of 4,000 bariatric procedures annually.
However, the serious lack of NHS resources—both in terms
of equipment and appropriately trained staff—makes achieving
even this (modest) goal very unlikely. The independent sector
has sufficient capacity to provide a range of services for the
treatment of the morbidly obese—including bariatric surgery.
By ensuring careful patient selection, post-operative care and
long-term monitoring, optimal clinical and cost-effective outcomes
can be achieved.
8. A NEW TREATMENT
MODEL
The standard of care for obese patients in the
UK has, historically, been extremely poor. Obese patients are
not regarded as a priority and there is an all-pervasive climate
of therapeutic nihilism when it comes to medical treatment. This
means that countless thousands have effectively been abandoned
to dubious weight loss clinics, whose sole treatment approach
is to dish out dangerous and unlicensed drugs, or a slimming industry
which has grown to become a multi-billion pound enterprise.
For the past three years or so, I have been
working with colleagues to develop a more effective treatment
model for obesity and its co-morbidities. This work began with
a review of the scientific literature, to understand which approaches
appeared to hold the best prospects for future development. I
then consulted widely and visited a number of programmes in Europe
and North America. Based on this extensive preparatory work and
the model which eventually evolved, we began active treatment
of obese patients at our centre some two years ago. Our approach
to the diagnosis and management of obesity is based upon the following
fundamental principles:
— Obesity is a primarily a health issue—not
a cosmetic one.
— The environment—not the individual—is
the problem.
— Weight management in today's environment
is a skill to be learned.
We implement three main treatment strategies:
(1) Medically Supervised Weight-Loss
Programme
Patients undergo careful medical and behavioural
evaluation and then enter a 12-week programme. Briefly this consists
of weekly classes built around a behavioural core, providing intensive
lifestyle education and behavioural strategies for change. Key
elements of the programme include portion control, nutritional
education, environmental management, increased physical activity
and patient accountability.
(2) Pharmacotherapy
Patients who require pharmacological intervention
are carefully assessed prior to treatment. This ensures that drug
therapy is adjunctive—ie it is supportive of behavioural
and lifestyle change, not instead of it.
(3) Obesity Surgery
A small proportion of seriously obese patients are
referred for specialist surgical intervention, but then return
to the Centre for further monitoring and care. Post-surgical lifestyle
management is even more important for these patients.
(4) Programme Results
To set the results in context, it is important to
remember that most experts regard a weight loss of 5-10% of baseline
weight as a successful outcome. Preliminary data from our programme
are as follows:
— Average BMI at the commencement of
the programme was 36 kg/m2.
— Average weight loss over 16 weeks
is 35.75 lbs representing 15.7% of baseline weight.
— Patients improve coronary risk factors,
lower blood pressure, and decrease or discontinue diabetes and
hypertension medication.
Data from specialist NHS weight loss programmes
suggests a loss of 17 lbs in 30 weeks weeks. Therefore, our data
suggests that—compared with specialist NHS programmes—we
are achieving twice the weight loss in half the time. Although
the social class mix of our patients is broad, it might still
be argued that there is a significant selection bias in our programme,
because we only recruit patients who are clearly ready for change.
However, this actually supports the point made earlier—that
only those individuals who are truly ready to making long-term
behavioural changes should be recruited into weight-loss programmes.
9. CONCLUSION
Obesity is a serious, chronic medical condition
which is strongly associated with a range of debilitating and
potentially life-threatening conditions. It imposes a great and
growing financial burden on the NHS and on the wider community.
The fact that the recent dramatic increase in obesity has occurred
in such a short time and within the same genetic pool, suggests
that biological factors are not the key determinant of the current
epidemic. On the contrary, the evidence points overwhelmingly
in the direction of environmental factors (low-cost, energy- dense
foods, increasing portion sizes and sedentary lifestyle). To confront
this enormous public health challenge will require concerted action
at both the population and the individual level.
Because the average weight of the population
determines the proportion of overweight or obese individuals,
the first aim should be to halt the year-on-year increase in average
weight, which we have seen over the past several decades. To achieve
this will require an integrated, multi-level approach encompassing
initiatives at individual, community, environmental, and policy
level.
At the individual level, we need to provide
relevant information and identify those most at risk for early,
targeted intervention. We must direct scarce resources to those
who are ready for change, recognising that poor patient selection
invariably means poor outcomes. We also have to move away from
the blame culture which has to date hampered our understanding
of this complex and serious disease. We need to promote a positive
attitude among health professionals, many of whom persist in believing
that obesity is the visible expression of gluttony and sloth.
We will also need to provide programmes which focus on health
outcomes, recognising that even modest weight loss may result
in significant health gain and reduced healthcare costs downstream.
The model we have developed may well provide a blueprint for the
future.
We have to accept that this problem will not
go away. This is a public health time bomb. Unless we take concerted
action now, we will condemn large numbers of people to a future
marred by ill-health and disability and a bankrupt health care
system.
May 2003
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