Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 180-199)

26 JUNE 2003


  Q180  Dr Taylor: Did you say there is or there is not?

  Professor Sir George Alberti: There is not. It is pretty clear for obesity and heart disease, so there is no question that people ought to lose weight, but it is not clear that they will abruptly reduce their cancer rate by doing it, because, on the whole, cancer rates tend to go up and down many years after what causes them.

  Q181  Dr Taylor: The huge point is you have never to become obese.

  Professor Peto: Well, I would be very surprised if 20 years later there was not a huge benefit in losing weight but that has not been demonstrated in prospective studies.

  Dr Taylor: Thank you.

  Q182  Dr Naysmith: I would like to spend a minute or two with Professor Lacey exploring the link between mental illness, obesity and overweight. I wonder if you could tell us what the link is or what your observations are on that.

  Professor Lacey: There is not a direct and obvious link between psychological disorder and massive obesity. If I could specify: with people with a BMI, say, over 40 (which is the usual group that we see) you cannot by clinical examination determine any particular grouping of symptoms that would tend to lead to it. Sometimes from psychological inquiry you can determine why it may have occurred. An example, perhaps, is incestuous abuse or something like that, and by becoming obese you no longer are attractive and you also switch off your own libido too, so within that sort of context. But they are sort of a rare, small-print end of the market. There are significant psychological effects of the obesity itself. That certainly includes depression, it includes phobic symptoms, it includes anger. It also includes a lot of social issues, loneliness and the like. The actual causes, in so far as they can be detected, do not fall into natural major psychiatric disorders but tend to stem from interpersonal or family problems. But that is when you find it. In the majority it is not determinable. There is not a clear link between massive obesity and a pre-existing psychological problem; rather there is evidence of psychological sequelae from the massive obesity itself.

  Q183  Dr Naysmith: How serious is this for the National Health Service, for the nation's health?

  Professor Lacey: I think it is best to look at it from the individual. I think it is quite marked from the individual. It changes their whole lifestyle, the way people look at them, judge them; their capacity to form relationships; their economic capacity; and of course the other complications are physical complications too, which in themselves have emotional sequelae. It is very, very significant to the individual and to their families.

  Q184  Dr Naysmith: What about the relationship between eating disorders and obesity? Is there a clear one?

  Professor Lacey: Yes. Within massive obesity there is a significant sub-group who eat by means of binge-eating. Really their presentation—and perhaps I should have made this clear at the beginning—is very similar to bulimia nervosa, except the fact that they are obese rather than normal weight. Broadly speaking, that is behaviourally determined. This is a group that binge-eat but do not vomit afterwards, so their weight continues to go up. They, as a group, can be treated by psychological means. The sort of treatments that have been shown to be effective for bulimia nervosa—which is a very, very treatable condition—both cognitive and focal interpretative therapies, can be used with the bulimic obese to remove the binge-eating symptoms but it does leave them obese. Although that can then perhaps be addressed by dietetic counselling or even by surgical means, it is usually considered a good result if you can deal with the binge-eating and cause some loss of weight whilst leaving them still overweight.

  Q185  Dr Naysmith: Could I pick up on something you said earlier which has already been picked up. I just wonder whether any other members of the panel agree with you, this suggestion that overweight people tend to be unpopular with their peers and also with some doctors.

  Professor Lacey: I said that because the question was: Why was it not addressed? I think you have to answer the question: Why has their been enormous interest amongst doctors and researchers, myself included, in anorexia nervosa, bulimia nervosa, but not a much more common condition, which is obesity, the subject of this inquiry? One of the reasons, I would tentatively suggest, is that as a group the massively obese do not seem popular. It often gets into these rather spurious debates about self-inflicted injury and such like. When I at a clinical level am attempting, for instance, to get funding to treat patients, I find that they are much more sympathetic at other aspects of eating disorders or psychiatry than the massively obese. Rather they are seen to have brought it on themselves.

  Q186  Dr Naysmith: How true do you think that is? Is there a measure of truth in it?

  Professor Lacey: Only in the same way that certainly other lifestyles can give rise to cardiological disorders. Or you could make the same argument for a number of psychiatric disorders too. So only in that capacity but not any more than that.

  Q187  Dr Naysmith: Is there any evidence of a predisposition towards the condition? Is there a group of the population which can be identified who are more likely to end up this way?

  Professor Lacey: Yes. Well, as the papers show, it is something that tends to run in families, there is an increase in certain ethnic groups.

  Q188  Dr Naysmith: Then we get the old argument about environment versus genetics.

  Professor Lacey: Indeed. Genetic evidence, to my mind, is not satisfactory, so it is really much more in the environmental field.

  Q189  Dr Naysmith: Would Professor Wardle like to comment on any of this?

  Professor Wardle: I think I would agree with quite a lot of what Professor Lacey said. Generally there is not a very strong association emerging in the scientific literature between psychological disorders and obesity. The same appears to be true even if you look at data from younger age groups, adolescent groups, who you might think would be the group at particular high risk. There tends to be slightly more sign of a psychological disorder when you study clinic populations than when you look at the difference between overweight and non-overweight and obese groups in community populations. Then the effects are lower. That is one thing. A second point which I think seems relevant to the issue—you asked: How much truth is there in this idea that we are talking about something which actually is people's fault and so on?—is that we have to remember that probably 95% of the explanation for the increase in obesity that we see is because the entire population's weight has shifted upwards. We are not talking about something odd happening to some sector of the population; we are talking about a population shift, just the same as we have seen for height, which is generally going up. When you recognise that it is more important to talk about a mean change in BMI (which of course means there is going to be a bunch more people at the top end of things), then it draws your mind to the proper kinds of explanations there might be for this rather than thinking only of, there is this subsect that is increasing. The third thing I would like to say about that is in terms of the stigmatisation issue or social problems which accrue to people who have overweight. The evidence is very strong there in terms of teasing and social rejection, particularly in the adolescent years and in childhood years. A recent study, not yet published but reported at a conference, showed that teachers underestimate the IQ of overweight children more than they underestimate the IQ of normal weight children. There are many studies which show that health professionals have strongly negative views towards the overweight, and, even if they deny them consciously, if you do studies—you use a test called the Implicit Association Test—you can show that the same kind of negative views are held. One of the things though we have to wonder is how these people who suffer prejudice in all kinds of walks of life manage to sustain not being depressed and not having low self-esteem necessarily. It is a testament, I think, to the strength of the human spirit that they make it.

  Dr Naysmith: Thank you very much.

  Q190  Andy Burnham: Most often people will attribute their own weight gain to their own metabolism rather than lifestyle choices. To what extent is that true? To what extent do some people have a much greater propensity to put on weight because of the way their body functions? Do we need to think more, if people do have that propensity, of what we do with those people?

  Professor Wardle: I think this is a very important question. It seems to me that on the whole the evidence supports there being quite a strong genetic influence explaining why within a population some people are at one end of the distribution and some people are at the other end of the distribution. Of course that genetic factor does not explain why the whole population shifted. So I think we do know, and there is lots of other data which you can accrue to make that case. Animal breeding studies show very clearly that you can breed for leanness or you can breed for obesity. Studies of adoption, with people being adopted at birth: people who are adopted into more overweight families, have no increase in their risk.

  Q191  Andy Burnham: Part of what I am getting at, though, is do people overestimate—you know, "Well, it is my metabolism"—as a way of not confronting lifestyle choices?

  Professor Wardle: They may underestimate the extent to which their weight is modifiable. I think people do have a sense: "That is just the way I am, that is just the way my family has always been, that is not something I can do anything about." I think that to have a fatalistic view about it is inappropriate and incorrect because we clearly know that these things can be changed. I think people's sense that there is some metabolic oddity or mysterious underlying illness is by and large not true. But, for some people, this process, whatever it is, is an awful lot easier than it is for others. If you had to choose between calling them a victim or a criminal so far as their obesity was concerned, then victim is closer to the truth.

  Professor Sir George Alberti: But I think it is overestimated. Yes, there is a range of basal metabolic rate. A very simple example of that is that males, by and large, have a bigger caloric intake than females—and I have to keep persuading my wife that she ought to eat less than I do, which she resents! But I think it is used as an excuse often. I always say to patients—I do not know if Professor Lacey does the same thing—"I can guarantee that I can help you lose weight on a particular caloric intake." Once people have it shown to them that they actually can ... That was bringing them into hospital—in the old days, when we actually had beds still in hospital! We used to bring them in, 600 calories for a week, and everyone loses weight, undoubtedly, and then you find the person's own level.

  Q192  Jim Dowd: Could I follow up with what I believe to be a related aspect. I am not a medical person, so you will forgive the generalisation. The human body generally develops defensive mechanisms for threats to its well being. Why is it then that so many people seem to like foods that are bad for them and do not like the stuff that is good for them?

  Professor Wardle: One explanation is you have to look to our evolutionary past. In our evolutionary past, clearly getting energy intake was crucial, and there were not the kind of designed foods which we see now which have this very unusually high proportion of fat or unusually high energy density. We are talking about an organism that developed in a different food environment, where there would be every reason to expect that it would have been adaptively positive that you should eat when food was available. If food only appears now and then, when the tribe kills a mammoth or whatever, and you say, "I'm not hungry today"—

  Q193  Jim Dowd: It happens in Lewisham all the time!

  Professor Wardle: You can see that there would be evolutionary pressures for broadly speaking a genotype which supported energy intake and supported being sedentary when you did not need to be wasting energy. We now find ourselves in a situation where there are technological advances within the food industry, within transport, within engineering and homes, where the opportunities for being sedentary and the opportunities for eating high energy foods are ever present, and we are responding with what people would call our Stone Age genotype to all of this.

  Professor Sir George Alberti: It is a thrifty genotype. There is a big hypothesis built round that, which is for intermittent eating: you would need to stuff yourself pretty well and then you would wait another four days. But not many of us do that any more.

  Q194  Chairman: Could I come back to Professor Lacey. I was struck by evidence that we had received that obese women are around 37% more likely to commit suicide than women of normal weight. The source of that was the National Obesity Forum. Presumably you would confirm that from your own experience. I wonder whether, in view of the impression we are gaining from all the witnesses who have spoken so far of a kind of lack of interest and urgency in this from the medical profession, perhaps generalising, and government, bearing in mind that suicide reduction is a key health target, is that not a way into doing something about it?

  Professor Lacey: I am sorry.

  Q195  Chairman: Are the suicide figures I have just quoted not a way into trying to get this issue taken more seriously?

  Professor Lacey: Yes. I think that is the case. At the coal face it is very frustrating. Obesity clinics are needed for the massively obese and they are few and far between. In fact, most of the staffing necessary is there. Usually a very small amount of funding is needed, or will, or managerial skills—often the latter, and we so often undervalue the need for managerial skills in the NHS—actually to bring the relevant multi-disciplinary team together. Because I would strongly argue that to deal with the massively obese is not one individual clinician; it is rather a multi-disciplinary team that would involve surgeons, physicians, psychiatrists, and much more, occupational therapists, dieticians and the like. It is the way in which those teams are managed and brought together for the benefit of the patient, and we lack skills in dealing with that. Apart from those skills, often very small amounts of money are required—or perhaps little at all. The big expansion, for instance, in my own service for eating disorders, stems from the internal market: then, the money could be made available. With the lack of that, what seems to be needed is another way of dealing with it. I mean, it caused a lot of problems, etcetera, but it did, for certain specialist areas, allow considerable expansion to the benefit of patients. What is now needed, within our current structure, is a way of getting very small amounts of money to the required place. If it is given generically (or whatever the word is), almost certainly it will get lost, for the reasons and the prejudices that I have indicated. Some way in which some ring-fenced money can be got to the point of need would open up services. Much of the skills are there.

  Professor Sir George Alberti: I would add that managers do not like putting money into services which are not particularly successful—so we have trouble explaining to them. You should not underestimate how difficult it is, as a doctor, to see recurrently a group of patients, most of whom actively are not helping. That is what really gets at the professionals. You need the oddballs, like my colleague here, who continue to be enthusiastic regardless—and there are a few of us around.

  Professor Peto: If I could make a general comment. The massively obese are not the problem, because they are less than 1% of the population. The overweight are not the problem; they are half the population. The bulk of the excess mortality occurs in the obese, who are 20% of the population. I think it is important to focus on that. The NHS cannot provide intensive clinic services for 20% of the population. For cancer, for example, the obese account for two-thirds of the excess mortality. The overweight, who are a much larger proportion of the population, are at an increased risk but not much of an increased risk. Obviously a campaign that puts pressure on obese people to lose weight will in fact spill over into the overweight. Although what Jane says is true, there has been a shift in the entire weight distribution and that has had the effect of increasing the upper end, which is where the mortality risk is, I think that is where the focus should be. It is neither the top ½% nor the 50% who are overweight, but it is the 20% who are obese who have to be focused on. And somehow or other you have to stigmatise them unfortunately. That is the real difficulty that everybody is skirting round. The way Californians gave up smoking was because smoking became socially unacceptable. That is a real problem. I have a young acquaintance who was obese and had been since being a teenager. Finally, in her twenties, her boyfriend told her she was too fat and within a year she had lost a great deal of weight. And she has actually been much happier ever since. So I am not sure that stigmatisation is a bad thing but I think that has to be addressed. This is not really a medical problem.

  Dr Barrett: In childhood obesity there is an interest from paediatricians in the subject, together with mounting apprehension as to what is happening. Obesity-related illness is not supposed to be a problem in childhood and it certainly was not until up to, perhaps, five or six years ago. From about 2000 onwards we have started seeing children with obesity-related diabetes (which has never really been described in this country before) such that now it accounts for about 6% of all children presenting with diabetes in our clinic. Out of the 20 children with diabetes this year, six of them have obesity-related diabetes. The youngest one I saw four weeks ago was an eight-year old girl who had developed some symptoms. She would come into the super-obese category because of her diet and because of her snacking at school. We do not know what is going to happen in the future, because it is a new problem, but one would anticipate that the complications of diabetes have a whole lifetime to develop. My colleagues in North America, in Winnipeg in Canada, have followed up the first 50 or so teenagers with Type 2 diabetes over 12 or 15 years. They presented last year in America. Of the girls who got pregnant, about one-third of them had miscarriages. So they had about a 30% miscarriage rate with Type 2 diabetes in their twenties, but, also, some of these 50 who had gone on into their twenties were on kidney dialysis machines and had retinopathy as well. The complications of Type 2 diabetes are going to occur in the twenties and thirties if we follow the pattern in North America.

  Chairman: We will be exploring the issue of children in a moment or two in a bit more detail. I am grateful for that comment.

  Q196  Mr Burns: Could I turn to the economic impact of obesity. The NAO has recently put a conservative estimate that the cost to the NHS is about £2.6 billion in 2001. I was wondering if you would like to comment on that figure, whether you think it is a valid one or whether it is an underestimate or an exaggeration.

  Dr Rayner: I think the NAO would say it is a starting-place figure. I think that is the problem. We are always looking backwards and we need to look forwards. We need to see the picture in 20 years time and then come backwards. I prefer to look at the American data, which is more complete, in a way, and gives a much bigger picture on how overweight and obesity issues are driving costs. One of the points of that is that obese and overweight patients—set aside the overweight—seem to generate higher treatment costs than people with alcohol problems or tobacco problems. We need to think not just of the costs for the health services but of the costs for the general economy, for the driving of jobs. Obviously there are some benefits to this: the manufacturers of slimming food products are doing very well out of these things. To look at the complete picture, you have to go beyond just the costs to health services. One of the figures I put in front of you is that by 2011 the US health care costs are going to be in the region of 17%: more than 17% of their GNP spent on health care. The biggest cost push within that, I would argue, is the general area of non-communicable disease, and this is a prominent part of them. So, yes, these costs are rising. I think what needs to be looked at again—I think the NAO report was a starting place—is the total social costs, economic costs to the economy, to the people themselves, in terms of affecting their employment, and so on. We need to look far more at that. I think the NAO report was particularly good—coming back to the point of the Chairman—because it actually dramatised issue and brought it to government, but I would like to see further research on that and obviously that there will continue to be interest. I think this is the Treasury's problem as well. It is not just the Department of Health. I am pleased to see that Derek Wanless, who did the study for the Treasury looking at health care costs, actually has come back to looking at the fully engaged scenario; that is to say, the difference between really effective engagement with the public about these non-communicable diseases and the ineffective. I think that is the research that needs to be done: more modelling about what the costs might be in the future, from some of the trends that our colleague here has identified, in terms of the younger age groups. We are still talking about the conversion of costs in older groups and, actually, when you start looking at these problems appearing in younger age groups and then generating the costs ahead, the figures start to get very large.

  Q197  Dr Taylor: Could we turn to the costs of diabetes—and really this is a question for Professor Alberti. We have been told that diabetes consumes something like 10% of the NHS budget. Is that right? Can you give us a breakdown? Which bits of those are savable?

  Professor Sir George Alberti: Certainly, the estimates that have been made based on data from Wales—I do not know if you are allowed to take evidence from Wales!—and also from East Anglia—and it is a fairly universal figure actually worldwide—is 10% of healthcare budgets. The biggest proportion of that is the complications of diabetes. Certainly, if we have this evidence which we have of younger people developing Type 2 diabetes, which is the big burden here younger, we are already seeing in the South Asian population in this country that something like approaching 20% of adult South Asians have diabetes, another 25% have impaired glucose tolerance. So virtually half are either diabetic or at high risk of heart disease. We are going to see a lot more vascular disease early. That is where the big costs are coming, together with renal replacement therapy. That is going to burgeon and is savable (i) if we can deal with the obesity problem, and (ii) if we treat diabetes better, of course.

  Dr Taylor: Thank you very much.

  Q198  Julia Drown: I want to pick up on the comments that Time Barrett made about the emergence of Type 2 diabetes in children. Is that largely due to obesity or are there other factors as well? In so far as it is obesity, when you are talking to the parents involved, is there real worry about eating disorders which stops parents dealing with the first signs of obesity? Other people may want to come in on that as well, but I am particularly interested in your view on it.

  Dr Barrett: We have tried to do a national survey through our own professional body of how common obesity-related diabetes is in children. Nationally, it is probably still less than 1%, but those children are all in the obese or super-obese category.

  Q199  Julia Drown: That is 1% . . .

  Dr Barrett: Of all children with diabetes have obesity-related diabetes across the country on a first survey. But locally, in areas where there is a more cosmopolitan population, such as Birmingham, the figure is up to 6%. So we are seeing an increased proportion in inner city areas and that reflects differences in population. All of these children with Type 2 diabetes are obese or more obese than that, super-obese again, so there appears to be an association with that. It does appear to affect children of South Asian origin disproportionally, as Professor Alberti was alluding to, and I think this is because they have extra susceptibility factors on top of the obesity that make them prone first, which may be genetic or may be racial but probably reflect the increased prevalence of diabetes in the adult Asian population.

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