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
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
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
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
Q184 Dr Naysmith: What about the
relationship between eating disorders and obesity? Is there a
Professor Lacey: Yes. Within massive
obesity there is a significant sub-group who eat by means of binge-eating.
Really their presentationand perhaps I should have made
this clear at the beginningis 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 nervosawhich is a very, very treatable conditionboth
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
issueyou 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 studiesyou use a test called the Implicit Association
Testyou 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 overestimateyou know,
"Well, it is my metabolism"as a way of not confronting
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
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 femalesand
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 patientsI 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 hospitalin 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
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 skillsoften the latter, and we so often undervalue
the need for managerial skills in the NHSactually 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
requiredor 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 successfulso 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 regardlessand 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 patientsset aside the overweightseem
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 againI think
the NAO report was a starting placeis 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
goodcoming back to the point of the Chairmanbecause
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 diabetesand 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
WalesI do not know if you are allowed to take evidence
from Wales!and also from East Angliaand it is a
fairly universal figure actually worldwideis 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,
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
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