Memorandum by the National Obesity Forum
(OB 18)
1.1 A WHO report published as long ago as
1997 described obesity as "one of the greatest neglected
public health problems of our time with an impact on health which
may well prove to be greater than smoking". There is little
doubt that this prediction is coming true. The health risks of
overweight and obesity are well defined and they increase with
greater degrees of obesity as well as with central or visceral
fat accumulation.
1.2 The National Obesity Forum (NOF) is
an independent medical organisation working within primary care,
whose aim is to raise the awareness of obesity as a serious medical
condition and to promote best quality management within the NHS.
Our professional membership is currently in excess of 1,200. The
NOF provides evidence based clinical guidelines for medical management
of adult obesity, childhood obesity and for pharmacotherapy for
obesity, which have been widely published and utilised by health
authorities within the UK and internationally. We award the annual
"Award for Excellence in Obesity Management in Primary Care"
and have published educational material for all healthcare professionals
on paper, CDRom and on the NOF website. The inaugural national
conference on obesity in primary care will take place in October
2003. The NOF is a first port of call for professional advice
to the media on all obesity related issues. The NOF helped establish
the All Party Parliamentary Group on Obesity in 2002, continues
to provide professional and secretarial support to the Chairs,
Dr Howard Stoate MP and Mr Vernon Coaker MP, facilitating four
parliamentary meetings each year, and we have provided expert
opinion for the National Institute for Clinical Excellence (NICE).
1.3 The NOF is the only organisation working
within primary care in the NHS which is fully aware of the devastating
effect of obesity on our patients, and the serious impact it has
on the resources within the NHS. The National Obesity Forum has
prepared this document to assist the Health Select Committee in
achieving an understanding of the health, financial and professional
consequences of obesity and is willing to provide as much help
as possible, including oral evidence if required, to this enquiry.
1.4 The NOF is deeply concerned about the
impact which obesity has on the health of the individual, and
the knock-on effect on the health and economics of the country.
However we are equally concerned about the lack of help and support
being offered to primary care to help to address the problem.
The vast majority of overweight and obese people are encountered
within primary care, either seeking help directly for their weight
problem, or indirectly because of a related medical condition.
It is primary care where the interaction with "target individuals"
takes place, where the ideal ability to intervene exists, and
therefore where the medical opportunity and indeed responsibility
lies to address the problem, and consequently where funds and
efforts should be concentrated to increase awareness, management
skills and resources.
2.1 General Practice, by definition covers
every possible aspect of medicine and surgery, from and yet there
is hardly a single aspect of the medical work of a GP or practice
nurse which does not involve overweight or obesity:
2.2 Cancer—Obesity is the cause for
around 20 different forms of cancer, including colorectal, breast
and ovarian cancer; obesity is thought to cause 10% of cancers
in non-smokers and there is a strong relationship between obesity
and a number of different types of cancer, including cancer of
the endometrium, kidney, gallbladder, breast etc. A recent paper
in the New England Journal of Medicine has confirmed that death
rates from all cancers were 52% higher in men with a BMI over
40, and 62% higher in women. Calle E et al. Overweight, obesity
and mortality from Cancer in a Prospectively Studied Cohort of
US Adults (2003) 348: 1625-1638.
2.3 Diabetes—80% of type II diabetics
are obese. Obesity is the major modifiable cause of type 2 diabetes.
BMI was a major risk factor for type 2 diabetes in the Nurses'
Health Study with the relative risk showing signs of increase
with a BMI of only 25. With a weight gain of 5-7.9kg over the
14 years of the study, the relative risk was 1.9. Colditz GA et
al. Weight gain as a risk factor for clinical diabetes mellitus
in women. Ann Intern Med (1995) 122: 481-486.
2.4 Cardiovascular disease—the risk
of coronary heart disease is increased four-fold being associated
with hypertension, stroke, coronary heart disease, heart failure,
and hyperlipidaemia. The relative risk of acute myocardial infarction
is doubled in patients with a BMI over 30 (ie obese patients)
compared to those of normal weight. According to a paper in the
New England Journal of Medicine in 1999, obese people are twice
as likely to die from cardiovascular disease as are people of
a healthy weight. Calle E et al. Body mass index and mortality
in a prospective cohort of US Adults. NEJM (1999); 341: 1097-1105.
2.5 There is a clear association between
obesity, quality of life, and psychiatric illness. For example
there is a 37% increased risk of suicide amongst obese women.
2.6 Respiratory disorders—Obesity
causes sleep apnoea and breathlessness. A Finnish study suggests
that weight loss in obese people with asthma improves lung function,
symptoms and general health. Stenius-Aarniala et al. Immediate
and long-term effects of weight reduction in obese people with
asthma: randomised controlled study. BMJ(2000); 320: 827-832.
2.7 Obesity increases surgical and anaesthetic
risk for any surgical procedure.
2.8 Obesity causes and exacerbates orthopaedic
conditions in adults and children.
2.9 Gastrointestinal—conditions such
as gallstones, GORD and Barretts oesophagus are common as a result
of obesity. Chow W-H, et al Body mass index and risk of adenocarcinoma
of the oesophagus and gastric cardia. J Nat Cancer Inst (1998);
90: 150-55.
2.10 Obesity causes infertility, and other
hormone related conditions such as polycystic ovarian syndrome,
as well as obstetric and intra-partum complications.
2.11 The increase in childhood obesity results
in many paediatric conditions becoming worse, including respiratory
disorders, orthopaedic, and psychological conditions.
2.12 Dermatological conditions such as leg
ulcers are worse in obese patients.
2.13 Dealing with obese patients puts an
extra strain on nurses especially nursing home nurses, and also
spouses who care for obese patients at home.
2.14 There is an increase in accidents and
injuries due to falls amongst obese people.
2.15 There is a nine-year reduction in life
expectancy amongst obese patients.
3.1 There is hardly a single area of medicine
delivered from primary care which is not directly affected by
obesity. Consequently, unless something is done to arrest the
predicted epidemic of obesity in the coming decades, primary care
will become even more swamped than it already is by the burden.
Already we know that obese patients require 30% more appointments,
and up to 30% more prescriptions than non-obese patients. All
this comes at a time when primary care is striving to comply with
the Government directive to offer 24-hour access to healthcare
professionals (nurses) and 48-hour access to GPs. However it is
not merely the increased number of patients which will overload
the system, but also the fact that the average BMI of obese people
will become greater, ie the fattest people will become even fatter,
will have greater degrees of co-morbidities and hence require
even more medical input.
3.2 There is increasing awareness of the
condition known as Metabolic Syndrome, and increasing recognition
of the pivotal role played by insulin resistance in obesity and
its co-morbidities. Insulin resistance leads to higher than normal
glucose levels, which may in turn lead to impaired glucose tolerance,
and eventually full-blown type II diabetes. The high glucose levels
lead to extra insulin production by the pancreas, known as hyperinsulinism.
The adipose cells of fatty tissue are also resistant to the effects
of insulin, which would normally suppress the breakdown of fats.
Insulin resistance therefore leads to increased fat breakdown,
and an abnormal lipid profile, with its accompanying risk of heart
disease and stroke.
3.3 Other tissues of the body, however,
still have a normal sensitivity to insulin, and are bombarded
with abnormally high levels of the hormone which has a "growth
factor" effect, causing stimulation, and cell division, which,
depending on the tissue or organ involved has a variety of effects.
These include cancers, for instance of the gall bladder and colon,
hypertension and salt retention by the kidneys, and abnormal levels
of sex hormones, leading to other "hormone related"
cancers.
4.1 Because of this chain of events, it
is becoming clearer than ever that obesity is central to a vast
array of illnesses, and must be treated as an absolute top priority.
It is insufficient, for example, to treat Type II diabetes and
neglect the patient's obesity, although this is commonly done.
To treat coronary heart disease without paying attention to obesity
is neglectful, but often attempted. Obesity should not be considered
as an afterthought once blood pressure, hyperlipidaemia, HbA1c
etc have been dealt with. On the contrary obesity should be treated
as one of the greatest priorities and if, once that has been successfully
managed, the blood pressure remains raised, it can then be assessed
and dealt with. This makes both clinical and economic sense by
avoiding costly polypharmacy and reducing the risks of other conditions
co-morbid with obesity developing subsequently.
4.2 At the time of the drawing up of the
National Audit Office report, the National Obesity Forum was already
vigorously involved in promoting better management of obesity
in primary care; many of the suggestions put forward in the document
were being put into practice at that time by the NOF, and our
ambitions closely mirrored the sentiments expressed in the document.
For instance the guidelines for weight management for adults had
already been distributed widely, and an education package for
GPs was already being drawn up. We were already acutely aware
of the shortcomings of primary care's attempt to tackle obesity,
and were striving to help overcome them by providing support to
GPs and health professionals.
4.3 Since then the NOF has grown, deriving
our membership from the whole range of primary care professionals,
and our aims and ambitions are parallel to those suggested in
the NAO report. Our Chair, Dr Ian Campbell was asked to deliver
presentation on the NOF primary care perspective on obesity at
the NAO Conference in January 2002 "Joining Forces to Tackle
Obesity" and at the Danish Government and EU conference on
Obesity as a European health issue in Copenhagen in September
2002. Dr Campbell and Dr David Haslam were pleased to have been
able to express our views at the Labour Conference in 2002.
4.4 The NOF will continue to strive to improve
management of obesity among our colleagues, and raise awareness
of the condition in the medical and lay press and in Government.
It will continue to forge links within primary care, with secondary
care groups such as the Association for the Study of Obesity,
and Diabetes UK and with government opinion leaders through the
All Party Groups, the Westminster Diet and Health Forum etc. In
order to do so effectively it is essential that decisions are
made at the highest government level to instigate change.
4.5 It is often said that obesity is a normal
response to an abnormal environment, and it is that abnormal environment
which must change. It is for the Department of Education to say
how we should increase the amount of exercise contained in the
school curriculum, for government to determine how the food industry
should act more responsibly for the benefit of our children's
health with more responsible food labelling and portion sizes
and for the Department of Transport to decide how to make safer
cycle lanes. Suffice to say that the changes must be made, partly
to potentiate the effect that the medical profession can have
on the condition, and partly to convince the most cynical clinician
that there is some point to attempting to manage the condition,
because at least he will see that others are pulling in the same
direction. The changes hinted at in the National Audit Office
report were to be implemented this would go a long way towards
improving the "abnormal environment".
5.1 The National Obesity Forum would wish
to see the following initiatives from government:
5.2 The appointment of a "Fat Czar"
to develop a central government strategy to tackle obesity on
all fronts, prevention and management and to oversee the following
recommendations.
5.3 The development of an Obesity National
Service Framework (NSF) for the NHS, and a statement direct from
government that obesity is now a WHO-recognised disease which
demands the same professional medical approach as that given to
cardiovascular disease.
5.4 Measures to make obesity management
a statutory requirement for chronic disease management, similar
to the priority and resources given to cardiovascular disease
and diabetes, to develop obesity "targets" for the NHS.
5.5 Provision of adequate training to undergraduate
and postgraduate health professionals to satisfy the growing desire
from doctors and nurses to be able to offer best practice in weight
management within the NHS.
5.6 Adherence by Health Care Trusts to NICE
recommendations on the provision of weight management services,
with particular reference to the use of medication and bariatric
surgery provision.
5.7 The provision of adequate resources
to fund weight management services in primary and secondary care,
both medical and surgical.
5.8 Stringent legislation to control the
current irresponsible advertising of obesogenic foods to children
on TV and in the media.
5.9 Further and immediate investigation
into the feasibility of stringent legislation to control the marketing
of obesogenic foods, with particular reference to food labelling,
food choice (schools, workplace) and convenience and fast-food.
5.10 Measures to increase availability and
quality, and decrease cost, of fruit and vegetable choices in
lower socio-economic areas.
5.11 Serious attempts to remove the shameful
health inequalities which are derived from obesity and its co-morbidities,
both in terms of socio-economic disadvantage, racial groups, and
male/female access to medical and commercially derived weight
management.
6.1 The National Obesity Forum welcomes
this Health Select Committee inquiry on obesity and remains willing
to co-operate in any way it can to facilitate the work of the
Health Select Committee.
April 2003
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