Memorandum by Dr Colin Waine OBE (OB 106)
"From Samoa to the Steppes, from Sao Paolo
to Sunderland—every country faces a potential public health
disaster if it fails to take decisive measures, not only to introduce
better management, for more effective preventative measures to
halt the slide we have seen accelerating over the past 25 years."
(James WPT 1999, Chairman International Obesity
Task Force.)
1.0 INTRODUCTION
1.1 Obesity is without doubt the most important
nutritional disorder facing the developed world. Back in 1976
a joint Department of Health and Social Security/Medical Research
Council concluded that "We are unanimous in our belief that
obesity is a hazard to health and a detriment to well being. It
is common enough to constitute one of the most important public
health problems of our time. Whether we judge importance by a
shorter expectation of life increased morbidity or cost to the
community in terms of both money and anxiety." 1
1.2 Twenty-seven years on from then the
position has seriously worsened. In fact the United Kingdom is
currently experiencing an epidemic of overweight and obesity as
the prevalence doubled between 1980 and 1991 and continues to
rise relentlessly.
1.3 Yet the fact is that historically although
obesity is a serious medical problem, it has been trivialised
by the media and marginalised by the health service.
1.4 The World Health Organisation (WHO)
despite its historical focus on malnutrition and starvation has
now begun to recognise the problem of over nutrition. In 1998
the WHO said "the epidemic projections for the next decade
are so serious that public health action is urgently required"2
and in 2000 called for "urgent action to combat the growing
epidemic of obesity which now affects developing and industrialised
countries alike".3
1.5 Although obesity is a serious medical
condition and is associated with a wide range of chronic and life
threatening conditions, although obese individuals suffer increased
psycho-social problems and reduced quality of life, and although
the growing prevalence of obesity has enormous implications for
the health service, it has not until quite recently attracted
the degree of scientific attention which its importance certainly
deserves.
1.6 Obesity is not just a matter of gluttony
or sloth, 4 it results from complex interactions between genetic
and environmental factors, some of which are beyond conscious
individual human control. 5
1.7 Obesity is associated with at least
43 co-morbidities so that it must be considered a disease in its
own right. If this is accepted then it is logical that it be managed
like any other chronic disease, eg diabetes with diagnosis, effective
interventions and continued support.
1.8 Any serious attempt to improve the health
of the nation must give tackling obesity a very high priority
with much better management and more effective prevention.
This will require the Government to launch in
combination with the food industry and local authorities a massive
public health population based approach to prevention and at the
same time a personal high risk approach through a dedicated team
of professionals.
2.0 THE HEALTH
IMPLICATIONS OF
OBESITY
2.1 "Obesity is not just a health risk
but a disease". Jung R T 19976
2.2 Obesity and mortality
The Nurses Health Study in America yielded valuable
information about the links between obesity and mortality. The
study involved 115, 195 women aged 35 to 55 years of age when
enrolled and were followed up for 16 years.
It was concluded that 53% of all deaths in women
with a BMI above 29 were directly related to their obesity. 7
In a study of 750,000 men and women published
in 1979 (Lew & Garfinkol 1979) relative mortality was highest
for diabetes mellitus followed by digestive diseases including
cancer. 8
2.3 Obesity and morbidity
"Type 2 diabetes is the most important
medical consequence of obesity and becomes progressively commoner
in populations with a higher percentage of obesity. It accounts
for 80-85% of the estimated 110 million people with diabetes world-wide,
a number which is likely to increase to 180 million by the year
2010 (WHO Study Group 1997). 9
Impact of Obesity on morbidity
| Cardiovascular system |
Hypertension |
| Coronary heart disease |
| Cerebrovascular disease |
| Deep vein thrombosis |
| Varicose veins |
Gastrointestinal system | Hiatus hernia
|
| Cholelithasis |
| Fatty infiltration of the liver
|
| Haemorrhoids |
| Hernia |
Colorectal cancer | Metabolic hyperlipidaemia
|
| Hypersinsulin/insulin |
| resistance type 2 diabetes
|
Respiratory | Breathlessness
|
| Sleep apnoea |
Pregnancy | Obstetric complications
|
Musculoskeletal | Osteoarthritis
|
Breast | Breast cancer
|
Uterus | Endometrial cancer
|
| Cervical cancer |
Skin | Fungal infections
|
| Intertrigo |
| Cellulitis |
| Lymphoedema |
Urological | Stress incontinence
|
| |
Conclusion
2.4 Obesity is a disease in its own right because……
— It causes extensive human suffering
— It has major genetic component which interacts
with environmental factors
— It has massive financial cost to society
— It deserves a plan management equal to those related
to diabetes, asthma and hypertension10
— If effectively managed it could bring significant
benefits to the quality and quantity of human life.
3.0 TRENDS IN
OBESITY
3.1 The prevalence of obesity is rising relentlessly
as is shown in the following table.
Country | Obesity
| Year | Ages
| Men (%) | Women (%)
|
England | 30kg/m2
| 1980 | 16-64 | 6
| 8 |
| | 1986-87 |
| 7 | 12 |
| | 1991
| | 13 | 15 |
| | 1993
| | 13 | 16 |
| | 1999
| | 17 | 21 |
| |
| | | |
3.2 The Health of the Nation Report One Year on, pointed
that over half of the adult male population and just half of the
adult female population were overweight to a clinically undesirable
degree. Men tend to predominate in the category BMI 25-30 whereas
there are more women than men who are obese (BMI 30-40) or severely
obese (BMI>40). Health of the nation 1992 targeted the reduction
in the proportion of obese people (BMI>30) to not more than
6% of men and 8% women by the year 2005.
4.0 CAUSES OF
THE RISE
IN OBESITY
IN RECENT
DECADES
4.1 The prime causes lie in the environment and behavioural
change although there are genetic, socio cultural and biological
factors which contribute.
4.2 Behavioural change factors
Physical inactivity
There are a number of behavioural influences of which probably
decreasing physical activity is of major importance and likely
to be the main factor behind age-related weight gain (Prentice
& Jebb 1995). 4 As the nation's epidemic of obesity has occurred
during decades of reducing food intake, the implication must be
that levels of energy expenditure decline even more rapidly. Support
for this view comes from the following evidence.
Mechanisms for regulating body weight were evolved historically
under conditions of high physical activity. The increasing affluence
of the post-war years has been matched by the adoption of increasingly
sedentary lifestyles: only 20% of men and 10% of women are currently
employed in physically active occupations (Allied Dunbar 1992).
11 Physically active leisure pursuits have been replaced by inactive
pastimes. The average person now watches television 26 hours a
week compared with 13 hrs in the 1960s. The Health Survey for
England (Colhoun & Prescott-Clarke 1997) 12 and the Allied
Dunbar National Fitness Survey11 revealed that in the previous
months:
— 30-35% of men had taken fewer than 20-minute periods
of moderate activity:
— 80% of men had not walked continuously for two
miles:
— only 20-30% of men had participated in vigorous
activity of any type.
In a Finnish study (Rissanen et al 1991) of 1,200
adults over a five-year period it was concluded that physical
inactivity was more important than diet as a cause of obesity.
13
English activity patterns have probably fallen by an average
of 800 kcal/day over the past 20 years (James 1995) while food
intake has fallen by about 750kcal/day. The result is small but
sustained imbalance between intake and output which has to be
a major contributory factor in the development of the current
epidemic of obesity. 14
Declining physical activity has been matched by the adoption
of increasing sedentary lifestyles. The eating of high fat diets
and small, frequent snacks contributes to obesity because they
reduce the conscious recognition that food is being eaten and
bypass feelings of satiety. In fact, one gram of fat provides
more than twice as many calories as the same quantity of carbohydrates
or protein. High-fat diets, which are often palatable without
inducing feelings of satiety, are certainly contributory. Fat,
unlike protein or carbohydrate, induces only a small rise in metabolic
rate.
"Faced by a life circumstance that discourages routine
physical effort and activity and that offers a surfeit of highly
palatable high-energy and high-fat foods in bewildering variety,
weight gain is an understandable consequence" (Hill &
Rogers 1998). 15
All of the above information has important messages for the
design of weight loss and weight maintenance programmes.
Physical inactivity—a dominant factor in causing obesity
Increasing use of motorised transport
— Energy sparing domestic devices
— Obsessive television watching
— Overuse of central heating
Dietary Intake
During the last 50 years there has been a marked increase
in the fat content of the British diet (MAFF 1994) 16 and there
is evidence that high fat consumption undermines the mechanisms
regulating energy balance. The eating of high-fat diets and small,
frequent snacks contribute to obesity because they reduce the
conscious recognition that food is being eaten and bypass feeling
of satiety. Although dietary studies suggest an association between
obesity and high fat consumption, they suffer from the well-known
unreliability of the recording of food intake. However a study
of 11,600 Scottish men and women (Bolton-Smith & Woodward
1994) related to the prevalence of obesity to the subjects' intakes
of sugars and fat. This study showed quite clearly that the groups
consuming the highest proportion of their energy from carbohydrate
were much less likely to be obese compared with low sugar, high
fat consumers.
Laboratory Studies lend support to these findings: 17
— The observation that the consumption of food is
associated with an increase in energy expenditure and oxygen consumption
was made by Lavoisier over 200 years ago. This effort is now termed
the "thermic effect of food" (or "dietary-induced
thermogenesis").
— There is now experimental evidence to show that
the thermic effect of carbohydrate vastly exceeds the thermic
effect of fat.
— Mechanisms for regulating body weight function
more effectively on a high carbohydrate, low fat diet than on
a high fat, low carbohydrate diet.
— Carbohydrate balance is accurately regulated by
increases in oxidation which are regulated by the autonomic nervous
system and help to compensate for excess energy intake.
— In humans, isotope studies have shown de novo
fat synthesis from carbohydrate is a minor process.
5. WHAT CAN
BE DONE
ABOUT IT?
TACKLING OBESITY
5.1 The epidemic projections for obesity mean that it
has become probably The Major Public Health Problem of Our
Time. It is likely to outstrip smoking as a hazard to health.
5.2 The current epidemic of obesity is a physiological
response to an abnormal environment. Man has been programmed to
withstand famine but now we live in an age of plenty. In addition
mechanisms for regulating body weight historically were evolved
under conditions of high physical activity.
5.3 Obesity must no longer be regarded as just a health
problem it must become a national and community problem because
its ramifications are so far reaching. In addition to the direct
costs of diagnosis, treatment and management (all of which are
as yet underdeveloped) there are the indirect costs of loss of
productivity due to obesity.
Direct costs of treating obesity and its consequences:
Direct Costs
| £9.5 million |
| Treating the consequences | £469.9 million
|
| Total | £479.4 million
|
| |
Source: National Audit Office Estimates
Indirect costs as defined in terms of lost output due to
sickness or death were estimated to be in the region of £2.1
billion in England in 1998. This figure breaks down as:
— £1.3 billion due to sickness absence caused
by obesity
— £0.8 billion due to premature mortality
— (National Audit Office, 2001)
These costs will inevitably escalate unless effective action
is taken to halt the burgeoning epidemic.
The future in terms of healthcare expenditure is bleak as
the prevalence of obesity is rising inexorably.
5.4 There are basically two approaches which are entirely
complementary. The first is a national, population based, public
health approach to prevention. The second is a personal or high
risk approach focusing on individuals who are already obese. Because
of the sheer size of the current obese population such an approach
will have to be selective.
The former attempts to reduce the prevalence of obesity in
the population while the latter targets high risk individuals.
5.5 The National, Population-based, Public Health Approach.
This will have to be delivered by a combined approach led by government
working in partnership with the food and leisure industries and
local authorities with the aim of making the whole environment
much less obesogenic.
"Individual change is more likely to be facilitated and
sustained if the macro-environment and micro environments within
which choices are made supports options perceived to be both healthy
and rewarding. Unless there is an enabling context, the potential
for change will be minimised".
WHO Technical Report Series 916 (2003)
Diet, Nutrition and the Prevention of Chronic Disease
The major intentions have to be
— Increasing the level of physical activity, especially
in the most sedentary
— Reducing the saturated fat content of the diet
while at the same time increasing the intake of poly and mono
unsaturated fats, complex carbohydrates and fruit and vegetables
— Co-ordinating agricultural production, food manufacturing
and marketing practices.
Progress here looks very promising with Sustainable Food
and Farming, the Food Standards Agency and the soon to be released
Food and Health Action Plan. The latter deserves all party support
provided that it addresses the major issues.
5.6 The personal or high risk approach. This is particularly
suited to the British system of primary care. About 75% of the
population see their general practitioner in one year and approximately
90% over a five-year period. Thus the opportunities exists to
identify opportunistically people at high risk and likely to benefit
from appropriate lifestyle advice and continuing support, supplemented
by the selective use of drugs and surgical treatment.
5.7 The role of primary health care teams has to be the
identification of people likely to benefit from lifestyle advice
and support. In providing this there is tremendous potential for
a collaborative approach involving the commercial sector, "Weight
Watchers", "Slimfast", "Rosemary Conley"
and the National Health Service (NHS). The commercial sector could
be asked to deal with the obese who would benefit from weight
loss but who do not have co-morbidities, the NHS should assume
lead responsibility for those people with obesity and co-morbidities
but in providing continuing support there is a great opportunity
to work in partnership with the commercial sector.
5.8 Primary healthcare teams are carrying a very heavy
workload. They are providing both routine care to the sick, a
very heavy commitment, and having to deliver the National Service
Frameworks (NSF) for Coronary Heart Disease, Diabetes, Older People,
those with Mental Illness. The forthcoming NSF for children will
no doubt add further to this workload. This means that they cannot
in addition, shoulder the additional burden of tackling obesity.
This will require the development of a dedicated obesity
service, staffed with appropriately trained professionals, to
which people with obesity and co-morbidities could be referred
for management and continued support. This would allow for a properly
co-ordinated approach across localities which could easily be
evaluated in terms of success and cost effectiveness. It would
eliminate "post code" approaches to managing people
with obesity, achieve the appropriate use of drug therapy and
referral of those most likely to benefit from surgical treatment.
5.9 The RCP have produced guidance on the use of drugs
in treating obesity18 and the National Institute of Clinical Excellence
have provided guidance on the use of the two available drugs Orlistat
and Subutrannine. These provide guidance but should not be allowed
to override experienced clinical judgement.
5.10 The place of surgery in the management of obesity
There is no doubt that in selective cases surgery has a part
to play in the management of obesity. The WHO, in recognising
obesity as a disease, acknowledges that surgery should be considered
in the management of its more extreme forms.
5.11 Selection of patients
These have been defined by the International Federation for
the Surgery of Obesity:
— BMI>40 or 35-40 in patients with co-morbidities
treatable by weight loss
— Being obese for a minimum of five years
— Failure of conservative treatment
— Aged between 18 and 55 years
— Acceptable operative risk
5.12 The benefits of surgery:
— Improved quality of life
— "Curing" type 2 diabetes
— Controlling hypertension
— Reducing health care costs
(Nashund and Agten, 1999) 19
— Improving lipid profiles
— Improving oesophageal reflex
— Helping urinary incontinence
(Kral, 1995) 20
6. ARE THE
INSTITUTIONAL STRUCTURES
IN PLACE
TO DELIVER
AN IMPROVEMENT
6.1 The short answer is no. Some good things are happening
like the forthcoming Food and Health Action Plan and I believe
that there are similar initiatives relating to physical activity.
Both the NSFs for CHD and Diabetes advocate action against
obesity. But the fact is that obesity can't be tackled on the
back of CHD and Diabetes. It deserves and requires a dedicated
high level task force with power of decision making and a realistic
budget. For too long we have been willing to address its consequences
while blithely ignoring its root causes.
7. CHILDHOOD OBESITY
7.1 Prevalence
There has been a significant increase in the prevalence of
overweight and obesity in children.
TRENDS IN OVERWEIGHT AND OBESITY IN ENGLAND
% | 1984 (%)
| 1994 (%) |
overweight boys | 5.4
| 9 |
| overweight girls | 9.3 |
13.5 |
| obese boys | 0.6 | 1.7
|
| obese girls | 1.3 | 2.6
|
20
|
| |
This upward trend has continued. The Health Survey for England
suggested that in the year 2001 8.5% of six year-olds and 15%
of 15 year-olds were obese. 21
The rapid rise in the prevalence of childhood obesity mirrors
the explosion of sedentary leisure pursuits—viewing television,
computer games. Only 50% of children make their way to school
on foot.
There are fewer family meals, more energy-dense snacks and
more grazing. The International Obesity Taskforce found that foods
sold adjacent to schools contained 40% saturated fat and that
girls by the age of 11 had virtually abandoned physical activity.
7.2 Identification
This must be done properly using body mass index percentile
charts as supplied by the Child Growth Foundation. Overweight
children are those with a BMI > the 91st centile and obese
those with a BMI > 98th centile.
7.3 Health associated risks
Rising rates in children are a particular concern as they
pose significant risks for the future health of the adult population,
increasing the risks of premature cardiovascular disease type
2 diabetes and certain concerns as well as musculo-skeletal problems
and psychological disorders; 8% of obese adolescents will become
obese adults.
7.4 80% of obese in adolescents will become obese
adults.
Being overweight or obese in adolescence doubles the mortality
for men aged 50 years and increases the risk of developing cancer
by 14% in men and 20% in women (Betts, P., Regan F. Abstract Child
Obesity Symposium 2003)
The Aron Longitudinal Study of Parents and Children (ALSPAC)
revealed that children as young as six with significant obesity
show abnormalities of left ventricular function.
Obese twelve year-olds show dysfunction, abnormal lipid profiles
and hyperinsuinaemic in 18% of cases. (These are all markers for
premature cardiovascular disease).
They also show a high prevalence of hypertension.
Type 2 diabetes is now emerging in children ( Shield J. Abstract
Child Obesity Conference 2003)
7.5 Suggested Actions
— Health nutrition and how to achieve it should
figure on the school curriculum
— School lunches consisting of nutritious food instead
of allowing children out to buy junk foods
— Curb the power and ubiquity of the marketing and
advertising of companies that specialise in producing energy dense
but low nutrient value foods and drinks and who target children
and young people
— Affects children's food preferences
and the foods and drinks heavily advertised and promoted to children
tend to have high sugar and or fat content, to be lacking in nutrient
value and not in line with diets promoted by public health boards.
Government
8.1 Appoint a cabinet minister to develop a cross departmental
approach to prevention involving not only government but also
the food and leisure industries and local authorities.
— Prohibit the marketing of high salt, high fat
foods to children.
— Adopt an approved labelling scheme.
— Ensure that future urban planning encourages physical
activity.
— Promote research into what works.
— Request Offsted to report on nutrition and physical
activity.
8.2 Food Industry
Develop healthy alternatives to the currently offered drinks
and snacks.
Refrain from promoting high salt high fat foods.
Actively promote an increase in the fruit and vegetable content
of the diet.
8.3 Fiscal measures
— Statutory controls on the marketing of high fat,
high salt foods.
— Enforce labelling standards.
— Tax incentives for employers who encourage physical
activities.
— Possible subsidies for fruit and vegetables.
8.4 Food Industry
— Develop healthy fast foods.
— Improve access in low income areas
8.5 Local authorities
— Recognise obesity as an environmental not solely
a health problem.
— Promote safe walking and cycling routes.
— Ensure safety of parks and play grounds.
— Plan to encourage physical activity.
— Assign a chief officer with cross departmental
authority to promote anti-obesity programme in collaboration with
other relevant bodies, e.g local food and leisure industries.
REFERENCES
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2 World Health Organisation (1998) Prevention and Management
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3 World Health Organisation (2000) Preventing and Managing
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21 The Health Survey for England 2001.
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