Select Committee on Health Minutes of Evidence

Memorandum by Dietitians in Obesity Management (UK) (OB 29)

  Dietitians in Obesity Management (UK) are an Interest Group of the British Dietetic Association. It aims to facilitate the development of dietetic best practice, within the context of integrated care, in order to improve prevention and management and thereby reduce the impact of obesity in the United Kingdom.

  Dietitians are a graduate profession, who are highly trained in the science of food and health in the widest sense: food production and processing; the factors that influence food choice; the digestion, absorption and metabolism of food; and its effect on nutritional well-being; treating disease and preventing nutrition-related problems.

  Their special skill is to translate the scientific and medical decisions relating to food and health into terms that everyone can understand. Dietitians work to promote good health by teaching the public and other health professionals about diet and nutrition.

  Currently, there is a national shortage of dietitians just when their specialist skills and expertise are most required in the overall treatment and prevention of obesity.


  Obesity has a major impact on health and the economy. The escalating trend in obesity is a cause for concern and action is needed to halt its progression. The main causes of obesity are linked to changes in diet and levels of physical activity over the past few decades. Responsibility for preventing and treating obesity lies with all elements of society, from individuals to the NHS, education services, the food industry, leisure services, commercial organisations and the government. Action needs to be well co-ordinated with clear messages reaching the general public.

  Obesity needs to be recognised as a chronic disease requiring lifelong management and weight management programmes must incorporate weight maintenance strategies. There needs to be responsible multi-agency programmes in place to help treat and prevent obesity. Research funding needs to be available to guide effective action.

  Dietitians working in Obesity Management (UK) [DOM (UK)] have a key contribution to make to development of obesity strategies at national level and dietitans working in community posts can provide expertise at local level to Primary Care Trusts. Dietitians working in clinical settings provide expert guidance to individual patients, as well as playing an important role as part of multi-disciplinary team approaches.

  The dietetic profession are key players in combating the obesity epidemic.

  1.   The health implications of obesity

  Obesity is a chronic disease, which has been shown to have a major impact on people's physical, psychological and social well-being. It is strongly associated with an increased risk of developing a number of life-threatening conditions including diabetes, heart disease, strokes and some cancers. Of particular concern is the strong causal link with the development of type 2 diabetes. One study suggests there is a 93 fold increase in risk of developing diabetes in those with a BMI above 35 [Colditz et al, 1990]. This is supported by the clinical observation of 75% of newly diagnosed type 2 diabetics having a BMI outside a healthy range [Seidell et al, 1996].

  The economic and social costs of obesity are enormous. A National Audit Office report estimated costs to the wider economy to be in the region of £2 billion with the NHS shouldering at least £½ billion in treatment costs alone. Obesity accounts for 30.000 premature deaths per year, shortens lives by nine years and results in 40,000 lost years of working lives [National Audit Office, 2001].

  2.   Trends in obesity

  The incidence of obesity is increasing at an alarming rate. Some experts estimate that the costs of treating Type 2 Diabetes alone will not be sustainable by the NHS in 10 years' time.

  Recent figures suggest 20% of men and 23.5% of women are obese and 46.6% and 32.9% of men and women respectively are overweight [Health Survey for England, 2001].

  Although there has been some debate over the definition of childhood obesity, it is widely accepted that it is increasing. One report suggests 3% of UK children are obese and 16% overweight [National Diet & Nutrition Survey, 2000]. In 2002 the first cases of type 2 diabetes were reported in children [Drake et al, 2002]. This emergence of adult diseases in children is clearly concerning and seems likely to place an additional burden on the health service and wider economy.

  Obesity in childhood increases the risk of obesity in adulthood and the long term physical and psychological consequences are likely to be substantial.

  3.   What are the causes of the rise in obesity in recent decades?

  The environment in which we live is recognised as the key contributory factor in the rising trend in obesity. High fat diets are linked with increased risk of obesity primarily due to their effect on energy density [Poppitt & Prentice, 1996]. Over the last decade the nation's intake of dietary fat has increased at the expense of starchy carbohydrate foods. High intakes of fruit and vegetables linked to the reduction of energy density are in general below recommended levels. A recent survey of children observed one in five ate no fruit and vegetables during the week of the survey [National Diet & Nutrition Survey, 2000].

  Increasing portion sizes are also believed to play a role in the development of obesity [Young & Nestle, 2002]. Portion sizes of snack foods, many manufactured products and meals eaten outside the home have increased over recent years. It may be that this has influenced people's perception of appropriate portion sizes for healthy eating. There is an abundance of high-energy dense foods available, which are heavily marketed and packed in a way that is attractive to adults and children alike.

  Paradoxically research suggests that average energy intakes have declined at the same time as obesity has increased [Prentice & Jebb, 1995]. Although consideration should be given to the impact of misreporting of food and energy intake on the results of such studies, much of the discrepancy between lower energy intakes and increasing obesity has been explained by the substantial decrease in the nation's activity levels.

  Reduced physical activity is a major contributing factor towards obesity. Obesity is also linked with poverty and low levels of education, thereby having a greater impact on the most disadvantaged groups in society.

  4.   What can be done about it?

  It is clearly time for action. The human costs in terms of the psychosocial aspects are very familiar to dietitians working in clinical practice, as well as those involved in health promotion and public health work. The health benefits of treating obesity are well recognised, and supported by the recent research from USA and Finland in which modest weight losses reduced risk of developing type 2 diabetes by 58% [Knowler et al, 2002; Tuomilehto et al 2001].

  There needs to be a co-ordinated national approach at primary and secondary care level with cohesive strategies in place encompassing all aspects of management.

  4.1  Prevention:

  Obviously, prevention is the ideal, but simply halting the increasing trend would be a realistic initial target. Prevention involves a wide number of approaches at different levels, both national and local.

  Responsibility lies with individuals and groups as well as government.

  We know that eating healthier diets and being more physically active is the key both to prevention and treatment. All initiatives need to focus on these key messages.

  Schools need to teach the importance of healthy eating and lifestyles, provide practical instruction on food preparation and cooking, promote and provide the facilities for physical activity and produce healthy school meals and snacks. National funding and support will be required to achieve this.

  Physical activity initiatives need to be properly funded and supported.

  Community development programmes which support healthy eating and physical activity initiatives have a key role to play in the prevention and treatment of obesity. It is essential that such community initiatives be comprehensively evaluated to determine efficacy.

  4.2  Treatment:

  The WHO classifies obesity as a chronic disease and its management needs to be viewed as lifelong. It is important that treatment of obesity is seen as having a weight loss phase and a weight maintenance phase. Traditionally, the focus has been on weight loss alone. Maintenance of weight loss is notoriously difficult and research funding needs to be directed to this area. It would be helpful to have a National Weight Control Registry akin to the US version to provide a resource for research initiatives.

  4.2.1  The role of the NHS:

  With one in two of the population overweight and one in five classified as medically obese, the majority of people need to be treated in primary care, supported by specialist services in secondary care for the treatment of the morbidly obese. Primary Care Trusts need to have clear strategies in place to support the prevention and treatment of obesity.

  Training of health professionals at undergraduate and postgraduate level in the knowledge and skills to manage obesity is required. The Royal College of Physicians, 2002 report, Nutrition & Patients, a doctor's responsibility, highlighted the lack of nutrition training for doctors and the need to recognise and address this shortfall. Specific training in obesity is inadequate for many health professionals, resulting in lack of confidence in their ability to help patients implement change. Dietitians are ideally placed to deliver training on nutrition and behaviour change skills to other health professionals.

  Drug treatment plays an important role in the treatment of obesity for some patients. Recommendations are in place to support their use, but many dietitians report that patients have not been given appropriate dietary advice before commencing treatment. Further research is required to evaluate practice and determine whether suitable advice and support is routinely provided. It is vital that drug treatment is used as an adjunct to lifestyle changes. Currently, dietitians are viewed as "ordinary members of the public" by the Medical Control Agency, thereby preventing them from receiving information directly from drug company representatives. This is clearly undesirable as dietitians have the training and expertise to advise on all aspects of obesity management, and need to be aware of current information in relation to drug therapy.

  There are insufficient specialist centres in the UK to deliver the multi-disciplinary approach to the management of morbid obesity with particular reference to surgical intervention.

  The management of morbid obesity in childhood is woefully inadequate with even fewer specialist centres established than for the adult population. These centres would offer the opportunity for additional research in determining the most effective treatment approaches.

  4.2.2.  Practice Related Research:

  Much of the research in the obesity field has centred on understanding the causes of obesity. Less attention has been given to understanding which interventions are the most effective in treating and preventing this disease in various populations and healthcare/community settings. It would now seem prudent to give greater emphasis to practice related research that focuses on the many pragmatic issues in the management of obesity. Historically this type of research has struggled to attract funding.

  Very little is known about the strategies that work best in populations whose needs may be very different to those on which many intervention programmes are tailored eg low income, ethnic groups. More research is required to determine the most effective strategies in such groups.

  4.2.3.  Commercial Options:

  There is a wide range of commercial options available and indeed the slimming industry is big business. With one in three of the female population reportedly trying to lose weight, there is a need to provide the general public with direction as to the appropriate and inappropriate methods of management.

  Commercial slimming clubs have an important role to play for those who wish to take responsibility for their own weight or who do not wish to have medical interventions. Clearly the NHS cannot cope with the increasing numbers without support from outside organisations. It is important that criteria are in place to guide members of the public and healthcare professionals alike on what they should look for in a commercial slimming club. It is essential that these clubs offer weight management programmes, which emphasise weight maintenance as well as weight loss. Rigorously designed studies to evaluate long-term success needs to be undertaken by responsible clubs.

  Only 1% of men attend commercial slimming clubs, so other approaches need to be encouraged. Workplace schemes may be more appropriate.

  There are a whole host of other commercial approaches available, which include home-based programmes, website programmes, books, tapes, videos, slimming pills and private slimming clinics. DOM (UK) is currently developing evidence-based guidance documents on the different dietary approaches to inform health professionals and members of the public. It is worth noting that the American Heart Association recently "declared war" on fad diets.

  Obesity has crept up on this generation and it is clear that despite an increase in media coverage there is a lack of awareness amongst the general public about how obesity affects individuals. There needs to be a campaign to raise awareness and promote self-help. Canadian research has shown that TV advertisements are an effective way of doing this. Posters and other means of communication can also help. The media can also be used to help change negative attitudes and discriminatory behaviour towards the obese.

  The food industry needs to address its marketing. It has a vital role to play in providing healthy food choices.

  5.   Are institutional structures in place to deliver an improvement?

  The DoH are best situated to direct national public health campaigns and to ensure that consistent messages are delivered. They can influence public health and health promotion strategies at regional and local level. It is crucial that the DoH links with other government departments and The Food Standards Agency as well as medical bodies, physical activity services and the food industry.

  Dieticians are trained to understand the role of different agencies and they can play a vital role in influencing decision-making. There are well-established community dietetic services across the country, which have a public health remit, as well as a health promotion, training, community development and clinical role.

  6.   Recommendations for national and local strategy

  Government strategy needs to be clear and supported by realistic targets with appropriate timescales. At the moment obesity strategies are "lost" in other policies. Obesity needs a higher profile and higher priority. Key policies need to address the food supply chain and physical activity. There seems to be a lack of co-ordination currently and this needs to be address through better integration of services.

  Priorities for action include:

    —  Raising awareness amongst the general public and healthcare professionals

    —  Prevention strategies aimed at children and families and involving schools and education services

    —  Stop advertising unhealthy foods to young people

    —  Better food choices in fast food outlets and restaurants

    —  Public health initiatives to support more physical activity.

  Dietitians are key professionals with the knowledge and skills to play a major role in combating the epidemic of obesity with involvement at national and local level initiatives as part of a multi-agency co-ordinated approach to the treatment and prevention of obesity.


  Colditz G, Willett WC, Stampfer MJ, Manson JE, Hennekens CH, Arky RA, et al Weight as a risk factor for clinical diabetes in women. AmJEpidemiol 1990; 132:501-13.

    Seidell JC, Verschuren WMM, Van Leer EM, and Kromhout D Overweight, underweight and mortality: a prospective study of 48,287 men and women. Arch Intern Med 156; 958-963, 1996.

  National Audit Office (2001). Tacking Obesity in England. London: The Stationery Office.

  Gregory J, Lowe S National diet and nutrition survey, young people aged four to 18 years. London: Stationery Office, 2000.

  A J Drake, A Smith, P R Betts, E C Crowne and J P H Shield. Type 2 diabetes in obese white children. Archives of Disease in Childhood 2002; 86:207-208.

  Poppitt SD, Prentice AM. Energy density and its role in the control of food intake: evidence from metabolic and community studies. Appetite 26(2):153-74, 1996.

  Young LR, Nestle M The contribution of expanding portion sizes to the US Obesity Epidemic. AmJPublic Health 92[2]:246-249, 2002.

  Prentice AA, Jebb SA. Obesity in Britain: gluttony or sloth? BMJ. 311: 437-439, 1995.

  Knowler WC, Barett-Connor PH, Fowler SE, Hamman RF, Lechin PH, Walker EA, Nathan DM. Reduction in the incidence of Type 2 Diabetes with lifestyle intervention or metformin. Diabetes Prevention Programme Research Group. NEJM 2002; 346[6]:393-403.

  Tuomilehto J. et al Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New Engl J Med 2001; 344:1343-1350.

  Nutrition and patients, a doctors responsibility. Report of a working party of the Royal College of Physicians, 2002.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2004
Prepared 27 May 2004