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.
SUMMARY OF
EVIDENCE
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.
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