Obesity - expensive and expansive

Lucy Turnbull, chair of the Obesity Specialist Group at the British Dietetic Association, examines the obesity crisis facing Britain and how hospitals and dietitians can best manage the issue

Obesity is a growing problem in most developed countries and is responsible for a significant degree of morbidity and mortality in the Western world. More than 2.1 billion people — nearly 30 per cent of the global population — are overweight or obese. Obesity, is responsible for about five per cent of all deaths worldwide. The McKinsey Global Institute report, ‘Overcoming obesity: An initial economic analysis’ found the global economic impact from obesity is roughly $2.0 trillion, or 2.8 per cent of global GDP, which is roughly equivalent to the global impact from smoking or armed violence, war, and terrorism.

The UK has the highest rates of obesity in Europe. Although this recent increase in the prevalence of obesity has been seen in virtually every country in the world, the rate of increase in England has been particularly high. The prevalence in England has more than doubled in the last twenty five years, with results for 2013 showing that around 62.1 per cent of adults were overweight or obese (67.1 per cent of men and 57.2 per cent of women).

The Health Survey for England data also showed that between 1993 and 2013, the prevalence of severe obesity (defined as adults with a body mass index [BMI] 40kg/m² or more) increased dramatically. The proportion of people with severe obesity in England is predicted to rise further over the next twenty to thirty years. According to the Foresight Report, by 2050 the prevalence of obesity is predicted to affect 60 per cent of adult men, 50 per cent of adult women and 25 per cent of children.

According to the McKinsey report obesity currently costs Britain’s economy £47 billion a year. They also estimated that the NHS currently spends about £6 billion a year on the direct medical costs of conditions related to overweight and obesity, five per cent of the entire NHS budget, and a further £10 billion on diabetes. It is forecast that the cost to the NHS will increase to almost £50 billion by 2050, prompting the 2011 Department of Health policy ‘A call to action on obesity in England’.

Societal factors
Conventional wisdom says that weight gain or loss is based on the energy balance model of ‘calories in, calories out’, which is often reduced to the simple refrain, ‘eat less, and exercise more’. However, there are many complex behavioural and societal factors that combine to contribute to the causes of obesity. The foresight report referred to a ‘complex web of societal and biological factors that have, in recent decades, exposed our inherent human vulnerability to weight gain’. They list over 100 variables that directly or indirectly influence energy balance which can be cut into seven cross-cutting predominant themes.

Professor Jimmy Bell, obesity specialist at Imperial College, London, said: “Genetically, human beings haven't changed, but our environment and our access to cheap food has. We're being bombarded every day by the food industry to consume more and more food. In the United Kingdom, the spread of fast food chains and cheap unhealthy food.”

While unhealthy diets and lack of appropriate physical activity are also considered leading causes, some experts argue that this is not the case. Professor Bell, continues, contrary to popular belief, that the people of the United Kingdom have not become greedier or less active in recent years. One thing that has changed is the type of food that we eat. Western diets rely more on highly processed foods high in fat and sugar and this may be leading to increase in obesity.

An obesity condition
There are also a number of genetic, medical and psychological factors that may play a part in the nation's culture of obesity. Medical conditions such as diabetes, hypothyroidism, polycystic ovary syndrome and various endocrine disorders can be contributing factors to weight gain. Medicines such as anti-psychotics, anti-depressants, corticosteroids and contraceptives are also examples of a long list of medications that can contribute to weight gain. Attention must always be given to psychological causes including binge eating and comfort eating; a complex psychological issue in its own right. The prevalence of obesity appears to be higher where there is deprivation and in individuals with lower levels of educational achievement.

There is increasing awareness of an element of genetic influence on obesity. The possibility of determining this opens the potential of effective interventions in the future. It is emerging that obesity is the result of a complex pathophysiological pathway involving many factors that control adipose tissue metabolism. Cytokines, free fatty acids and insulin all play a part and genetic defects are likely to have a significant effect on the fine balance of this process.

Reversing the problem
So what can we do to slow down or reverse this crisis? Over recent years the UK has taken measures in an attempt to tackle its obesity problem. It ideally involves joined up working between health and social care. Unfortunately, the treatment and care is not consistent across the UK with some areas having these services in place with other having very little obesity care.

This can be split into four tiers. Tier 1 involves environmental and population wide services, and includes public health initiatives such as the change4life campaign. The government also used the London 2012 Summer Olympics to help tackle obesity and inspire people into a healthy active lifestyle. A £30 million grant was issued to build cycle paths, playgrounds and encourage children to cut out snacks. There are also public health campaigns by charities such as the British Heart Foundation and the Children’s Food Campaign to remove unhealthy food from supermarket checkouts. These are just a couple of examples of many public health campaigns to help prevent obesity, however, the UK spends less than £638 million a year on obesity prevention programmes, (approximately one per cent of the country's social cost of obesity).

The tier 2 model involves lifestyle interventions, such as commercial slimming clubs, local activity and nutrition programmes. These should include dietitians or qualified nutrition professionals to ensure the correct evidence based advice is being given. Dietitians are trained to translate nutrition science into understandable, practical information about food, allowing people to make appropriate lifestyle and food choices. Dietitians are governed by the HealthCare Professionals Council (HCPC) to ensure that the advice they give is safe and evidenced based.

Tier 3 weight management involves non-surgical specialist weight management services. This is a multi-disciplinary, intensive service that includes dietetics, psychology, specialist physical activity advisors and medical input. The tier 3 services are usually offered to those with a BMI >40kg/m² (or BMI >35kg/m² with co-morbidities). In April 2013 the NHS Commissioning Board published guidelines that stated that all bariatric surgery candidates must in the first instance access a local Tier 3 service for a period of 12 to 24 months.

Tier 4 usually refers to bariatric (or weight loss) surgery, such as gastric band, sleeve or bypass. Bariatric surgery is a highly specialised intervention used in appropriate, selected patients with severe and complex obesity that have not responded to all other non-invasive therapies. Patients need to be motivated and adequately prepared for surgery and for the post-surgical treatment and monitoring which is necessary for success. Currently bariatric surgery costs the NHS approximately £6,000 per surgery.

No single solution creates sufficient impact to reverse obesity. Education and personal responsibility are critical elements of any program to reduce obesity, but they are not enough on their own - only a comprehensive, systemic program of multiple interventions is likely to be effective. These include: national and local governments; retailers; consumer-goods companies; restaurants; employers; media organisations; educators; health-care providers; and individuals.

Restructuring the context that shapes physical activity and nutritional behaviour is also going to be a vital part of reversing the obesity trend. Thus, public health strategies such as town planning, convenience store planning, school food and exercise programmes and good information campaigns are needed. Other identified examples include reducing portion sizes of packaged foods and fast food, changing marketing practices, and changing physical activity curricula in schools. Such interventions rely less on individual willpower, but make healthy lifestyles easier to achieve. The National Obesity Observatory was set up in an effort to collate the research information and to provide a single point of contact for wide-ranging authoritative information on data and evidence relating to obesity, overweight, underweight and their causes, in order to support policy makers.

A future action plan
In 2013 doctors of the United Kingdom united to form what they call a 'prescription' for the UK's obesity epidemic. The report presents an action plan for future campaigning activity, setting out 10 recommendations for healthcare professionals, local and national government, industry and schools which it believes will help tackle the nation’s obesity crisis.

Recommendations include: food-based standards to be mandatory in all UK hospitals; a ban on new fast food outlets being located close to schools and colleges; a duty on all sugary soft drinks, increasing the price by at least 20 per cent, to be piloted; traffic light food labelling to include calorie information for children and adolescents – with visible calorie indicators for restaurants, especially fast food outlets; £100 million in each of the next three years to be spent on increasing provision of weight management services across the country; a ban on advertising of foods high in saturated fats, sugar and salt before 9pm; and existing mandatory food- and nutrient-based standards in England to be statutory in free schools and academies.

The McKinsey report concludes that additional interventions need to rely less on conscious choices by individuals and individual responsibility, and more on changes to the environment and societal norms. These interventions reset the default and make healthy behaviour easier and more normal. It reports that ‘as many interventions as possible must be delivered to have significant impact. A holistic approach by the public, private, and third sectors is the best way forward’.