Responding to the obesity challenge

The growth in population obesity is greater than the effect of interventions to address it and as a result the prevalence of obesity is increasing. This increase has significant health, social and economic consequences. Many areas have developed obesity care pathways with effective interventions however the impact of these in isolation is inadequate to make a difference. The transfer of public health to Local Authorities in England has provided a unique opportunity to accelerate action to reduce obesity. Health and Wellbeing Boards are providing leadership; bringing NHS partners, local authorities and the voluntary sector together to tackle issues such as obesity that require a system wide approach.
Financial pressures within the public sector increase the need for investment in strategies that are evidence based and will provide a return on investment. Specific evidence relating to successful strategies for the prevention of obesity is limited (although growing) which weakens the case for investment, however, the predictions of the future scale and cost of obesity are frightening and mean that to do nothing is not an option. There are several options for a strategic approach to tackling obesity based on international evidence and approaches.  

Gathering evidence
The Australian Assessing Cost Effectiveness (ACE) IN Obesity and ACE Prevention studies have assimilated a broad range of evidence for the prevention of obesity in Australia. These studies appraise both prevention and treatment interventions in children and adults.

Interventions were assessed for comparative effectiveness and cost effectiveness. Of 20 interventions, eight were found to be both health improving and cost saving and a further three were cost effective. The conclusion from the ACE studies is that policy approaches generally show greater cost effectiveness than health promotion or clinical interventions.  
No intervention, however effective will be sufficient to reverse the obesity epidemic in isolation. Solutions need to be multifaceted, with initiatives throughout governments and across several sectors. Interventions that might have quite small effects when assessed in isolation may still constitute important components of an overall strategy.

It has been argued that obesity prevention interventions should be universal across entire societies including people at every age and regardless of risk factors given that we have too little data available on effective ways to identify and manage individuals’ obesity risks to justify a population strategy that would devote resources to sorting people by risk or readiness. However, there are specific times in the life course where there is greatest potential to impact on obesity including maternity, where there is opportunity to affect the future health risk of the child and the mother; early childhood where there is a high level of parental control and eating and activity patterns and preferences are being established; and school aged children where there are opportunities through schools to regulate eating and activity and to influence the family through the school. Evidence from a growing number of studies has indicated that treating obesity before puberty may have more long lasting effects on relative weight in the long term than providing similar treatment after puberty or in adulthood.
Individual level approach
Whilst the collective systems approach being driven by Health and Wellbeing Boards is being prioritised to address obesity at a population level, healthcare organisations require an individual level approach to support the management of many health conditions. Obesity is an independent risk factor for premature death, but it is also strongly associated, probably causally, with a number of other serious medical conditions.
Overall obese people are two to three times more likely to die prematurely than their lean counterparts and on average obesity reduces life expectancy by about nine years.

Lower morbidity
There is good evidence that losing even small amounts of weight can decrease the occurrence or severity of risk factors for disease e.g., insulin resistance, dyslipidaemia etc., but there is only limited evidence as yet from long-term prospective studies with hard outcomes on overall impact such as incidence of diabetes or reduced mortality. Nonetheless the decrease in obesity-related morbidity with weight loss of even five to 10 per cent among obese people (15 to 20 per cent in those with a BMI over 35), brings significant benefits to the individual including reductions in medication for other diseases, improvements in physical functioning and quality of life.
Primary care staff have a key role in supporting patients to maintain a healthy weight by: monitoring weight; raising the issue of weight gain or obesity and providing brief interventions to encourage behaviour change; providing access to weight management services appropriate for the individual; and by monitoring progress.

Commercial slimming groups have been shown to be effective and cost effective for the majority of those who are ready to lose weight.

These are often provided on an NHS referral scheme. Those with more complex obesity require specialist support with input from a dietitian often in collaboration with a specialist physician, psychologist and physiotherapist. This multidisciplinary approach allows the patient to be assessed for and supported with lifestyle, psychological and medical causes and consequences of obesity simultaneously. Specialist weight management services often called tier 3, also support assessment for bariatric surgery to ensure patients referred for surgery understand and are able to apply the lifestyle changes required to achieve a successful outcome.

Childhood obesity
Childhood obesity is a particular concern with a third of children overweight or obesity in England. 85 per cent of obese children will become obese adults so failure to address childhood obesity is storing up problems for the future. The population preventative measures highlighted at the beginning of this article are the main intervention for preventing childhood obesity. For those children who are already obese, it is our clinical duty to raise awareness of this and offer support. Childhood obesity is not puppy fat and children rarely grow out of it. Children’s BMI is measured on gender specific BMI charts rather than adult charts.
In summary, obesity is a major health concern requiring action at many levels by many organisations. A systems approach involving all partners is recommended with actions focused on population level for prevention alongside individual level support.

Further information