The huge cost of obesity to the health service is increasingly well known - but is the NHS partly at fault in failing to provide the level and type of services needed? Alison Moore reports

'Thou seest I have more flesh than another man and therefore more frailty, ' declares Falstaff in Shakespeare's Henry IV. Fat did not stop Falstaff enjoying life to the full, at least until his untimely death, but for the two-thirds of English men and half of English women who are overweight or obese it is contributing to ill-health and ultimately will cost many of them their lives. That is not the only price: last month a report from the National Audit Office put the cost for the NHS alone at£485m a year.

The report also highlighted the patchy and limited nature of help available from the NHS, despite the high costs of treating patients with obesity-related health problems such as type-2 diabetes, hypertension and coronary heart disease.

Part of this may be shorttermism - tackling highly visible and measurable problems, such as waiting lists, rather than longer-term issues which bring benefits many years in the future, according to Donald Reid of the UK Public Health Association.

But obesity is creeping up the health agenda. Janice Miles, policy manager at the NHS Confederation, says provision has probably improved since the 1999 NAO survey of health authorities found that although 83 per cent identified it as a public health risk in their health improvement programmes, only 28 per cent had taken action. This has been partly due to the national service framework for coronary heart disease. The impending publication of a diabetes national service framework may have an impact in the future. Obesity is a key risk factor for both of these diseases.

For most obese or overweight patients, the first contact with obesity services is likely to be through their GP. The NAO report highlighted GPs' uncertainty about the effectiveness of treatments available to them, and the lack of protocols or guidance on managing obese patients. It recommends greater appraisal of effectiveness of treatments and clarifying GPs' responsibilities for identifying 'at risk' patients.

Dr Colin Waine, a former GP with a special interest in obesity and now director of health programmes at Sunderland health authority, argues that obesity needs to be tackled like any other chronic disease with diagnosis, advice or treatment and regular follow-ups.

'A primary care group or primary care trust could develop a weight loss and management programme which people could be referred to, ' he suggests. 'This centre could then do the followup. '

He is hoping to pilot a weight loss programme with a local PCG, which will offer intensive support for 12 weeks and then ongoing monitoring to keep weight stable.

Intervention may be more effective at critical points in patients' lives such as when a relative develops obesity-related diseases, he suggests. But Dr Alan Maryon Davis, a public health consultant and spokesman for the Faculty of Public Health Medicine, says GPs and practice nurses may need more training in nutrition to be able to assist patients who want to lose weight.

They also need additional services they can refer patients onto - and these are often limited.

There is a nationwide shortage of trained dieticians - some areas employ only one dietician per 300,000 people - and it would be impossible to set up a comprehensive service for all obese patients even if funding was available.

The pressure for better dietary advice for patients is likely to increase if orlistat (Xenical) is given the National Institute for Clinical Excellence's backing in the next few weeks.

The first of a new generation of weight-control drugs, it will need to be prescribed within the context of structured dietary advice. But Professor Chris Drinkwater, public health spokesman for the NHS Alliance, argues that the focus of the NHS ought to be on encouraging people to expend more energy.

'On the whole, on the medical side we tend to focus on the energy intake rather than the output, ' he says.

'But the best buy in terms of public health medicine is increasing levels of physical activity in the population.

'My major worry would be that we go down a road which is about 'magical' solutions, such as antiobesity drugs, ' he says.

Longer-term, preventative measures can have an effect - but the public is notoriously resistant to the 'eat less, exercise more' message.

Dr Maryon Davis suggests a carrot and stick approach:

'Youngsters could have their computers and televisions linked to a dynamo, ' he says.

'If they stop pedalling, they stop watching. '