By mid-century the cost to the NHS of weight related health problems could double to more than £8bn and a quarter of UK children may be obese. Emma Dent asks what is being done about a huge challenge
- Sixty per cent of men and 50 per cent of women in the UK could be obese by 2050.
- The government wants to reduce the number of obese and overweight children by 2020.
- Obesity management is far less embedded in general healthcare than smoking cessation.
Of all the looming crises facing the nation’s health and subsequently the NHS, obesity is perhaps the greatest. Since the early 1990s, rates in the UK population have been accelerating at a pace most often described as “relentless”. But is it unstoppable?
Though the UK is hardly alone in facing this epidemic, the figures make sobering reading. An oft-quoted 2007 report by government think tank Foresight pulled no punches when it predicted that if no action is taken, by 2050, 60 per cent of men, 50 per cent of women and 25 per cent of children will be classed as obese, alongside increases in obesity related diseases such as heart disease, stroke, diabetes and some cancers.
“Many commentators believe efforts so far are essentially tinkering around the edges”
The report’s predicted rises in costs were no less horrific. It claimed the cost of obesity to the economy overall is around £16bn a year, and likely to rise to £50bn a year if left unchecked.
Costs to the NHS, currently £4.2bn a year, were predicted to more than double by 2050.
An inquiry this February chaired by leading epidemiologist Sir Michael Marmot for the World Cancer Research Fund found that, in addition to poor diet and growing alcohol consumption, obesity could contribute to the number of people dying from cancer doubling in the next 40 years.
Obesity related costs in the NHS are already on the increase. At the extreme end of the scale, bariatric (obesity) surgery - such as the fitting of gastric bands and “stomach stapling” - and the prescription of drugs to help manage weight are both on the increase. NHS Information Centre figures show the number of bariatric procedures carried out has increased by 40 per cent in the past year.
An increase in surgery is likely to be related to an increased number of trusts carrying out such procedures in a bid to meet demand. Anecdotally, the demand and subsequent cost are such that many primary care trusts are unable to refer all suitable patients, leading them to restrict eligibility criteria, such as only offering such options to people with a body mass index of 50 or above (obesity is classed as having a BMI of over 30 and morbid obesity a BMI of over 40).
In the face of such daunting challenges, government has little choice but to respond. Early attempts did not fare well. The 1992 Health of the Nation report set targets for weight reduction in the English population by 2005, but obesity rates continued to climb.
More recently, a plethora of initiatives aimed at preventing people from becoming overweight or obese have been launched. An obesity toolkit was launched in April 2007 by the Department of Health, followed by the 2008 cross-government strategy Healthy Weight, Healthy Lives.
Cross-government moves to increase the number of babies that are breastfed, establish a voluntary “healthy food code” with food and drink manufacturers, restrict the number of adverts for unhealthy food that children are exposed to and invest in so-called healthy towns are all included in this.
Public health practitioners have concerns about the voluntary nature of much of this work, such as schemes to signpost how healthy a type of food is.
“Having one clear, national way of labelling food would really help. There is a difficult decision to be made here about the role of government in legislating on such issues,” says Association of Directors of Public Health president and North Lancashire PCT director of public health Frank Atherton. He adds that local authorities need to be involved with work on measures such as keeping tighter controls on the number of fast food outlets that open on one high street, or near a school.
There are also concerns about the need for measures to encourage activity, such as making cycling and walking attractive to all. An initiative led by the ADPH has called for a shift away from car dominated transport plans.
“Local authorities should be setting themselves targets in terms of increasing the amount of local walking and cycling by making them attractive alternatives,” says Dr Atherton.
While such moves point to the need for a society-wide drive towards improving health, many government initiatives focus on managing children’s weight and encouraging an early interest in healthy eating and getting enough exercise - a key government target is reducing the number of overweight and obese children by 2020.
Since 2005, the national child measurement programme has measured the height and weight of primary and middle school children for inclusion on a national database. Since 2008, it has sent results of the measurements to parents.
It has also been interwoven into non-health settings. At 10 years old, Healthy Schools is one of the longest standing health initiatives for children, with over 70 per cent of schools awarded “healthy” status under the programme.
“The programme really resonates with what the vast majority of schools see as a vital part of their role with children and young people - helping to improve their health and wellbeing while raising standards, improving behaviour and attendance. We have also been successful in making sense of, or translating, health and education agendas for the school setting,” says programme head Richard Sangster.
He is convinced that the lessons children learn often extend beyond their school day.
The most recent and perhaps most high profile DH effort is Change 4 Life. With its brightly coloured adverts offering simple advice on avoiding sugar and giving children smaller portions, the campaign is aimed squarely at families. It includes a survey asking families to give details of their “eating and activity habits”, to be followed up by tailored advice.
In early 2009, it was joined by Be Active, Be Healthy, a campaign to “get couch potatoes off their sofas” as a DH press release put it. Health secretary Alan Johnson was quoted as saying he wanted to capture the “Strictly Come Dancing effect” to increase people’s physical activity.
The initial focus on children has been criticised for leading to insufficient attention being paid to adult weight and for being an easier win - children can be told what to do while adults can’t, and targeting schools makes for easier hits.
But being given information at school is of little use if your family has bad habits at the evenings and weekends. DH director of health and wellbeing Will Cavendish acknowledges families need to be tackled as a whole.
“Our first priority is to give people the information and support they need to be able to lead healthier lives and we know family based programmes are an effective way of doing this,” he says, adding that the current focus on children will be followed up by a greater emphasis on adults at a later date.
Weight and health
Much of this relies on giving people information and hoping it will spur them into action, but many doubt the public yet fully understands the links between their weight and their health, which means PCTs must act.
Mr Cavendish knows obesity management can lead to government treading a fine line between the “nanny state and the no state”.
But despite all the initiatives and Mr Johnson’s call for a national drive, many commentators believe efforts so far are essentially tinkering round the edges.
“We have no coherent public health drive on this. There is no co-ordinated approach, although the Foresight report showed all work on this is inadequate unless it is done alongside fundamental changes to the environment, so I give Change 4 Life a one in 10 chance of success,” says International Obesity Task Force chair Professor Philip James.
“It would be nice if at this stage we could be more co-ordinated. There has to be national leadership,” adds King’s Fund research fellow in public health Tammy Boyce. “The World Health Organisation [says] 95 per cent of research into obesity is looking at the problem while only 5 per cent is about evaluation. We need to start looking at this issue in terms of solutions.”
Including obesity in the quality and outcomes framework is one way to involve GPs, but Ms Boyce is concerned obesity management is still not intrinsic in general healthcare. She advocates every healthcare professional in contact with a patient being in a position to “do something or ask something” about a patient’s weight.
And while Mr Cavendish says the DH wants every PCT to have its own weight management scheme and a number of PCTs have included obesity in their world class commissioning targets and local area agreements, efforts to date are considered to be patchy, often hampered by inadequate or short term funding.
“There is a key issue with getting GPs to understand the local problem,” says Faculty of Public Health president Dr Alan Maryon-Davies. “But services could be swamped. What is the referral process? There are community dietician and exercise facilitators in place, but it is not like smoking cessation, which is well co-ordinated. A lot more investment is needed.”
Mr Cavendish puts PCTs’ variable success to date down to the lack of a “gold standard evidence base” in effective weight management.
“Lots of PCTs are doing this for the first time. This is challenging work and has to be done with sensitivity and tailored to local communities. It will take a couple of years to get going.”
But National Obesity Forum clinical director David Haslam dismisses suggestions that weight management techniques cannot be used now.
“All the reports, Foresight included, shrug their shoulders and say there is no evidence. But answers to the obesity problem are well known, can make a difference and can be rolled out to anyone,” he says, citing among others the Rotherham model (see box).
Prevention is easier to tackle and for government to use to show they are doing something, says Dr Haslam. “It would cost an enormous amount but this should be seen as an investment, not a cost,” he adds. He admits the scale of the problem can make it daunting.
One thing that is agreed on is that it will take at least a generation to see a significant change in the nation’s habits and weight and to see the public’s waistlines return to measurements last seen 20 or 30 years ago.
“Over the last two years we have not seen a significant change in levels of child obesity. That is an early sign of hope. We hope we are at the end of the beginning of the journey but we need to press on,” says Mr Cavendish.
TACKLING A STEEP RISE IN OBESITY LEVELS
The Rotherham PCT model
Yorkshire and the Humber bears the dubious honour of facing a “particularly steep” (according to the Foresight report) rise in obesity levels, with a staggering 70 per cent of its population predicted to be obese in 2050 if nothing is done. Currently, 60 per cent of adults and a third of children in the region are classed as obese.
Tackling such numbers needs bold action, which is what Rotherham PCT has decided to take.
“Our obesity profile is similar to the wider region and we know that if we don’t do anything it will be a massive problem,” says PCT public health specialist Carol Weir.
Having made obesity a priority through its world class commissioning process, Rotherham has established a three year £3.5m strategy.
The scheme is divided into initiatives for children and adults. At the start of the four tier process for both is prevention work.
“It is a healthy weight framework not just a weight management framework, where we work with our local authority partners on improving the built environment, transport and planning as well as issues such as school meals,” adds Ms Weir.
“Obesity prevention work has to be in everything.”
The first tier of the scheme puts in place standard primary care contacts with health visitors, GPs and school nurses for children and contacts with GPs, health visitors and leisure services for adults. Tier two involves a 12 week community based weight loss programme run by Carnegie Clubs (similar to Weight Watchers or Slimming World).
If that is not enough for a patient to start losing weight, they are referred to the tier three service, which comprises a multidisciplinary obesity team - based in a GP practice - including access to an exercise specialist, dietician, cognitive behaviour therapy and a nurse.
Children who have come through the service so far and still need to lose weight are referred to the tier four six week Carnegie residential camps.
“They are not boot camps or fat camps,” says Ms Weir, who has suffered many a sensationalist headline over the camps. “So far, 38 children have been on the programme and between them they lost 30 stone, which is an immense achievement, both in terms of improving self-esteem and self-confidence as well as losing weight. They have also continued to lose weight since, which is brilliant.”
Adults who are referred on to tier four services are considered for bariatric surgery. Obesity medications are also being considered for adults and children over 12.
“We are looking at this service working with 2,000 children and 2,000 adults, all of whom will have tier two interventions, a smaller number in tier three and a smaller number still in tier four,” says Ms Weir.
“With adults, we are aiming for a 5 per cent weight loss. It is harder to measure with children because they are still growing but longer term we want to see weight loss continued and are looking at measuring whether and why people end up coming back into the service at a later date.”
Ms Weir believes the PCT is unique in taking such a bold step.
“The residential camps have been a huge investment without a huge amount of evidence. But without the work, we won’t be able to show the benefits.”