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The problem of rising prevalence in obesity may get much worse—rates could climb still further, bankrupting the health system and leading soon to reductions in life expectancy. So, can we offer effective management? And can we reverse the rising trend in the prevalence of obesity, and if so, when?
Recent headlines highlighting the current and projected obesity levels in the United Kingdom—in 2010 a third of adults will be obese—reiterate the cry that “it's time to do something about it.” As already shown in this series, the consequences of obesity affect all ages and nearly all organ systems. Obesity diminishes quality of life, and many problems begin well before reaching a body mass index of 30. Well over half the entire population of the UK have a BMI of >25, and they will experience greater morbidity and total mortality.
Although the old attitude of “pull yourself together, eat less, and exercise more” is receding, it is still evident among less perceptive health professionals and is commonly voiced by the media. Most overweight or obese individuals would prefer to be normal weight, and many are doing as much as they can to keep their weight lower than it would otherwise be.
It is increasingly apparent that most individuals are unable to make enough “proactive” changes to prevent excess weight gain but are simply “reactive” to their environment. Thus education alone will fail to halt this obesity epidemic, and environmental changes (physical, food, and fiscal policy) are urgently needed
We are all to some extent addicted to food. As with any disorder, people with excessive addiction to food require help, advice, and sympathy. Many become caught in a negative cycle of excess energy intake, continuing weight gain, and impaired appetite regulation, with physical inactivity an inevitable compounding factor.
People clearly have some responsibility for their health, but society and government have a responsibility to make the preferred, easy choices healthier ones. Health professionals have a responsibility to treat patients with understanding and sympathy and to call for changes in the food and activity environments to support improvements in public health.
Rates of adult obesity in the Japanese and the French are strikingly lower than in the US and the UK, despite no evidence that they are more physically active. Their food cultures, however, are very different. Traditional ways of providing and eating food—such as families eating together at table—persist, albeit under threat from globalised catering, especially among young people
More attention could usefully be paid to the trends and differences in and between countries. Economic analyses show that recent increases in energy intake may be the predominant cause of increasing obesity, with physical inactivity playing an early facilitating but now compounding role. For example, in the United States, dependence on motorised transport, automated appliances in the home and workplace, and television viewing was established by 1970. However, obesity rates only began to accelerate in the '80s and '90s. This coincided with steady increases in food production and decreases in relative food costs, combined with more snacking and eating away from the home and consuming energy dense foods that are provided in ever bigger portions. The same trend now exists in other countries.
Maintaining a stable weight is easier than losing excess weight. Indeed, a third to a half of all obese patients will not lose weight by any medical method. Much more effort should focus on discovering how to prevent individuals becoming overweight or obese in the first place and maintaining current weight. Prevention is the only economic long term solution to the problem. Even a complete understanding of the genes and peptide cascades that regulated appetite and metabolism can never reverse an epidemic driven by environmental and cultural change.
If environments—physical, food, fiscal, and social environments—have become highly obesogenic, can they be changed? Although this has not yet happened anywhere, food consumption patterns can be adapted to enable people to satisfy both energy needs and taste buds without much conscious thought.
This can be facilitated by altering our physical activity environment. But changes are also needed both in the practices of the food industry and in the attitudes and behaviour of the public. Only small changes are needed, but it is difficult to imagine this all happening without an agency dedicated to combating obesity—with multifaceted specialist inputs and high level political influence.
The 2002 joint consultation of the Food and Agriculture Organization of the United Nations and the World Health Organization used a systematic approach to published evidence to rank possible interventions. This ranking may, however, be misleading because comparable research efforts have not been applied to these or to other, potentially valuable measures. Furthermore, individual interventions may not be effective in isolation.
The food industry is the largest, most powerful industry of all; food is essential for life and health, and the industry must remain profitable. The industry is largely driven by commercial forces aimed at maximising consumption and hence profit. Given people's increasing reliance on processed and precooked food, the industry needs to assume much more responsibility for preventing obesity. Governments, as custodians of public health, have keys roles in creating the conditions for this to happen. Voluntary agreements have not been enough. Foods that are less energy dense are needed; this would reduce the total energy content of what is sold and eaten in meals and snacks, without reintroducing calories in other foods.
What is provided determines what is eaten, and so what is provided has to change. This will require attention to pricing and marketing policies, product design, portion sizes, energy content and density, and customer information. Moreover, the advertising of energy dense foods needs to be substantially curtailed—“out of sight, out of mind” holds especially true for children.
The Treaty of Rome included the principle that public health consequences should be considered for all decisions made in public life: ministers can no longer ignore this issue. We need effective regulations or active support and incentives for measures that reflect “corporate social responsibility.”
The measures outlined above may not succeed unless the public is also persuaded to change its dietary and physical behaviour. Intensive efforts, supported by government, are also needed to change the prevailing food and drink culture.
A reasonable educational target for the near future might be to teach the simplest principles of energy balance at primary school level. But education alone may have only a limited effect, and even that is likely to be mainly among those best able to assimilate knowledge. The highest obesity levels seem to be among those in the most deprived socioeconomic areas, particularly in women (although many factors other than knowledge are relevant here). Education is essential at all levels—for children and adults, and for policy planners.
More innovative ways of educating the public, including children, are clearly needed. The media also have a role in disseminating messages and must be trained appropriately.
Obesity affects all branches of medicine and surgery, and all doctors can contribute to its treatment and prevention either directly or by appropriate referral
Historically, nutrition has been poorly taught to doctors, but the General Medical Council's Tomorrow's Doctors initiative has urged improvements in nutrition education for medical undergraduates.
A strong case now exists for making obesity a core part of all medical curriculums and part of the training of all other health professions. Continuing emphasis should be placed on obesity in postgraduate teaching—both in the early generic professional training programmes for all specialties and then later in relevant specialty programmes. In other words, any contact between a medical professional and a patient is an opportunity to assess whether that patient has a weight problem—and to offer advice.
Some issues peculiar to obesity remain complex—for example, what constitutes success for medical interventions against obesity. The goals of public health planners (such as halving the rate of weight gain and reducing the prevalence of obesity related diseases) do not easily translate into management targets for individuals' weight loss and maintenance. Even the internationally accepted target for weight loss (5-10 kg)—which confers a high proportion of the potential medical benefit, through loss of intra-abdominal fat—is rarely acceptable to patients.
The UK now has safe, effective adjunctive drug treatments that are approved by the National Institute for Health and Clinical Excellence, and evidence based surgical methods for obesity are also available. Routine health care now offers evidenced based, structured multidisciplinary management of obesity. In the UK, Counterweight (an obesity management project in selected general practices around the country) is a good example.
In the Counterweight programme, patients have six appointments or group sessions over three months, with follow-up sessions every three months for one year then annual reviews. The aim is to achieve at least 5-10 kg weight loss, then weight maintenance—the success rate in the programme so far is about 30-40%. The programme is continuously evaluated and improved
Not all patients are willing or able to participate fully in such programmes, but for over half of those who do, quite modest, achievable weight loss brings major benefits for obesity related diseases in every system of the body. Once a weight management programme is established, we have a duty to evaluate and improve the programme. Doctors, patients, and healthcare providers must recognise the costs of not providing effective weight management.
Health services and governments need to realise that the research conducted so far has not answered all the essential questions. Researchers have tended to focus on the efficacy and safety of interventions. Much more research is needed on routine services in community and population settings to provide a basis for future interventions. There is also a need for continuous evaluation of current policies, commercial practices, and cultural attitudes to help in the understanding of current trends in and between countries and to shape improved approaches. New research skills, new methods, and new funding pathways are needed.
Medical practice must adapt to the current epidemic of obesity and nutrition related diseases. The profession must unite the forces of public health and acute services to generate sustainable changes in food and lifestyles, matters at the heart of our cultural identities. Furthermore, training in public health medicine should urge all doctors to contribute towards bringing changes in the food industry and in the environment that will lead to a more physically active, healthier, and happier population.
Society has accepted long term expensive drug treatments to reduce risks from preventable conditions such as type 2 diabetes, hypertension, and coronary heart disease. To be consistent, it must accept that many people now need drugs (and in some cases, surgery) to cut risks of and disability from obesity, and to limit its progression.
As the prevalence and costs of obesity escalate, the economic argument for giving high priority to obesity and weight management through a designated coordinating agency will ultimately become overwhelming. The only question is, will action be taken before it's too late?
The photographs of cycle lanes, ice cream drink, and swimming are published with permission from Martin Bond/Alamy, Martin Parr/Magnum, and SIPA/Rex respectively.
Laurence Gruer is director of public health science, NHS Health Scotland, and Sir George Alberti is senior research fellow at Imperial College and emeritus professor of medicine, University of Newcastle Medical School.
The ABC of Obesity is edited by Naveed Sattar (firstname.lastname@example.org), professor of metabolic medicine, and Mike Lean, professor of nutrition, University of Glasgow. The series will be published as a book by Blackwell Publishing in early 2007.
Competing interests: For series editors' competing interests, see the first article in this series.
This is the final article in the series