Big problem

Obesity is growing in the UK, causing a growth
in related ill-health. But P J White finds that health and social
services are poorly prepared for the consequences.

If a seriously obese person sits in a standard
NHS wheelchair with a maximum load bearing capacity of around 140
kilograms, it will collapse under the strain. No surprises there.
But what is surprising, and worrying, according to Nottingham-based
GP Ian Campbell, is that when it happened to one of his patients,
no one was expecting it – and no one had planned to deal with the
situation.

The
anecdote could be a metaphor for the UK’s current approach to
obesity. An entirely foreseeable overstrain is imminent, yet there
is limited or non-existent planning for it. The obesity epidemic is
on its way, but no one is really sure what to do next.

West
Sussex social services director John Dixon says the true impact of
obesity on services is largely unknown. No one monitors the
problems. Because health services have tended to take the lead on
obesity, social care has a long way to catch up.

Much
of obesity is obscured. When the disability living allowance
advisory board looked at claims for DLA resulting from obesity it
found that it was rarely stated as the main disabling condition.
Instead, it was presented in combination with one or more other
conditions such as arthritis, back pain, hypertension or
depression. It is not surprising then that the first response from
social services departments is to wonder where to fit it in. Is it
a physical disability or a mental health issue?

Campbell, who runs an overweight
clinic and chairs the National Obesity Forum, has seen the impact
on both. Obesity is connected with a range of serious life
threatening illnesses including diabetes and heart disease. It is
the single biggest cause of preventable cancers after smoking. “The
weight bearing joints are greatly affected by obesity,” says
Campbell. “That affects walking, mobility generally and self-care
as well as causing an increase in chronic pain.”

Obesity also has crippling
psychological effects. Loss of self-esteem and depression are
common and have ramifications for families. People who are
seriously obese may have struggled unsuccessfully with their weight
for years and have a high incidence of underlying psychological
problems.

Obesity is not a marginal problem
for a few individuals – one in five adults in the UK is obese. The
rate of obesity in the UK has tripled since 1980. In three years’
time it is expected that 20 per cent of men and 25 per cent of
women will be obese. If trends continue, in the next 10 to 15 years
around 30 per cent of the population will be obese.

The
World Health Organisation has raised the issue of a growing global
epidemic of obesity.¹ Earlier this year the National
Audit Office estimated that direct costs of obesity to the NHS were
£500m a year.² Extend the calculations to include
costs to the wider economy and at a conservative estimate another
£2.1bn is added to the bill. Since these wider costs are based
on sickness absence and premature mortality, the human impact – to
individuals and families – is clearly substantial.

What
these headline figures don’t show is how some groups of people are
more at risk than others. Obesity is more prevalent among those
living in poverty. People with learning difficulties have higher
obesity rates, and not just in syndromes such as Prader-Willi where
obesity is implicated from a chromosomal disorder. One study
suggested that nearly half of all adults with Down’s syndrome were
obese.³

That
means obesity can be an issue in care homes for people with
learning difficulties, says James Churchill, chief executive of the
Association for Residential Care. Some staff will argue for the
right of people with learning difficulties to be obese, in defence
of their personal choice. It strikes others as an easy
cop-out.

Even
people who for most of their lives have had few weight problems can
develop them when they access social care. Sheila Scott, chief
executive of the National Care Homes Association, says: “If you are
an elderly person living alone, struggling to manage household
duties, who then goes into a care home with three meals a day
provided, an increase in weight can be a problem.”

Kate
McGrath, co-ordinator of voluntary organisation The Obesity
Awareness and Solutions Trust (Toast) is emphatic about the need
for action: “It just seems ludicrous that it has taken so long for
people to deal with this. Hospitals have been dealing with the
indicators of obesity for many years. But no one has actually said
hang on, we can save ourselves millions if we look at the root
cause.”

The
root cause is simply stated. People get fat because they consume
more calories than they use up in activity. But for obese people
the simplicity often ends there. McGrath says: “People don’t put on
weight for the same reasons. Some people might be lacking
education, so something like Weight Watchers that educates you on
eating healthily would help that kind of person. But another person
might eat because they have got emotional problems and so a
counselling service might help.” Toast advocates a variety of
treatments geared to individual need.

Looked
at from a public policy angle the situation is just as complex. Why
is there an epidemic now? Experts suggest that obesity is a normal
response to an abnormal environment, rather than the reverse. That
abnormal environment consists of a combination of high fat, high
sugar foods, sedentary lifestyles, fewer sport and exercise
opportunities, more car journeys, and more energy-saving devices
such as lifts, escalators and automatic doors.

The
cast list at a National Audit Office conference Joining Forces to
Tackle Obesity in January this year reflects the level of concern.
Yvette Cooper, minister for public health, Richard Caborn, minister
for sport, Tom Jeffrey from the Department for Education and
Skills, Sue Campbell from the Department for Culture, Media and
Sport, Nick Cavill from the former Department of Transport, Local
Government and the Regions were present. It will demand a lot of
joined-up government thinking to come with a coherent solution that
goes beyond mere sound eating advice. As the 46 MPs who signed an
Early Day Motion calling for action on obesity put it: “While
helpful, government advice to eat five portions of fruit and
vegetables daily and take appropriate exercise has not stemmed the
tide of obesity, and is inadequate for those already
overweight.”

The
task is enormous. It is not helped by society’s widespread
disapproval of obese people. Children in the playground shun fat
children, a bias that continues to adulthood. There is more public
understanding for people who misuse alcohol or drugs than for
people who are seriously overweight.

Such
stigmatisation causes vast amounts of human misery for people who
are struggling with their weight and the attendant medical and
psychological problems. Like all prejudices, it thrives on
ignorance and gets in the way of the solution. As Campbell says:
“Obesity is seen as a result of indolence and greed – when those of
us who work with severely obese people realise that it is clearly
not the case.”  

¹World Health Organisation
consultation on obesity www.who.int/archives/inf-pr-1997/en/pr97-46.html
 

²National Audit Office,
Tackling Obesity in England, NAO, 2001,
atwww.nao.gov.uk/guidance/chiefexec2b.htm
 

³V P Prasher, “Overweight and
obesity amongst Down’s syndrome adults” Journal of Intellectual
Disability Research, 39(5), 437- 441,
(1995).

Toast website at
www.toast-uk.org.uk/NAO_Review.html

Body mass index

The body mass index or BMI is an accepted way
of calculating body fat based on height and weight.

Divide a person’s weight in kilograms by their
height in metres squared. If the resulting figure is over 20 but
under 25 there is no weight problem. BMIs of between 26 and 29
suggest a person is overweight, and 30 and over is obese.