What help is there

What help is there for fat people?

Dear all. Obesity is no joke. So why isn’t anyone doing anything about it?

Predictions are that by 2050, half of the British population will be obese and bankrupt the NHS. Our obesity is killing us, with an obese person dying, on average, nine years prematurely. Globally, someone dies of an obesity-related illness every 11 seconds. Yet long before the grim reaper arrives, obesity sucks the joy out of people’s lives. So, just what has been done by successive governments to help stem the crisis?

Up until 1992 and the publication of the Health Of The Nation Report, obesity had had little attention from the government, being seen primarily as the problem of the individual, who was implicitly judged to be a gluttonous, weak-willed creature who should just eat less. However, the report identified the co-morbidities and therefore some of the financial costs of obesity and set targets to reduce the incidence from 12% back to the 1980 level of 8%. Around the same time the World Health Organisation labelled obesity an epidemic.

Now that a pound sign had been put next to obesity, the government began to sit up and take notice. But they organised a mere one-day symposium to implement a series of strategies to reduce obesity. The symposium was held under the joint auspices of the Health of the Nation Nutrition and Physical Activity Task Forces. And therein lay a major design flaw, which was to be repeated several times over in a succession of government papers. The ‘expert panel’ that day was drawn from a pool of nutritionists and exercise specialists who created the overly simplistic ‘eat less, move more’ model. Neither party could realistically be expected to provide any clues to rising obesity beyond the usual, clichéd list of superficial factors. Ever since, this limited ‘eat less, move more’ model has drawn a veil over pioneering research and creative thinking. The psychology of obesity has rarely been factored in.

Even back in the 90s, many fat people were veterans of the skill of calorie counting. What few lay and professionals alike were willing to explore was why the handing out of diet sheets was proving so ineffective. Why was it that even those with steely determination so often struggled to make the healthy choice when opening the fridge? Put simply, no one was about to shine a light inside an obese person’s head and gain an authentic understanding of the problem. Few cared. It was as if the fierce prejudice that fat people have been subjected to throughout history had blinded the establishment.

The one-day symposium led to a depressingly redundant report, which simply focused on healthy eating and physical activity as the solutions to the epidemic. There was no discussion on why people overeat and how to help them make better choices. Four years later the powers that be published a progress report, which if it were a school report would have read ‘could do better’. Not only had the government failed to reach its targets but obesity was still on the increase.

Next, in 1999, came Saving Lives: Our Healthier Nation, which shockingly failed to report on the targets at all, and omitted to talk about obesity altogether. The biggest health problem in the country had no mention, no targets, no strategy. Yet again, the obese had been left on the back shelf of healthcare. The obesity crisis had effectively been dropped from discussion.

In 2007, the Foresight Report made headlines when it predicted that by 2050, 60% of men, 50% of women and 25% of children would be clinically obese and suggested that costs to the NHS would increase seven times over. This led to the launch of the government’s 2009 Change4Life scheme, its first national social marketing campaign to tackle the causes of obesity. Change4Life targeted families, encouraging them to make small, sustainable ‘yet significant’ improvements to their diet, activity levels and alcohol consumption. Suggestions included cutting down on sugar, fat and salt, eating five a day, and exercising. While their recommendations might well aid weight loss they are already embarrassingly obvious to most people. The scheme completely fails to address why so many are frequently failing to achieve them.

It was followed in 2011 by the controversial Responsibility Deal, which encouraged business, supermarkets, pubs and restaurants to choose from a series of pledges, such as reducing salt, fat and calorie content in food. The scheme was met with opposition from many in the obesity world, who felt the commercial sector (and the food industry in particular) was unlikely to take the deal seriously, or to be totally transparent its marketing. The bottom line is that none of the above policies have made even a slight dent on rising obesity figures. Entire generations of obese and overweight people have been abandoned in benign and virtually meaningless paperwork. The whole issue needs to be approached with entirely new thinking.

“Obesity is the new smoking. It represents a slow-motion car crash in terms of avoidable illness and rising healthcare costs.”

Simon Stevens, NHS England Chief Executive Officer

Taking this into account, you would think that the medical profession would be armed with some inspired strategies to stem the tide. But the stark reality is that doctors receive limited, if any, training about Britain’s biggest health crisis. Many fail to grasp the true nature of the problem.

Dr Matt Capehorn runs the Rotherham Institute of Obesity, one of the very few specialist centre dedicated to researching and treating obesity. He despairs of the widespread ignorance of many fellow GPs.

“Regrettably, GP training on obesity remains shockingly poor and a disgrace. For those with an interest, there are some courses available outside NHS training at additional cost. But most doctors have to learn how to manage obesity by attending their own voluntary health conferences. My own obesity knowledge has been gained from many years of self-directed learning, along with attending educational meetings and conferences and networking with like-minded colleagues who share knowledge and ideas. I received no formal education on obesity, or how to treat obese patients, as part of my undergraduate or postgraduate training, because there was none.”

Dr Matt Capehorn

The Obesity Review Group is asking for GPs to play an active role in identifying and helping patients who are overweight or obese. It is disappointing to see that discussions still continue as to how to incentivise GPs to take action in this area. Dr David Haslam, medical director of the National Obesity Forum, comments: ‘We need more proactive engagement by healthcare professionals on weight management, more support and better signposting to services for people who are already obese. We’ve seen hard hitting campaigns against smoking and it’s time to back up the work that’s already being done with a similar approach for obesity.’

While there has been some lobbying about the problem within the medical establishment little, if anything, has been achieved. In 2013 the Royal College of Physicians published Action On Obesity: Comprehensive Care For All, which called for more obesity specialists and new training in behavioural-change therapy relating to weight loss to be mandatory for all trainee doctors. To date, none of these recommendations have been met.

Meanwhile, NICE, which provides national guidance and advice to the Department of Health, has very little wisdom to offer on the topic. It recommends patients with a BMI of 35 or over who have co-morbidities (type 2 diabetes, heart disease, sleep apnoea, etc) be assessed for bariatric surgery. It decrees that patients must have tried and failed to achieve clinically-beneficial weight loss by all other appropriate non-surgical methods. Where pre-surgery referrals for counselling are provided, they are often little more than tick-box exercises. What this costly strategy fails to do is help patients understand why they became obese. It neglects to help them gain the cognitive skills to make lasting changes to their behaviour. Despite decades of evidence which show that various methods of weight change are improved when combined with cognitive behavioural treatment, NICE has only belatedly begun making noises about the need for resources that encourage sustained ‘behaviour change’ and it is still light years away from effectively pioneering them.

Dr Capehorn says: “If an eating disorder (such as anorexia) is identified, the GP will refer the patient to local specialist services, which is important, as the key to weight management relies on identifying the underlying emotional reasons for the eating disorder. This is an example of where the psychology of eating behaviours is deemed important. Unfortunately, it doesn’t apply to obesity cases.”

In April 2013 Dr Jonathan Valabhji was appointed National Clinical Director for Obesity and Diabetes at the NHS Commissioning Board. Although some in the medical profession saw his appointment as a progressive step, others were less enthusiastic. After all, merging obesity into the diabetes agenda meant the two issues were, at the very least, likely to become clouded.

“I am very excited to be taking up this position. The increasing prevalence of both obesity and diabetes in the UK is one of the greatest health challenges the country faces, and I look forward to working with healthcare colleagues across the country to try to address this.” He later added: “Those responsible for (diabetes) innovation include those with diabetes themselves, healthcare professionals at the clinical coalface, healthcare leaders and organisations, academics and universities, third-sector organisations and industry.” 

Dr Jonathan Valabhji

Unfortunately, no such comment was made about the field of obesity.

In October 2014 the NHS Five Year Forward View was launched. This paper summarised various strategies in England to prevent ‘avoidable illnesses’ caused by obesity, smoking and alcohol. The paper was written at the behest of NHS chief Simon Stevens. In regard to obesity, it put the entire onus on employers, suggesting they introduce measures such as voluntary weight-watching schemes and reduce staff access to unhealthy food and drink. In reality, the Five Year Forward View was a useless piece of paper which offered nothing new in the treatment of obesity. In fact, it was markedly left to Public Health England to flesh out a series of details in a report issued on the same day. However, in regard to obesity, these were mainly rehashes of old ideas with calls to sell the importance of five a day, getting more families signed up to Change4Life, and encouraging local authorities to get behind better nutrition in schools. Public Health England still sought to treat obesity as a food problem, rather than a complex condition that ultimately begins in the mind.

Nearly 25 years after the powers that were decided to only invite nutrition and exercise specialists to that one-day symposium, the promotion of ‘eat less, do more’ has neither halted the increase in overweight and obesity nor resulted in their decline. Speak to the obese themselves and many will talk of ‘comfort eating’ to cope with boredom, stress, anxiety, tiredness, anger… Yet the solutions typically on offer have little to do with the emotional coping mechanisms of comfort eating. They focus on the physical symptoms such as the diet sheets provided by doctors, the dieticians, the slimming clubs. While knowing the food to put on your ‘good list’ is useful, the real question lies in knowing how to choose the good food when all you crave comes from your ‘bad list’. Although acknowledging the power of the individual, with more than half the population overweight or obese, we, society and industry must take responsibility for the very strong pressures that are exerted and work together.