A heavy burden

The authors acknowledge the support of an educational grant from Abbott that assisted with the research for and preparation of this manuscript. A medical writer assisted with the drafting of the paper. However, the final manuscript remains the authors’ sole responsibility. The views expressed are those of the authors and may not necessarily be those of Abbott.
    
Tackling the growing epidemic of excess weight in the UK needs to be a priority for politicians, physicians and those running primary care organisations (PCOs). Obesity is already one of the biggest public health issues and the numbers affected, and the resources consumed, will increase dramatically over the next few years. Unfortunately, prevention and management of obesity has not traditionally attracted either the attention or resources that its prevalence and clinical importance warrant.
    
Although we have some way to go to establish the quality of evidence base in obesity prevention and management that is available to some other interventions such as cardiovascular disease, national guidance is sufficient to allow us to act now in many ways. PCOs need to invest appropriately to proactively address the obesity epidemic within the frameworks provided by the government.
    
This includes helping to implement the Department of Health’s (DH) ‘Healthy Weight, Healthy Lives: A Cross-Government Strategy for England’, which aims to create “a healthy society – from early years, to schools and food, from sport and physical activity to planning, transport and the health service.” The initiative – launched in January 2008 and supported by funding totalling £372 million – encompasses five broad elements, some of which fall within the remit of PCOs.1 Against this background, this feature aims to set the costs of obesity in context.

Morbidity and mortality
In 2003/2004, the mean body mass index (BMI) among UK men and women was 27 kg/m2. As this is above the upper limit of the healthy range (25 kg/m2), the average person in the UK is now overweight. Meanwhile, 23.6 per cent of men and 23.8 per cent of women were classified obese (BMI of more than 30 kg/m2) and the proportion of obese people continues to rise rapidly. Epidemiologists expect that by 2010, 33 per cent of men and 28 per cent of women will be obese.2 Unless PCOs and society more widely takes effective action soon, 60 per cent of men, 50 per cent of women and about 25 per cent of children less than 16 years of age could be obese by 2050.3
    
Numerous diseases become markedly more common with increasing BMI, which drives a considerable economic burden. For example, the risks of developing type 2 diabetes (T2DM) and hypertension are 20 and five fold higher respectively in obese people compared with those of a healthy BMI. The risk of coronary artery disease and stroke increases 2.4 fold in obese women and two-fold in obese men under the age of 50 years.2
    
Not surprisingly – given this range of serious morbidity – obesity and its complications exert a considerable death toll. For example, diabetes may shorten life expectancy on average by five to ten years4, while obesity contributes to one-in-ten deaths from cancer among non-smokers2. The National Audit Office (NAO) estimated that obesity caused more than 30,000 deaths in England during 1998, equivalent to six per cent of mortality. By way of comparison, smoking accounted for ten per cent of deaths and road accidents for less than one per cent.5 The World Health Organization estimates that excess weight causes 9.6 per cent and 11.5 per cent of deaths among men and women respectively in the developed world. Assuming that these rates applied to England during 2001, excess weight caused 52,500 deaths – making the death toll broadly equivalent to that associated with smoking.6

The economic burden
Apart from the clinical toll, obesity imposes a heavy economic burden. The House of Commons Clerk’s Department Scrutiny Unit estimated that the direct cost of treating obesity in England in 2002 was £46-£49 million. Treating the consequences of obesity costs between £945 million and £1,075 million. The annual indirect costs of obesity increased from £830 million to £1.1 billion for premature mortality and £1.3 billion to £1.45 billion for sickness absence between 1998 and 2002.6
    
However, the Health Select Committee (HSC), which requested the analysis, remark that the Scrutiny Unit’s total estimated cost (£3.3 billion to £3.7 billion) “should still be regarded as an under-estimate.” The Unit based their analysis on the 20 per cent of adults who are obese.6; it excludes costs arising from being overweight.
    
To gain an impression of the total economic burden, the HSC assumed that the costs associated with being overweight are, on average, half of those associated with being obese. Because there are more than twice as many overweight men and women as there are obese, the overall cost associated with excess weight is estimated to be between £6.6 billion and £7.4 billion annually.6

A growing problem
This economic burden will become heavier over the next few years. The HSC highlighted how elevated BMI is a risk factor for numerous diseases, including T2DM, coronary heart disease and stroke. Managing these diseases currently consumes 6 per cent of the NHS budget. Unless we take urgent action, obesity-related conditions could account for 13.9 per cent of the NHS budget by 2050. This equates to spending £22.9 billion on diseases linked to an increased BMI and £9.7 billion managing obesity.2
    
Clearly, PCO managers need to expect and plan for a marked rise in costs associated with obesity over the next few years. These costs are likely to fall across both prevention and treatment elements and should be balanced between the two. PCOs are currently in a generally favourable position with regard to resourcing preventative interventions but many need to expand treatment pathways within and from primary care. The growing number of overweight and obese people raises the pressure on increasingly stretched prescribing budgets. For instance, the costs of lipid lowering drugs increased more than three fold between 1998 and 2002.6 Furthermore, the prevalence of T2DM among men in England more than doubled between 1991 and 2003. In women, the prevalence rose by 80 per cent over the same time.7 New advances in management of T2DM, such as dipeptidyl peptidase IV (DPP IV) inhibitors and incretin mimetics, will further increase expenditure.
    
Indeed, the diversity of diseases linked to obesity means that managers should expect increasing expenditure in most areas of the prescribing budget. A study from 23 UK general practices found that obesity more than doubled prescribing rates across most drug categories. 36 per cent and 46 per cent of patients who were obese received at least one cardiovascular or central nervous system drug. This compared with 20 per cent and 35 per cent of people of a healthy weight. Prescribing rates among obese people were also higher for, among other categories, drugs used to manage endocrine disorders (26 per cent versus 18 per cent) and musculoskeletal and joint disease (30 per cent versus 22 per cent). Drug categories significantly affected by obesity accounted for 87 per cent of primary care prescribing.9
    
However, the costs associated with obesity extend far beyond the NHS. The NAO estimated that obesity accounted for 18 million days of sickness absence in 1998. Of this, obesity directly resulted in 418,000 certified sickness days. The consequences of obesity accounted for the remainder. T2DM, hypertension and angina together accounted for three-quarters of the sickness days associated with obesity. Around 9,000 of the deaths related to obesity occurred before state retirement age, resulting in a loss of over 40,000 years of working life.5 A more recent estimate suggests that the cost of incapacity and unemployment benefits associated with obesity is probably between £1 billion and £6 billion, excluding social care provided by local authorities.2

Cost-effective treatment
Tackling obesity effectively and efficiently depends on implementing nationally agreed initiatives locally. According to ‘Healthy Weight, Healthy Lives’ the government plans to promote healthier food choices and build physical activity into our lives through, inter alia, planning regulations. The strategy also envisages “Stronger incentives for individuals, employers and the NHS to prioritise the long-term work of improving health” and “personalised advice and support.” The latter includes ensuring that the NHS Choices website offers advice about diet and activity levels, as well as “clear and consistent information” on maintaining a healthy weight. The DH will also increase funding over the next three years to commission a greater number of weight management services.1
    
PCOs and other local stakeholders will need to introduce some of the tactics envisaged in the initiative in their community. Existing Health Trainer schemes, food workers, physical activity referral schemes or public health nutrition and dietetic programmes can be complemented where appropriate with additional innovative and experimental “personalised advice and support” managers and ‘information’ hubs in surgeries, clinics, libraries and accessible community venues. Such hubs allow the user to tailor information on the internet and elsewhere to meet patient’s needs.
    
Initiatives may, however, need to be audited or more formally evaluated depending on their evidence base, and additional thought needs to be given to ensuring the neediest and most vulnerable in society also have mechanisms and support to make healthy choices. PCOs, professionals and patients should take advantage of resources provided by the National Obesity Forum (www.nationalobesityforum.org.uk), NHS Direct (www.nhsdirect.nhs.uk) and NHS Choices (www.NHS.uk) and Change for Life (www.changeforlifeonline.com).

Prescriptions
Drugs can be an important component of successful change for some patients, especially those who feel that they cannot make such changes without support. Prescribing a medicine ensures engagement with medical services, which helps maintain motivation and compliance with lifestyle measures. Some patients seem to be under the impression that pharmacotherapy and even bariatric surgery offers an ‘easy option’ for losing weight. The entire healthcare team should emphasise that drugs are additional to, rather than a replacement for, lifestyle measures and long term behavioural change.
    
NICE guidance recommends considering orlistat (Xenical) and sibutramine (Reductil) when diet, exercise and behavioural approaches fail to produce adequate weight loss. NICE advocates continuing therapy for more than three months in patients who lose at least five per cent of their initial body weight since starting drug treatment.10 NICE recommends rimonabant (Acomplia) only if patients show an inadequate response to, are intolerant of, or have contraindication to, orlistat and sibutramine.11
    
According to a NHS Health Technology Assessment (HTA) report, low calorie diets produce an average weight loss of 5.31 kg after 12 months.12 Weight loss continued for three years. Adding drugs to diet further reduced weight by, on average, 3.26 and 3.40 kg with orlistat and sibutramine after two years and 18 months respectively.12 The cost per additional life-year or quality-adjusted life-year (QALY) associated with treating high-risk individuals with drugs or surgery is probably no more than £13,000.12 The NHS HTA estimated that the cost per QALY with sibutramine was £10,500.13 The scale of the problem is such that health communities will need to consider affordability and opportunity cost alongside cost-effectiveness as with other large scale interventions.
     
Obesity is a complex problem arising from the interaction of genetic, environmental, social and cultural factors. Dealing with the epidemic of obesity therefore requires a change across many aspects of society. “Preventing obesity is a societal challenge, similar to climate change,” a report from the Government’s Office for Science remarked recently. The report added that preventing obesity “requires partnership between government, science, business and civil society”.3 As such, PCO management has a critical role in developing service delivery strategies that ensure that the millions of overweight and obese people in the UK receive the help they deserve.

References
1. DH Government announces first steps in strategy to help people maintain healthy weight and live healthier lives Department of Health 23 January 2008
2. Butland B, Jebb S, Kopelman P et al Tackling Obesities: Future Choices – Project Report 2nd Edition Government Office for Science 2007 www.foresight.gov.uk/OurWork/ActiveProjects/Obesity/KeyInfo/Index.asp
3. Foresight Tackling Obesities: Future Choices – Summary of Key Messages Government Office for Science 2007 www.foresight.gov.uk/OurWork/ActiveProjects/Obesity/KeyInfo/Index.asp
4. Donnelly R, Emslie-Smith AM, Gardner ID, Morris AD. ABC of arterial and venous vascular disease: Vascular complications of diabetes.BMJ 2000;320:1062-6
5. National Audit Office Tackling Obesity in England Publication date: 15/02/2001 HC 220 2000-2001 ISBN: 0102814015
6. HSC House of Commons Health Committee Obesity Third Report of Session 2003–04 Volume 1 10 May 2004
7. Allender S, Peto V, Scarborough P et al Coronary heart disease statistics. 2007 BHF: London www.heartstats.org/uploads/documents%5C2007.chapter12%281%29.pdf
8. Boseley S Drug prescriptions for obesity soar to 1.06m The Guardian February 1, 2008
9. Counterweight Project Team The impact of obesity on drug prescribing in primary care Br J Gen Pract 2005;55:743-9
10. NICE clinical guideline 43 Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children 2006 www.nice.org.uk/CG043
11. NICE technology appraisal guidance 144 Rimonabant for the treatment of overweight and obese adults http://www.nice.org.uk/nicemedia/pdf/TA144Guidance.pdf
12.    Avenell A, Broom J, Brown TJ et al Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement Health Technol Assess 2004;8(21)
13.    O’Meara S, Riemsma R, Shirran L et al The clinical effectiveness and cost-effectiveness of sibutramine in the management of obesity: a technology assessment Health Technol Assess 2002;6(6)