A huge burden

One in four adults in the UK is obese, and each will lose an average of almost a decade of life, a cumulative loss of 100,000,000 years for the current adult population. Fat people outnumber normal weight individuals by almost 2:1. Because of its link with diabetes, heart disease and other serious chronic conditions obesity costs the economy around £4 billion per year, a sum growing rapidly enough to bankrupt the NHS imminently. Yet the government is content with a policy of obesity prevention.
    
Obesity prevention strategies have always been with us, since the Law of Moses – the Biblical diet and public health manual – which was God’s word presented to the Hebrews with a promise of disease prevention if obeyed. Across ancient religious texts, the problems associated with eating too much are also starkly illustrated. Proverbs advised potential sinners: “Do not join those who drink too much wine or gorge themselves on meat, for drunkards and gluttons become poor, and drowsiness clothes them in rags.” Hindus were warned of ‘numberless diseases’ in store for the “thoughtless glutton who gorges himself beyond his digestive fire’s limits”. Followers of Islam were taught: “The food for two persons is sufficient for three, and the food of three persons is sufficient for four.”

Medics and scholars concurred with the religious viewpoints. Over 3,000 years ago Hippocrates noted that “men who are constitutionally very fat are more likely to die quickly than those who are thin” and 1,000 years ago Avicenna, the great Persian physician, wrote that “most illnesses arise solely from long-continued errors of diet and regimen”. Both devised methods of health maintenance, and risk reduction.

Modern day health initiative
A sequel to the Law of Moses, another diet and public health initiative is now with us – once again conveyed to the population from a powerful unseen force: in this instance, not God but the Department of Health. However, in some respects this modern interference has changed very little since the Law of Moses: less emphasis on circumcision, cloven hoofs and the abomination of eating bats, and more on Bogeyman soup, and strawberry and banana smoothie (recipes from Change 4 Life). The difference is that Moses, Hippocrates and Co were preaching maintenance of health to a lean population, whereas we now exist in the middle of an obesity epidemic, and the advice hasn’t been updated to reflect the fact.
    
Change 4 Life is a first rate piece of social marketing, and is proving popular with mothers and families. Saatchi have developed an entertaining user-friendly concept using instantly recognisable bright colours and logos, combined with witty and effective material to produce a highly engaging product which will be important in preventing obesity for the next generation. However, they have deliberately avoided graphics which might have a negative impact or appear unpalatable, nagging or nannying to the target audience. Thus Change 4 Life portrays a Utopian world in which no inhabitant carries a single extra ounce while they happily dance and leap around and bounce balls on their head. It is like a children’s story without any villains which might upset the delicate flowers. Couch potatoes and computer game addicts are saved from obesity by a vision of an arteriosclerotic future before the bump begins to show. Even the written advice embraces only prevention: “Middle age comes to everyone – ‘middle aged spread’ doesn’t have to.”
    
Change 4 Life is unique, sophisticated and brilliant at what it does, and prevention is a crucial part of the battle against obesity, but preventative measures in the absence of tactics to actually deal with the current obesity epidemic is like someone standing in a blazing housefire and calling Health and Safety to check the plugs, when what is really needed is the fire brigade.

Targeting the already obese
The only reason a government could possibly have for wishing to prevent obesity in people they will never meet, is to prevent the expensive health consequences: diabetes, heart disease, stroke, cancer and other conditions. So an obesity prevention strategy is actually an illness prevention strategy, but one done on the cheap because it ignores those people who are at the highest risk of illness – the currently obese. It is the equivalent of an HIV prevention strategy which ignores prostitutes, intravenous drug users and homosexuals, and instead targets monogamous couples.
    
Obesity is not only a significant health hazard to an individual, it is also a massive expensive to the NHS and to the Nation. The National Audit Office compiled figures in 2001: 30,000 deaths a year and 18 million sick days attributed to obesity. The Foresight Report published in 2007 gazed into the future, estimating that increasing levels of BMI will add £7.7 billion to annual costs to the NHS by 2050, and if the ratio of the total wider costs of overweight and obesity to solely NHS costs remains similar, a total cost to the Nation per annum of £49.9 billion attributable to increasing BMI will ensue (assuming the value of money remains the same). However, in 2001 a paltry £9.5 million was spent on obesity treatments per annum.
    
Clearly the cost of overweight and obesity is huge, but paradoxically the financial resources required to treat obesity are relatively small, and also offset by the savings made in reduced healthcare, and prescribing costs. The Counterweight programme of weight management for obesity in primary care has been shown to induce multiple health and quality-of-life benefits, is widely available in Scotland, and being commissioned in growing numbers in England. It demonstrates that weight management can be highly cost-effective even taking into account only the reduction in costs of three out of the many clinical consequences of obesity: type 2 diabetes, coronary heart disease, and colon cancer. The findings of the cost-economic data within Counterweight demonstrate that using the programme is cost-dominant, therefore providing in effect a free intervention for obesity management.
    
Results generated by the Counterweight analyses were all well within accepted NICE thresholds for cost-effectiveness of £20-30,000/QALY, interventions with lower ICERs being judged to be a good use of healthcare resources. Counterweight also analysed the increasing prescription costs of the top ten most expensive drugs from the formulary, including pariet, lipitor, efexor and others, with each increment rise in BMI, inducing a dramatic escalation of costs with increasing levels of obesity.

Cost savings
The most emphatic example of cost savings with obesity management is with bariatric surgery. Operations such as the laparoscopic adjustable gastric band, and the Roux-en-Y gastric bypass cost around £7,000 and £12,000 respectively, but pay for themselves within 3.5 years of surgery being undertaken. With the insertion of a gastric band, up to 73 per cent of cases of newly diagnosed type 2 diabetes have been shown to achieve remission, and around 80 per cent of all cases of type 2 diabetes with gastric bypass. An Australian paper demonstrated that surgical intervention for diabetes saved AUD2,400 after ten years compared to conventional treatment, not in itself a huge amount of money, but representing considerably higher savings if other obesity related conditions such as CVD were taken into account. Yet PCTs are routinely contravening NICE guidelines by turning down patients deemed appropriate for surgery by NICE, using their own, arbitrary, non-evidence-based thresholds. Some patients are therefore denied life-saving treatment, others are even being forced to deliberately gain weight in order to meet strict Specialist Commissioning Group criteria.
    
The choice is a simple one. The government must prioritise the management of obesity alongside its prevention, or witness epidemics of diabetes, stroke and heart disease as a consequence of the obesity epidemic, and ultimately a bankrupt NHS.