The rising tide of obesity

Recent figures from a WHO survey have shown that one in ten of the world population is now obese. There is now a greater problem with worldwide obesity than with malnutrition. Unfortunately, the problem is escalating rapidly, and in some countries, obesity is now the norm.
    
In England the proportion of men classified as obese increased from 13.2 per cent in 1993 to 23.6 per cent in 2007, and from 16.4 per cent to 24.4 per cent for women over the same timescale. Approximately 1.9 per cent of the population is classed as morbidly obese. That is, obesity severe enough to cause medical co-morbidity.
Amongst the Organisation for Economic Cooperation and Development (OECD) nations, the UK ranks as fifth in the league table of obesity prevalence. Across England, there is both geographical variation in prevalence and variation according to social class.

The breakdown in food behaviour
The rising incidence of obesity indicates a dramatic change in food behaviours across the developed and developing world. Countries that have seen a rapid rise in affluence or security see are rise in average bodyweight in successive generations. This is especially marked in the Middle East and the Indian sub-continent. The Westernisation and commercialisation of food, coupled with an attitude of ’plenty is better’ has led to a breakdown of the correct relationship between eating behaviour and our body’s capacity to cope with food.
    
Hunger has been successively portrayed as a social evil. Snacking has been invented as an activity to banish hunger. Yet hunger remains a basic physiological function to prepare the body for the next meal. Without hunger, and a suitable gap between meals in which to feel hungry, the body never starts to burn stored fat, and so the pathway to obesity starts. Once these behaviours are established, their change is difficult. Food is a necessity and a comfort – drawing the line between just enough and too much, is very difficult on an individual basis.
    
For some the need for food and its relationship to learned behaviour becomes pathological. The term addiction can be appropriate, and the prevalence of disordered eating is more widespread than generally appreciated. Sufferers need constructive help rather than ridicule or beratement.

The consequences – Medical and Social
Obese people are shown to have low quality of life scores when compared to normal weight counterparts, and when compared to themselves after successful weight loss.
    
This translates into low self-esteem and decreased effectiveness at work. Many admit to poor home lives and a disinclination to interact socially for fear of ridicule.

The link between diabetes and obesity is well established1 and unsurprisingly, the rise in obesity prevalence has been mirrored by that of diabetes. The NHS Information Centre estimates that 2.6 million people in the UK have diabetes and this is predicted to reach 4 million by 2025. Prevalence between PCTs varies from 2.5 per cent to 5.7 per cent2. Approximately one quarter of all diabetics are poorly controlled, and these patients go on to develop costly complications.
    
Other conditions that have a causal link with obesity include hypertension, metabolic syndrome, obstructive sleep apnoea, cancer, degenerative arthritis, intracranial hypertension and stroke. The plethora of well-described co-morbidities associated with obesity are clearly a significant resource issue for the future NHS.

The consequences – Economic
At present the cost of obesity to the NHS is estimated to be £4.2 billion and the cost to the wider economy is £16 billion. These costs are projected to increase to £10 billion per year by 2050, with the wider costs to society and business reaching £49.9 billion per year, at today’s prices3. The cost of diabetes to the NHS is £649.2 million (just under ten per cent of the NHS budget for England and Wales), a cost that has risen by 40 per cent over the last five years2.

There is strong data highlighting the cost effectiveness of metabolic surgery. Table 1 summarises the cost effectiveness of metabolic surgery in different patient groups as analysed in the Health Technology Assessment of 20097. On the whole, NICE will not recommend any treatment which costs more than £20k-£30k per Quality Adjusted Life Year (QALY). The incremental cost per QALY for metabolic surgery falls well below this. However, many PCTs seem to be turning a blind eye to this evidence. It may be that PCTs recognise the long term cost benefits, but their interest lies in the shorter term and many PCTs find the upfront costs of metabolic surgery prohibitive to their annual budget plans. It remains difficult to encourage the PCTs to think otherwise. In order to encourage investment in metabolic surgery across the UK healthcare system, the NSCG needs to be allocated a budget centrally, which can be distributed to help meet the upfront costs of metabolic surgery.

Implications for the NHS
Given the unequivocal evidence base for treatments dealing with obesity, including metabolic surgery6, the NHS is faced with a number of significant challenges if this rise in obesity related expenditure is to be tackled. Clearly, those in most clinical need require targeted resources and money spent in an effective manner. For those with morbid obesity, metabolic surgery offers the most cost effective solution.
    
Each PCT has a different level of demand for metabolic surgery, as well as different commissioning priorities. Many PCTs are modifying the NICE guidelines, for example by raising the BMI thresholds, in order to ration the numbers of patients they will fund. This is sometimes referred to as the ‘postcode lottery.’ Again, central planning by the DoH and NSCG should enable strategic allocation of resources to match the expected regional demand.
    
Hospital capacity for offering metabolic surgery is not readily available. With 2.7 acute hospital beds per 1,000 of population, the UK health system is already stretched, providing for other established medical conditions. Many hospitals simply do not have the available facilities to offer a metabolic surgical service of suitable quality. This includes too few surgeons, of which there are less than 100 in the British Isles.
Certainly, the number of hospital beds occupied by patients suffering from the complications of obesity will increase as obesity prevalence increases. In order to halt this spiral, the UK Government does recognise that obesity management is a health priority4.     
   
However, funding does not seem to have been targeted successfully. By allocating metabolic surgery centres, the DoH can ensure that the difficult balance of demand, funding and availability is met as efficiently as possible. This would also ensure adequate specialist training and workforce planning.
In many quarters, the health and economic benefits of metabolic surgery have yet to be fully understood, not only by the public at large, but also by many health professionals. Although a large amount of evidence exists2,8,9 and more is on the horizon10, it seems that it is being ignored. This situation is not unique to the UK11. However, with the NHS being funded centrally and to a large extent policy being driven from the centre, it would appear that the devolution of the evidence from the top down should be easier than in more disparate healthcare systems. A coordinated approach between public health, clinicians, medical schools, the NSCG and DoH officials should enable the evidence base to be thoroughly analysed, understood and disseminated to healthcare stakeholders and providers.

Solutions and Strategies
Public health measures and educational initiatives have been shown to be of limited impact in the management of obesity. We need to think smarter and harder about how this problem should be tackled to stop the creep to obesity. The alternative is a nationalised healthcare system crippled by failure to plan.
    
With this in mind, the government’s Comprehensive Spending Review announced the aim that England was to be the first major country “to reverse the rising tide of obesity and overweight in the population, by ensuring that all individuals are able to maintain a healthy weight.” This aspiration was given a strategic framework with the launch of ‘Healthy Weight, Healthy Lives.’4

Many of the clinical guidelines used to deliver this lofty ambition were summarised in the NICE document: ‘Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children’5
    
Coercion and ‘nudging’ do not work. People need to be educated regarding diet and lifestyle and rewarded for compliance. Taxes on prepared foods (ready meals/take-aways) and high calorie foods could also be one disincentive to eat excess.
    
However, we already have a cohort of the population for whom lifestyle change and dietary advice alone is not enough. For those, an agreed and equitable system for access to effective treatment must be organised.
    
Medically supervised weight management clinics must be developed as a support for primary care initiatives. These can then identify patients for whom metabolic surgery is the only way to control their morbid obesity.
Unless this problem is rapidly acknowledged and tackled sensibly, many of us in this field believe that the obesity epidemic will break the NHS.

Shaw Somers BSc(Hons) MD FRCS, is Consultant Upper GI and Bariatric Surgeon for Portsmouth Hospitals NHS Trust/Streamline Surgical LLP.

References
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2.Prescribing for Diabetes in England: 2004/05 to 2009/10. The Health and Social Care Information Centre. 2010
3.Tackling Obesities: Future Choices. UK Government Office for Science. 2007
4.Healthy Weight, Healthy Lives. A Cross Government Strategy for England.  UK Department Health. 2008
5.Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children CG43. UK National Institute of Clinical Excellence. 2006
6.Dent M, Chrisopoulos S, Mulhall C, Ridler C. Bariatric surgery for obesity. Oxford: National Obesity Observatory, 2010
7.J Picot, J Jones, JL Colquitt, E Gospodarevskaya, E Loveman, L Baxter and AJ Clegg. The clinical effectiveness and cost- effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technology Assessment. 2009. 13: No. 412
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9.Buchwald H, Estok, R, Fahrbach kK, Banel D, Jensen MD, Pories WJ, Bantle JP, Sledge I. Weight and Type 2 Diabetes after Bariatric Surgery: Systematic Review and Meta-analysis. American Journal of Medicine. 2009 122: 248-256
10.Sangeeta R. Kashyap, Deepak L. Bhatt & Philip R. Schauer, Bariatric surgery vs. advanced practice medical management in the treatment of type 2 diabetes mellitus: rationale and design of the Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently trial (STAMPEDE). Diabetes, Obesity and Metabolism. 201012: 452–454
11.Buchwald H, Scopinaro N. An Invitation to our Medical Colleagues: Work With Us. Obesity Surgery. 2010 11: 1465-1467