Shedding pounds

Obesity is wreaking havoc on the UK population’s health, and on its bank balance, yet the evidence suggests that it can be managed successfully and cost-effectively.        

The Public Health White Paper ‘Healthy Lives, Healthy People’ threatens to derail the medical management of obese individuals, by diverting funds from NHS treatment into localised prevention initiatives, despite the fact that a quarter of the adult population already suffer from obesity and for whom prevention has long been irrelevant.
   
GP consortia will have the autonomy to decide whether or not to prioritise the identification, screening and management of obese individuals, or to save money in the short term by ignoring obesity, turning a blind eye to its delayed but expensive complications such as diabetes, heart attack and stroke.

Headline making news        
“£80m bill for obesity: Benefit claims by those too fat to work have soared under Labour,” reported the Daily Mail.
   
“Fat people will cost £75 more to bury than those who are thinner, because they take up more space in a cemetery,” reported the Daily Telegraph.
   
Obesity is headline news, because of the effect is has on all aspects of life, including the financial costs to the individual and the tax-payer.
   
Obesity prevalence in the United Kingdom has tripled over 25 years, a quarter of UK adults possessing a Body Mass Index (BMI) >30kg/m.     
The most recent reported official figures from the Department of Health (DoH) in 2010 estimate the financial impact of obesity on the NHS at £4.3bn. The DoH reported that: “Around ten per cent of all cancer deaths among non-smokers are related to obesity. The risk of coronary artery disease increases 3.6 times for each unit increase in BMI, and the risk of developing type 2 diabetes is about 20 times greater for people who are very obese (BMI >35), compared to individuals with a BMI of 18-25. These diseases can ultimately curtail life expectancy. Some studies have shown that severely obese individuals are likely to die on average 11 years earlier than those with a healthy weight.”

Hidden costs
Obesity increases drug prescribing in all the most expensive categories. In a cost-economic analysis by the Counterweight team a higher percentage of patients who were obese, compared with those of normal weight, were prescribed one or more drug in the following disease categories: cardiovascular (36 per cent versus 20 per cent), central nervous system (46 per cent versus 35 per cent), endocrine (26 per cent versus 18 per cent), and musculoskeletal (30 per cent versus 22 per cent). All of these categories had a P-value of <0.001. Other categories, such as gastrointestinal (24 per cent versus 18 per cent), infections (42 per cent versus 35 per cent), skin (24 per cent versus 19 per cent) had a P-value of <0.01, while respiratory diseases (18 per cent versus 21 per cent) had a P-value of <0.05.
   
Total prescribing volume was significantly higher for the obese and was increased in the region of two-to-fourfold in a wide range of prescribing categories: ulcer healing agents, lipid regulators, adrenoreceptor drugs, drugs affecting the renin-angiotensin system, calcium channel blockers, antibacterial drugs, sulphonylureas, biguanides, NSAIDs, fibrates, and thyroid drugs.
   
The impact on prescribing volumes in obese patients is from numbers of patients treated, greater dosages and longer duration of treatment in those who are obese. It concluded that obesity more than doubles prescribing costs in most drug categories.

A time burden
Counterweight also demonstrated the increasing burden obesity puts upon GP, nurse and hospital time, whether or not co-morbidities are present in an individual. For every co-morbidity category, and at similar ages, obese patients visit the GP more often than their normal weight counterparts. Even when no co-morbidities are present, the obese make more visits to the GP and PN. Obese individuals make significantly more visits to hospital outpatient units than normal weight patients, and are admitted to hospital more often.
   
So obesity is a major health hazard and a massive expensive to the NHS and wider economy. Even a decade ago the National Audit Office assessed how dire the situation had become: citing 30,000 deaths a year and 18 million sick days attributed to obesity.
   
However in 2001 whereas £480 million was spent on treating the consequences of obesity, only a paltry £9.5 million was spent on treating obesity.
   
Similarly in Scotland only two per cent of the total obesity-related expenditure is spent on treating obesity and 98 per cent is consumed by the treatment of co-morbidities .
   
Healthcare provision is at a crossroads thanks to the imminent abolition of PCTs. Although the management of obesity, including identification, screening for co-morbidities, global risk reduction and management of co-morbidities, will be in the hands of GP consortia (and could be transformed for the better and arguably save the NHS from future bankruptcy), funding for interventions is actually at high risk because of the delay in savings appearing on the balance sheet. But the price of doing nothing is far too high.
   
The resulting NHS costs attributable to overweight and obesity are projected to reach £9.7 billion by 2050, with wider costs to society estimated to reach £49.9 billion per year according to the Foresight report.

Anti-obesity remedy
Bariatric surgery is a good example of an anti-obesity remedy to demonstrate the financial benefits; weight loss is sufficiently rapid and clinically meaningful for its economic impact to be assessed within a short time span.
   
In its report Shedding The Pounds, the Office of Health Economics looks at wider societal savings, rather than simply health costs taking into account the potential of patients to return to work post-bariatric surgery: “The contribution of additional paid work generated following bariatric surgery off-sets the costs of surgery. This is achieved one year after surgery. There are also benefits through reductions in benefits paid and, although the evidence base is limited, savings for the health service that can also be realised. Around one and a quarter billion in savings to the economy could be achieved if twenty five per cent of eligible patients received bariatric surgery. In addition, from the Government exchequer point of view, around £150m per year in benefits would be saved.”
   
Additionally, although the gastric band and the Roux-en-Y gastric bypass cost around £7,000 and £12,000 respectively, the clinical costs of the reduction of drug prescribing, clinician visits and the reduction of disease and health risks offset the cost of surgery within three and a half years of surgery being undertaken.
   
To understand this it should be considered for example that with the insertion of a gastric band, up to 73 per cent of cases of newly diagnosed type II diabetes achieve remission, and around 80 per cent of all cases of type II diabetes with gastric bypass thereby avoiding the massive costs of hypoglycaemic agents, and of cardiovascular and microvascular complications such as myocardial infarction, stroke, blindness and amputation.
   
One paper demonstrated cost savings of £1,500 per patient in diabetes management alone after surgical intervention after ten years compared to conventional treatment, a sum which would be much higher if cost savings for other conditions was taken into account.  

Barriers to overcome
Yet PCTs are routinely ignoring 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 to meet strict local criteria.
   
Lifestyle interventions alone for weight loss can achieve impressive results, thereby reducing future costs; the Diabetes Prevention Programme induced only 4kg sustained weight loss at four years, but reduced the cumulative incidence of diabetes by 58 per cent over that period. Mean weight loss in attenders on the Counterweight programme of diet and lifestyle intervention in General Practice, was 3kg and 2kg at 12 and 24 months, both 4 kg below expected weight given the normal 1kg/year background weight gain in the general population.
   
Counterweight delivery cost is £59.83 per patient, and therefore cost-dominant proving that it is cheaper to treat an obese patient than not to.
   
GP consortia will have the power to ensure weight management in obese patients is prioritised, to commission a wide variety of weight management services and to remove the barriers to bariatric surgery.            

This approach would save a vast amount of money in the long term, but there is a danger that commissioners might be too myopic to appreciate long-term gains.

For more information
Web: www.nationalobesityforum.org.uk