exorcising obesity

Improving health by tackling obesity and levels of physical activity

Obesity as a public health issue

People who are obese are at major risk of developing chronic diseases such as type 2 diabetes, cardiovascular disease, hypertension and stroke, and some forms of cancer. With obesity now having reached 'epidemic proportions' worldwide1, "battling the bulge" has become more important than ever before. Lothian NHS Board is implementing measures to tackle this issue.

1. What is obesity?

Obesity is most commonly measured by analysing the amount of fat a person has in their body. In order to do this, the body mass index (BMI) is used. This is a person's weight, in kilogrammes, divided by the square of their height, in metres (see Box 1).

A person with a BMI of over 25 is classed as overweight, whilst a person with a BMI of over 30 is classed as obese. Although there are some limitations to using BMI to measure weight notably its insensitivity to body shape and muscle mass - it is the standard index used by most health professionals working in this subject.

2. Why is obesity / being overweight dangerous?

Obesity has serious health implications. People who are obese and people who are overweight are at high risk from serious chronic diseases which can lead to premature death or reduced quality of life. These include type 2 diabetes, cardiovascular disease, hypertension and stroke, and some forms of cancer1.

3. Why are levels of obesity so high?

Although there is a genetic component to people's susceptibility to weight gain, the interaction between calorie intake and physical activity determines energy balance. Modernisation, urbanisation, consumerism and globalisation of food markets are some of the forces underlying the upsurge in levels of obesity. More people now live in urban areas where processed and fast-foods are often cheaper, more accessible and convenient than fresh food. As a result, diets rich in complex carbohydrates have been usurped by diets with an increased amount of fats, saturated fats and sugars. Alcohol consumption also contributes to increased weight gain. Alcohol is high in calories and drinking is regularly accompanied by or followed by foods high in calorific content. Such a culture is changing but must continue to be tackled if obesity is to become a problem of the past.

Physical activity levels have decreased for a wide range of reasons. There has been a decrease in physically demanding work as more advanced technology has entered the workplace. Increased car use has been facilitated by cheaper motoring costs and better roads. Many people travel long distances to work and their jobs are sedentary. For a variety of reasons, including perceived risks of accidents and injuries, children are less likely to walk to school or play unsupervised outdoors. Greater availability of home technology and passive leisure pursuits have added to this decrease in physical activity levels1.

Prevalence

In Britain in 1981, 34% of men and 24% of women were overweight and 6% of men and 8% of women were obese2. In 2002, 70% of British men and 63% of British women were overweight, and 20% of adults were clinically obese3. The most recent figures for Lothian indicate that 23.8% of adults are obese. More men, 25.5%, than women, 22.3%, are obese. This compares with 24.2% of Scottish people, 22.4% men and 26% women4. Figure one shows the upward trend in Lothian over recent years.

The issue of obesity in childhood is an area for particular concern. Obesity in children aged between two and four almost doubled in the UK between 1989 and 1998, and trebled in those aged 6–15 between 1990 and 2001. The Scottish Health Survey (2003) estimated that the prevalence of overweight or obese boys in Scotland, aged 2-15 years, was 34/6%, whilst the prevalence for the equivalent cohort of girls was estimated at 30%4. Table one gives a breakdown of these estimates. It is estimated that if rates continue to rise as they have done, at least a third of UK adults will be obese by 20203.

Prevention

The World Health Organisation drafted a response to this diet crisis and has outlined plans for national guidelines on diet and physical activity, which include a ban on food marketing that exploits children and a better food labelling system5.

1. Diet

The Scottish Executive's response to the guidelines on diet, Eating for Health - Meeting the Challenge6, identified three key areas which must be tackled:

The Scottish Executive response also encourages the NHS, local authorities, consumer bodies such as the Scottish Consumer Council and supermarkets and fast food industries to work together to create a healthier society.

NHS Lothian's response to the Scottish Executive's recommendations are reported in the Lothian Local Health Plan (2005). Box two outlines the health improvement fund (HIF) food and health projects that are underway. The Scottish Healthy Choices Award is a Lothianwide initiative available to caterers who serve large numbers of people; all the universities in the area have gained this award. Elsewhere the need to change environments in order to change people's attitudes and behaviours is a focus of work. Lothian and Borders' police for example, have begun to address this issue.

2. Physical Activity

The Scottish Executive's response to WHO's guidelines on physical activity, the Scottish Physical Activity Strategy (2003), sets out a plan for increasing physical activity in children and adults in Scotland by 1% per year until 20227. The national goal is for 80% of the child population to be active for one hour a day and 50% of the adult population to be active for 30 minutes a day, the minimum levels required for health. Structures and initiatives, such as Health Promoting Schools and Active Schools, a drive to re-ignite children's games in the playground, are intended to help deliver this.

Public sector organisations in Lothian have responded with the development of schemes which promote physical activity. Healthy walk schemes are being introduced and a Lothian-wide health walk network is being developed. Training in physical activity and health is continuing, and has been particularly helpful in supporting the assimilation of Active Schools. The 'Girls in Sport' programme is another initiative which is being developed in both Edinburgh and Midlothian. 'Sporting Chance' is an Edinburgh initiative which encourages young people to take part in physical activity. Although young people are being targeted extensively, NHS Lothian is committed to making physical activity available to people of all ages, including older adults. Some projects with this aim include 'West Lothian on the Move', 'Get-going East Lothian', and 'Move-it' in Edinburgh.

3. Disadvantaged Groups

In line with Health 218, WHO's initiative aimed at reducing health inequalities, NHS Lothian is targeting disadvantaged groups who can often be disproportionately affected by certain conditions9. One such group which requires further intervention is people with a learning disability where levels of obesity are higher than in the general population10,11 with an estimated prevalence of 10-56%12. Healthy eating can become an issue of duty of care within this sphere. Moreover, unhealthy habits of carers can also, inadvertently, lead to active encouragement of unhealthy eating patterns and sedentary behaviour13. Specifically developed interventions are crucial if there are to be effectual health improvements.

4. Cure?

Preventative measures put in place now will significantly reduce future levels of obesity in the population, but what options are available for those who are already obese? Press reports suggest a threefold increase in the prescription of anti-obesity drugs last year. This rise is attributed to the availability of new slimming drugs that work differently upon the body, for example, causing the user to feel full quicker.

NHS Lothian has witnessed an increase in demand for bariatric surgery, which is carried out to reduce obesity. This option is recommended only as last resort for patients who have tried and failed to lose weight and whose health is at serious risk from their weight. This is because bariatric surgery can have significant side effects, as can the use of slimming drugs.

Toast, The Obesity Awareness and Solutions Trust, reports that often people who are obese have managed to lose weight but put it back on again14. It seems that maintaining weight loss may be the most difficult element. Weight loss alone may have little long term benefit as without a change in eating behaviours and activity patterns, weight gain again becomes problematic.

Obesity is a psychological, physiological, social and environmental issue and for effective and long-lasting results, must be treated as such. Toast recommends the use of long term support networks and groups led by counsellors trained in obesity management14. Current SIGN guidelines for the treatment of obesity in children recommend increasing physical activity, decreasing energy intake and then maintenance of this as the best course of action15. Cognitive behavioural therapy has been recognized as the preferred intervention for tackling obesity16. However, as yet resources for this are limited. Involvement of the individual in treatment is a crucial factor as research indicates this can affect concordance with recommended health advice17.

The Future

Suggested measures in the fight against obesity include state regulatory strategies such as ensuring accurate food labelling, subsidising healthy foods and altering social environments, by, for example, providing playing fields in schools18. Many of these have now been implemented in Scotland and in Lothian. For those who are obese, psycho-social interventions for eating behaviours and support for the maintenance of weight loss are indicated as areas which could be important to develop further. The responsibility for change lies with policy makers, health professionals and individuals, working in partnership, and the first steps have been taken to exorcising obesity in hidden areas.

References

1. World Health Organisation (2003). WHO obesity and overweight fact sheet. http://www.who.int/hpr/NPH/docs/gs_obesity.pdf

2. Office of Population Census and Surveys (1981) OPCS Monitor Ref SS 81/1. (Cited in Royal College of Physicians, 1983)

3. Royal College of Physicians (2004). Storing up problems: the medical case for a slimmer nation. Report of a working party to the Royal College of Paediatrics and Child Health and Faculty of Public Health. London

4. The Scottish Executive (2003). Scottish Health Survey. http://www.scotland.gov.uk/Resource/Doc/76169/0019729.pdf

5. World Health Organisation (2004). WHO global strategy on diet, physical activity and health. Geneva WHO

6. The Scottish Executive (2004). Eating for Health – Meeting the Challenge. Edinburgh SEHD

7. The Scottish Executive (2003) Scottish Physical Activity Strategy, Edinburgh SEHD

8. World Health Organisation (1998). WHO health for all in the 21st century. Geneva WHO

9. Edinburgh Health Action Team (2004). Working for a healthier Edinburgh: Edinburgh Joint Health Improvement Plan 2003-2006. City of Edinburgh Council.

10. Rimmer, J.H. & Braddock, D. & Marks, B.(1993). Prevalence of obesity in adults with mental retardation: implications for health promotion and disease prevention. Ment Retard, 21: 105-10

11. Bell, A.J. & Bhate, M.S. (1992). Prevalence of overweight and obesity in Down’s syndrome and other mentally handicapped adults living in the community. J Intellect Disabil Res, 36: 359-64

12. The Scottish Executive. (2004). Health needs assessment report: people with learning disabilities in Scotland, Edinburgh SEHD

13. Smyth, C. & Bell, D. (2006). From biscuits to boyfriends: the ramifications of choice for people with learning disabilities. British Journal of Learning Disabilities, 34(4)

14. Health Committee (2005). Health Committee 5th Report. SP. Paper 315. http://www.scottish.parliament.uk/business/ committees/health/reports-05/her05-05-04.htm

15. SIGN (2003). SIGN Guideline 69: Management of obesity in children and young people. www.sign.ac.uk/guidelines/ fulltext/69/index.html

16. National Institute of Health (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Obes Res, 6(Suppl. 2i): 51S-209S

17. Myers, C. & Abraham, L. (2005). Beyond ‘doctor’s orders’. The Psychologist, 18

18. Wanless D. (2004). Securing good health for the whole population. London, HMSO.