5. Obesity: defusing a health time bomb : Department of Health

It is well recognised that overweight and obesity increase the risk of this country's biggest killer diseases - coronary heart disease and cancer - as well as diabetes, high blood pressure and osteoarthritis.

The National Audit Office (NAO) found that obesity is responsible for more than 9,000 premature deaths each year in England and reduces life expectancy on average by nine years. Obesity also has significant financial costs, both to the NHS and the wider economy. In common with other countries around the world, levels of obesity in England are rising. The consequences are serious.

Key points

Obesity levels in England have tripled in the past two decades; around a fifth (21%) of men and a quarter (24%) of women are now obese whilst almost 24 million adults are now overweight or obese.
Obesity is also rising among children - in the five years between 1996 and 2001, the proportion of obese children aged 6-15 years rose by some 3.5%.
Cases of maturity-onset diabetes are starting to emerge in childhood.
Worldwide, around 58% of type 2 diabetes, 21% of heart disease and between 8% and 42% of certain cancers are attributable to excess body fat.
Obesity is responsible for 9,000 premature deaths each year in England, and reduces life expectancy by, on average, 9 years.
Obesity costs the economy at least £2.5 billion a year - including costs to the NHS and cost to industry through sickness absence.
Stemming the increase in obesity rates will need effective measures to improve diet and increase exercise levels in the population.
Action by the food and fitness industries, as well as by government and local agencies, is needed.

The scale of the problem

The growth in the number of people in the population who are overweight and obese is of increasing concern in most developed countries of the World. So much so that it has been termed a 'global epidemic'.

Overweight and obesity are most commonly assessed through the Body Mass Index (BMI) - calculated by dividing a person's weight in kilograms by their height in metres squared (kg/m2). In England, an individual is considered to be 'overweight' if their BMI is between 25 and 30, and obese if over 30. Based on these definitions, around 21% of adult men and 24% of adult women are now obese. A further 47% of men and 33% of women are overweight. So, two-thirds of all men, and half of all women are now overweight or obese. This is almost 24 million adults. Rates have been rising in England, in common with other countries, and have trebled in the last 20 years.

Over the last few years in particular, public attention has been drawn by a number of influential bodies to the problem of obesity. This concern is not misplaced. Obesity rates have increased dramatically in most developed countries. Although levels of obesity in England have not yet reached those seen in the United States - where at the start of the 21st century almost a third (31%) of all adults are obese (an increase from a quarter just a decade earlier) - a continuation of the recent trend of rising numbers of overweight and obese people would be disastrous for the future health of our country. Globally now, more than one billion adults are overweight and at least 300 million are obese.

Prevalence of obesity in adults aged over 16 years in England

*Data for 1980 and 1986/7 are for adults aged 16-64 years in Great Britain. Source: ONS The Heights and Weights of Adults in Great Britain, 1980; ONS The Dietary and Nutritional Survey of British Adults, 1986/7; ONS, Health Survey for England 1993; National Centre for Social Research, Health Survey for England, 1994-2001

Children: a particular concern

Obesity is more common in older age groups but the growth in the proportion of overweight and obese children is a major concern. Analyses of the Health Survey for England suggests that a considerable number of children are either overweight or obese - for example, in 2001 8.5% of 6 year olds and 15% of 15 year olds were obese.

[Note: Calculations based on BMI above the 95th percentile to represent obese and BMI above the 85th percentile to represent overweight]

Despite differences of view on the definition of overweight and obesity in childhood, all recent studies, no matter which method is used, have shown that overweight and obesity are becoming more common amongst children in England. Between 1996 and 2001 the proportion of overweight children (aged 6-15 years) increased by 7% and obese children by 3.5%. Particularly worrying are the first signs of children presenting with maturity-onset (or Type 2) diabetes which in the past has occurred in middle and older age. Researchers in the United Kingdom have recently warned that the increase in obesity threatens to reverse gains in longevity made during the last hundred years and in some cases could result in parents outliving their children.

A health inequalities issue

Obesity is also a health inequalities issue - and there are large social class differences, particularly in women. The Health Survey for England has shown that in 2001 amongst professional groups 14% of men and women are obese, compared to 28% of women and 19% of men in unskilled manual occupations. Amongst women, there are also important differences between ethnic groups: in 1999 obesity was 50% higher than the national average amongst Black Caribbean women and 25% higher amongst Pakistani women.

Health risks of obesity

As well as increasing mortality, it is well established that obesity is also associated with increasing the risk of many serious diseases.

Obesity is associated with increased risk of:

Premature death
Heart disease and stroke
Type 2 diabetes
Hypertension
Angina
Gall bladder diseases
Osteoarthritis
Sleep apnea · Breathing problems
Some cancers, including postmenopausal breast cancer and colon cancer
Lower back pain
Complications in pregnancy
Complications in surgery
Psychological and social problems
Reproductive disorders

The rapid increase in obesity in the United States has also been mirrored by an increase in the prevalence of diabetes - by a third between 1990 and 1998. Such a scenario is also being seen here, where 75% of adults with newly diagnosed type 2 diabetes are overweight or obese. In 2002, cases of 'adult onset' diabetes in obese children were reported for the first time in the United Kingdom.

Implications

The World Health Organisation has recently highlighted that in 2002 alone, around half a million people across North America and Europe will die from obesity related diseases. It is estimated that if no action is taken, globally we will see a one third increase in the loss of healthy life as a result of overweight and obesity over the next 20 years, with the number of global deaths rising from three million to five million each year. The World Health Organisation estimates that around 58% of type 2 diabetes, 21% of heart disease and between 8% and 42% of certain cancers are attributable to excess body fat.

For the NHS, it has been estimated that, based on current trends of increase, a general practice with 10,000 patients and five doctors would have to cope with 80 new obese patients each year. Already there is a significant increase in NHS costs. Since the National Institute of Clinical Excellence (NICE) issued guidance on the prescribing of the anti-obesity drugs Orlistat and Sibutramine in 2001, the number of these drugs dispensed has trebled.

For those who are already obese, even a modest weight loss can have substantial benefits. A 10kg loss is associated with a 20% fall in total mortality and a 10% reduction in total cholesterol. Based on the National Audit Office figures, it is estimated that one million fewer obese people in this country could lead to around 15,000 fewer people with coronary heart disease, 34,000 fewer people developing type 2 diabetes, and 99,000 fewer people with high blood pressure.

Source: Reilly J J, Dorosty A R. Epidemic of obesity in UK children. Lancet 1999; 354:1874. (using data from Health Survey for England 1995/7)

Why has obesity increased?

Without periods of increased energy (calorie) intake and/or reduced physical activity, individuals will not gain weight, no matter what their genetic make up. The increase in overweight and obesity across the world has been too fast to be explained by genetic factors alone and is most likely to be due to changes in diet and in physical activity habits.

While dietary surveys in the United Kingdom seem to show a reduction in energy intake - an important and often unrecognised consideration is that our National Food Survey does not fully account for food eaten outside the home - including for example, work lunches, snacks and fast food meals. The number of meals and snacks eaten out has increased in recent years - as a nation, we ate 675 million restaurant meals in 2000 (up almost 13% since 1995) and, in 2001, we ate around 2 billion meals at "quick service" restaurants.

Meals and snacks eaten out tend to be higher in fat - with at least 40% of calories coming from fat in meals eaten outside the home, compared with less than 37% in food eaten at home. Calories from fat are particularly important. A high fat diet may predispose to weight gain - by undermining the normal mechanisms regulating energy balance and/or leading to passive over consumption. Although the National Food Survey shows that average total fat consumption has fallen in recent years, average total fat intakes remain above the 35% recommended by the Committee on Medical Aspects of Food and Nutrition Policy (COMA) in 1994.

People are also snacking more. While the National Diet and Nutrition Survey indicates that we are eating less cakes and biscuits, industry surveys show that sales of snacks and confectionery continue to increase, outstripping those in all other European countries. People are also drinking more sugared drinks, which may contribute to excess calorie intake. For example, consumption of carbonated drinks has almost doubled in the past decade. Young adults now drink an average six cans each week, around half of which are non-'diet' types containing sugar.

Evidence from the United States also suggests that portion sizes are significantly larger now than they were in the 1970s, especially for high calorie snacks and fast foods. The supersizing of fast foods and snacks is an increasingly popular trend in this country and may make it easier for people to overeat inadvertently. A king size version of a chocolate bar can provide around 100 extra calories over the standard bar. To put this in perspective, just 50-100 calories each day above energy needs could lead to a weight gain of 5-10lb in one year. Some kingsize bars available in the UK provide around a fifth of the daily calorie needs of a ten year old child.

Equally important is the fact that people are also becoming less active in daily life. The most recent surveys show that six in 10 women and seven in 10 men do not do the recommended 30 minutes moderate intensity physical activity on five days a week. Similarly, four in 10 boys and six in 10 girls are not meeting the recommended hour a day of physical activity for children.

Lower levels of activity in daily life are likely to be key to the rise in obesity and due to a range of reasons - including greater use of the car for short journeys (walking and cycling have decreased since 1975), an increase in sedentary occupations, lower sports participation and parental reluctance to allow children to play outdoors. Conversely, sedentary activities, such as watching TV, are increasingly popular. Indeed, the findings of a prospective study of nurses in the US suggest that following a relatively active lifestyle (watching less than 10 hours of TV a week and walking "briskly" for at least 30 minutes each day) could prevent around 30% of new cases of obesity. Limiting TV viewing in children has also been associated with a reduction in obesity - possibly by reducing the snacking associated with TV viewing as well as increasing activity.

Other changes in lifestyle may also be important - for example, alcohol intakes among women and young men have increased in England during the past decade; alcohol provides almost as many calories as fat and high intakes have been shown to contribute to weight gain and obesity.

What is being done to tackle obesity?

The World Health Organisation has recently highlighted prevention as the key to lowering the global burden of heart disease and stroke. More than half of deaths and disability from heart disease could be prevented by national and individual action to reduce major risk factors, including obesity.

The Department of Health cannot tackle obesity alone. Considerable action is being taken across government to tackle obesity, especially through improving diet and increasing physical activity levels. More needs to be done. The Department of Health is leading on the development of a new Food and Health Action Plan, which will be of direct relevance to the prevention and management of obesity. Focusing on nutrition policy in the broadest terms, it will set out a plan of action to address the range of factors that influence what we eat. It will look at food supply, production and, preparation, access to healthier choices and providing information for consumers about healthier eating.

On-going initiatives have a role in obesity prevention, including the reform of the Welfare Food Scheme, action to promote breastfeeding, various initiatives in schools to improve the diets of children, and the 5 A DAY programme to increase intakes of fruit and vegetables. In addition, the NHS Plan makes a commitment to improve the overall balance of the diet, including the amount of fat and sugar in food. I urge the food industry to consider what it can do to ensure that the levels of fat and sugar in products contribute to a healthier diet.

5 A DAY: Examples of what counts as a portion

To ensure that there is a co-ordinated and strategic approach to the planning and delivery of sport and physical activity across a diverse range of sectors - such as transport, countryside management and town planning -a Sport and Physical Activity Board (SPAB) has been established. The Board is to be jointly led by the Department of Health and Department of Culture, Media and Sport. It will oversee the co-ordination of action to increase activity levels, physical education, school sport and club links programme - which will help fulfil the Prime Minister's commitment to entitle all children to a minimum of two hours a week of high quality physical education and school sport.

Another key project in the current Department of Health's programme of work is the Local Exercise Action Pilots (LEAP) which are jointly funded with Sport England and the Countryside Agency, and which will test the effectiveness of Primary Care Trust led interventions to increase access and levels of physical activity in communities based in Neighbourhood Renewal Areas. Activities range from walking, cycling and swimming initiatives to clinical based programmes that are focusing on diabetes and weight management.

The Government has recently set a challenging target for 70% of the population to be active by 2020. The target - at least 30 minutes a day of a moderate activity, such as brisk walking - will only be achieved by helping people to build activity into their daily lives, in addition to encouraging participation in sports. Therefore, addressing transport to ensure that walking and cycling can be built in to daily life will be key.

Later this year I will be publishing a report that brings together the latest research evidence on physical activity and health. This report will inform local policy makers and health professionals to increase awareness of the strength of the evidence.

The NHS Priorities and Planning Framework for 2003-2006 requires practice-based coronary heart disease registers and systematic treatment regimes. This will include appropriate advice on diet, physical activity and smoking for patients with coronary heart disease and those at high risk of coronary heart disease, including those who are obese. Extending the availability of exercise referral schemes will be an important component of meeting this target. National Institute for Clinical Excellence guidance on drugs to tackle obesity, Orlistat and Sibutramine, has added another valuable approach to the options available to practitioners in tackling obesity.

The National Audit Office's report highlighted that the majority of general practitioners and practice nurses believed that guidance on effective interventions in primary care to tackle obesity prevention and management would be helpful, and the intention of the National Institute of Clinical Effectiveness to develop such guidance is welcomed, as is evaluation by the Health Development Agency of the evidence base for the prevention and management of obesity.

In the United States a range of fiscal and economic measures are being considered, as well as health "warnings" on foods. I am not opposed to such an approach here. Regulating the promotion of foods through schools and other approaches to discourage the consumption of products high in fat and added sugars are both worthy of consideration, including more radical fiscal options. The Food Standards Agency is currently carrying out research in to the impact of food advertising on children's diets. These findings will be important in planning future measures.

Conclusion

The growth of overweight and obesity in the population of our country - particularly amongst children - is a major concern. It is a health time bomb with the potential to explode over the next three decades into thousands of extra cases of heart disease, certain cancers, arthritis, diabetes and many other problems. Unless this time bomb is defused the consequences for the population's health, the costs to the NHS and losses to the economy will be disastrous.

No country has successfully tackled the problem of obesity. With a co-ordinated and comprehensive response from health and local authority services and across government and with the co-operation of the food, sports and leisure industries it is still possible to mitigate its impact on future generations.

Action Recommended

Obesity is a growing challenge for Government as a whole - action across Government Departments must increase if we are to effectively tackle obesity.
The food industry - including manufacturers, retailers and caterers - is strongly encouraged to address the added sugar, fat and salt content of foods, to ensure that consumers are able to make informed choices (for example, by providing clear information on product content - including those eaten at food outlets).
There is a case for adopting the precautionary principle for the marketing of foods to children. Industry should be asked to take a more responsible approach to the promotion (especially to children) of foods high in fat, salt and added sugars and balance this with the promotion of healthier options, including fruit and vegetables.
The leisure and sports industries - particularly those with high brand acceptance - should continue to market participation in exercise and sports as 'cool'.
Local government should review the facilities for exercise provided in their areas addressing the needs of all - e.g. sports, cycling to work, dancing, swimming. Policies that encourage active transport should be a priority.
Primary Care Trusts should work with partner organisations on exercise referral for high risk groups, including children (the new programme of Local Exercise Action Pilots will help with this).
Drug companies - such as those producing drug treatments for obesity - should help provide training for primary care professionals on effective ways of tackling obesity and implementing the NICE guidance.
General Practitioners and Primary Care Trusts should take action to prevent and tackle obesity in their practice populations using effective interventions based on evidence.
Health professionals - including general practitioners, school nurses, practice nurses and health visitors - should identify early signs of obesity in children and offer interventions at an early stage.
The Foods Standards Agency should examine options for reducing overweight and obesity through action to improve transparency in food labelling, improved consumer information on issues such as portion size and snacks, and alert consumers to the risks of regular consumption of foods high in calories, fat and sugars.
Regional Government Offices should put together a 'target obesity' programme for their regions, taking stock of the baseline prevalence of obesity.
To supplement data at a national level, Public Health Observatories should make regular public reports tracking the prevalence of overweight and obesity in their regions and identifying areas where progress is being made.

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