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Tuesday 23 June 2015

The Truth About Obesity

Two weeks ago, an article by Chris Snowdon appeared in the Spectator, entitled "The Big Fat Myths of our Obesity Epidemic". It suggested that the health risks and costs to healthcare of obesity have been over-stated, and that obese people dying younger would actually help. Nothing could be further from the truth. Last week a remarkably similar article appeared in The Scotsman, written by Allan Massie.
Snowdon, echoed by Massie, argued that "being fat is ... an issue of personal health and private behaviour". Obesity (like every disease) arises from genetic/epigenetic-environment interactions. Few elect to become obese. And our genes did not cause obesity until the last few years. The obesity epidemic (qua WHO, over 15% of the total population affected, therefore time for government intervention for prevention) is an extraordinary new phenomenon. It has only emerged over the past 40-50 years, coinciding with the massive expansion of marketing skills and budgets, principally to promote sales of 'added-value' foods and drinks, and their consumption outside normal meal-times. This is an inescapable truth. It is not possible to 'prove' causality, though highly probable. Tackling root-causes of obesity demands radical changes to behaviours which have become normalised across society. Lifestyle habits are not simply matters of personal choice and private behaviour, but arise through life-circumstances and have consistently proved resistant to education. They have been moulded by marketing, so their improvement has to involve curbing the 'normality' (availability, acceptability and affordability) of highly-promoted calorific foods and drinks. Notably, obesity is more marked, and its consequences more severe, among the more deprived, where its causes are least amenable to education.
Following a review of the evidence, the UK's Academy of Medical Royal Colleges has called for banning junk food advertising to children. At the 2013 British Medical Association Annual Representative Meeting, an overwhelming majority supported aban on the sale of junk food in hospitals. The sad fact that 50% of NHS employees are now overweight or obese is a clear example that education is ineffective when the food environment is working against you.
Medical consequences of obesity, accumulating gradually, mostly over the age of 40, affect every organ system of the body, precipitating and aggravating chronic illnesses (the most devastating being diabetes), CHD and several major cancers. More importantly for obese people, it leads to physical disabilities - breathlessness, asthma, fatigue, arthritis, back pain. Once obese, people commonly experience feelings of shame, self-reproach and inadequacy. Thus depression and anxiety compound the ill.
Snowdon critiques the 'wild predictions' of 'campaigners' that 75% of UK adults will be overweight or obese by 2030. It might actually be sooner: the figure is already 68%. By the age of 65, some 80% of UK adults currently become overweight, and almost 40% are obese. But BMI alone is not adequate to analyse obesity: it is a rather poor indicator of fatness. Waist circumference (alone) predicts total body fat, and multiple medical consequences of obesity consistently better than BMI. Surveys over the past 20 years have shown how weight and BMI increases most rapidly in early adulthood, and then tend to flatten out with age. Some recent surveys in UK and elsewhere have suggested modest reductions in the rampant rise in BMI, but In contrast, waists are still growing at around 8-10cm in each 10 years, right up into people's 70s. The reason for this is that as body fat accumulates in older people, muscle mass is gradually falling, so BMI fails to identify the excess fatness. Thus the epidemic is far from over. And worse, increasing body fat (bigger waists) but loss of muscle ('sarcopenic obesity') heralds more diabetes, with its complications, and more physical disability, falls and fractured hips in older people.
Snowdon's statement (echoed by Massie) that obesity saves money, because people die younger, is absurd. It is insulting to the intelligence of those who work to treat chronic diseases, and insulting to the obese people who struggle for years to try to control their problem. It depends on the premise that life is a burden: "It is longevity, not premature mortality, which places a burden on public finances". A Lancet analysis found that if rising life expectancy means years in good health then health expenditure due to ageing is only expected to increase GDP by 0.7% by 2060 in the European Union. But that is not true if longevity is accompanied by obesity and multiple medical consequences. Obesity brings a catalogue of unpleasant symptoms and expensive secondary chronic illnesses. Drug prescriptions to obese people are increased in virtually every prescription category, and total NHS healthcare costs rise incrementally with BMI, doubling as BMI doubles from 20 (normal) to 40 (severe obesity). Our research from Glasgow has shown that 40% of UK adults now become obese by age 65, and 70% of them already have secondary expensive chronic diseases. Using waist-circumference (a better indicator of total body fat and of chronic disease risks), the proportion affected is even higher: a staggering 47% of all Scottish women, and 29% of men, are in high-risk categories by waist so unhealthy older age will not be healthy, productive or cheap.
Health economic analysis worldwide, carefully checked by peer-review, have never produced any evidence that obesity is not a major burden on healthcare. In UK, obesity is directly costing the NHS close to £6billion per year. The additional indirect costs to the economy of diseases related to being overweight are colossal. Type 2 diabetes alone adds £20billion. These figures will rise and may double in the next twenty years if we fail to act. Only this week Diabetes UK released figures revealing that diabetes is at an all-time high, affecting 3.9million Brits, 90% of whom have type 2 which is entirely preventable, and largely correctable, through weight control.
NHS England's Chief Executive, Simon Stevens has called for 'wide ranging action - as families, as the health service, as government, as industry, using the full range of tools at our disposal' to combat the normalization of obesity. His calls are scientifically justified, and essential both for the sustainability of the NHS and for economic prosperity. Arguments to the contrary do not reflect the independent evidence, and reality, that obesity is a tremendous threat to public health.

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