Memorandum submitted by The Obesity Awareness
& Solutions Trust Limited (TOAST) (PAC 00-01/148)
TOAST RESPONSE TO: TACKLING OBESITY IN ENGLAND
REPORT BY THE COMPTROLLER AND AUDITOR GENERAL 2001
TOAST welcomes the publication of the National
Audit Office Report on obesity and is glad that at last there
is to be a joined up approach to tackling obesity. We support
the Government's promotion of a healthy diet, containing adequate
amounts of fruit and vegetables, coupled with good exercise as
one means of preventing further increases in the levels of obesity.
However, this advice has neither halted the increase nor resulted
in a decline. Indeed, the problem has reached epidemic proportions
according to the World Health Organisation. What must not happen
is that the emphasis be put just into prevention, important as
it is, there are still two thirds of men and half of women who
are currently obese or overweight. Obesity is caused by a diversity
of problems and needs a diversity of solutions.
The Health of the Nation Report in 1992 identified
the co-morbidities and therefore the financial costs of obesity
and set targets to reduce the incidence from 12 per cent back
to the 1980 level of 8 per cent. By 1999 it was obvious that the
targets would not be met and so, with the obesity epidemic raging,
"Saving Lives: Our Healthier Nation" dropped obesity,
setting no strategy to reduce or limit it. There was a feeling
amongst those living and working with obesity that the government
hoped that if they ignored obesity and the obese then it and they
would go away. TOAST is concerned that local and national schemes
will fail to include effective programmes; leaving obesity and
obese people labelled as hopeless and once again put on the back
shelf of health care.
There is no one single cause. At the simplest
level obesity is caused by eating more than a body needs. However,
the food choices of all human beings are made for a variety of
reasons, ranging through appropriate "dinner-time" hunger,
stress leading to undereating, stress leading to overeating, a
scrumptious looking dessert trolley to celebratory meals. We have
asked a variety of groups why they think obese people over eat;
the following list is a typical example:
||Because it's there|
||Stress||Pressure from other people
||Habit||Going to start a diet tomorrow
||It's Sunday||Not appreciated
As well as looking at the observable behaviour such as how
much is eaten, it's important to look at what drives food choices;
the cognitions and emotions that lie behind food choices.
For many types of obese there is a strong link to the problems
of those with a drink problem. The alcoholic doesn't drink too
much because they are thirsty. The alcoholic is not "cured"
because they have not had a drink for weeks, months or even years.
Treatment programmes use some form of counselling, recognising
that alcohol is often used as a coping mechanism; to drown sorrows,
for swallowing anger, blotting out the pain, to be part of the
crowd. Many overeaters will recognise these behaviours and reasons
for over consuming.
"The worst health problems in our country will not be
tackled without dealing with their fundamental causes." (NHS
Plan, 2000). We have to stop treating obesity at the simplest
level. The only direct statement in the Report that acknowledges,
". . . psychological problems may equally contribute to the
type of behaviours, such as emotional and binge-eating, that can
result in the onset of obesity" is in the appendices
(NAO Report 2001all italics refer to Report).
One of the major failings of the Report and in obesity management
in general is the focus on "Healthy Eating and Physical Activity"
(HEPA) as the main (if not only) solutions to the obesity epidemic.
The National Food Survey (1992) showed that energy intake
has decreased since the 1970's; however, the Survey did not take
into account that eating patterns have changed in the last 30
years; people eat away from home more frequently and this data
is not included in daily consumption. The "Effective Healthcare
Bulletin" (1995), although acknowledging that eating outside
the home "may also contribute to this trend" states
"This [the increase in obesity] has occurred despite a reduction
in the total average energy consumption, suggesting that sedentary
lifestyles are the most important factor." It is important
that such errors are not perpetuated and the solution to obesity
is not seen as just getting people to exercise more.
Exercise can have a part to play. Because losing weight reduces
the risk of coronary heart disease (CHD), obesity is mentioned
in the National Service Framework for CHD (NSF, 2000). However,
because the focus of this document is on reducing the risk of
CHD, the levels of activity recommended are also focused on how
much exercise an individual needs to do to reduce their risk.
Unfortunately, the level of activity required to be fit and the
level required for weight loss are different, but advisers are
not putting this information across. Thirty minutes a day is for
prevention of CHD; in order to lose weight this needs to be roughly
trebled, and this is assuming no overeating is going on. To burn
up one pound of fat a human being needs to walk or run 35 miles.
Whilst recognising the importance of improving diet in this
country, it is important that this is not confused with action
to deal with the obesity problem. The healthy eating advice that
is necessary for the average weight person is different from the
advice that an obese person needs. The "Balance of Good
Health" plate is an excellent way of putting across the
healthy eating message. But this message has been around for decades.
Education messages alone don't work; advice alone will not change
Most obese people have been on lots of diets and are dieting
experts. "I know what I should eatwill somebody help
me do it" is a common cry.
Our research (Cox 2000) showed 90 per cent of obese people
questioned thought that GPs did not, or only occasionally provided
the right kind of support. Similarly, 90 per cent thought dieticians
did not provide the right kind of support. Many tell us that they
felt their doctor was not interested, did not understand and did
not have time to listen.
3.25 ". . . we found that almost all practices
recorded the height and weight of all patients. In addition, about
95 per cent recorded the body mass index of all patients."
In contrast, work by Nick Finer at the Luton and Dunstable
Hospital highlighted poor GP referral letters to his obesity clinic.
Many did not include the weight of these patients. This low quality
may represent a negative attitude of the physician towards the
The National Service Framework for CHD gives milestones of
April 2001 and 2002 for action on obesity management. Our concern
is that many GPs as yet do not know of the milestones, let alone
actioned them. It will be 2003 before anybody realises this. We
would like to know the progress of the milestones and details
of the budgets for putting these policies into action.
3.17 ". . . A weight loss of 5kg (11 lbs) is equivalent
to a loss of some six per cent in body weight for a man or woman
of average height with a body mass index of 30"
TOAST recognises the health benefits of a 5kg loss. However,
we agree with the government's National Service Framework for
CHD statement, ". . . but the goal which patients should
be encouraged to aim is still a BMI in the average range".
One of the disadvantages of only focusing on the benefits
of a small weight loss is that it becomes the expected norm. We
must continue to find ways of helping individuals to reach and
maintain an even healthier weight. The health benefits increase
as the weight loss increases.
Identifying the overall cost of obesity is very different
from identifying what is currently being spent. The Report itself
acknowledges its underestimation of the costs of obesity. The
cost is probably around 2 billion, yet the NHS is only spending
Obesity! A complex problem
With many routes to becoming obese it seems realistic to
assume that "one size fits all" is not a useful approach
for treatment. One obese person may, for example, simply need
more knowledge about low fat eating, another may be a dieting
expert full of facts and figures but be unable to motivate her/himself
to put that knowledge into action. There are many influences on
an individual's obesity development. A fundamental flaw in the
government department system is the lack of attention paid to
psychology and emotional well being.
Too big a problem for the NHS to cope with alone
With 25 per cent of the population obese, Primary Care Teams
cannot deal with the problem alone. Any effective public health
strategy must recognise the wide range of factors that contribute
to the problem and provide for a range of solutions open to individuals
including, but not limited to:
Conventional dietary advice
Behavioural change, including exercise
Counsellingeg cognitive behavioural therapy
Nutritionally assured formula foods including very low calorie
diets and other meal replacement programmes
Medical interventioneg medication, surgery
There is a need for a new type of health professional to
specialise in obesity management.
What can we learn from others?
Within geriatric care the NHS and the commercial sector work
together; the NHS frequently treats medical symptoms and the commercial
sector frequently provides other care.
Treatment programmes for addictive behaviours provide motivation
for change and long term support. Many work with groups, which
have been shown to be effective, and are good use of the professional's
Training programmes used by industry and the public sector
aim to help people change attitudes, motivate themselves and work
towards achieving their and their organisations goals. They are
the culmination of decades of research into understanding these
The Health Education Authority's "Lifesaver" quit
smoking programme has provided varied support for those wishing
to stop smoking ranging from a screensaver"Smoking:
don't give up giving up" to a national media campaign.
The "whole practice" approach is a good method
of using skills and resources.
There is a need to co-ordinate initiatives including NHS,
policy makers, the food industry, slimming industry, Advertising
Standards Authority and other campaigns.
Promoting a healthy school environment, healthy travel to
school, sport and physical recreation in schools and healthy eating
in schools and, importantly, not forgetting bullying and the psychological
well being of the already obese child.
The message that the government puts out needs to be simple.
There have been so many conflicting nutritional messages over
recent decades that many are confused. One suggestion for getting
across the health message; "Obesity leads to diseases which
Recognise that the message on diet and exercise is important
but not the whole solution
There is a danger that Health Authorities providing "encouragement"
for people to eat healthily and to do more physical activity will
enable them to be seen as having an obesity management strategy.
When this fails (again), overweight and obese people will be seen
as too difficult to treat. We want to stop the government wasting
money in thinking that obesity will be solved by continuing with
more of the same policies that have blatantly not worked in the
Better information on food labels
Government advice is that only 25 per cent of our Calorie
intake should be from fat. Currently labels show fat weight, which
does not easily allow people to make that choice. Most people
would need a calculator to find the percentage of fat in the product.
Clear, readable labels showing percentage from fat Calories
would also stop X per cent fat free claims. Some products carry
a banner on the front of the packaging declaring the product to
be, for example, 85 per cent fat free. Most people interpret this
as meaning only 15 per cent of the Calories in the product are
from fat. In reality the percentage of Calories from fat can be
nearer 30 per cent.
Prevention alone is not good enough
Paragraph 3.13 of the Report suggests, ". . . A more
realistic five year aim might be to keep the local prevalence
of obesity constant. . . ."
A consequence of this message is that it will be taken as
a guideline to focus on prevention, ignoring the 10 million already
obese in this country. This approach will also lead to an increase
of the costs of obesity because the existing obese population
is getting older. To simply focus on prevention is not good enough.
Put in place weight maintenance programmes
Many obese have been successful at losing weight but only
a small percentage of those are successful at staying at the lower
weight. These two activities take place over different time frames
and require different skills. Most of the solutions to obesity
have only been solutions for losing weight and have not included
a solution for the much more difficult problem of keeping the
weight off once lost.
Set targets that reduce obesity
Failing to plan is planning to fail! It is important to reinstate
measurable targets for obesity reduction and identifying efficacious
weight loss methods and best practice. Uncertainty over the aetiology
of obesity remains one of the chief barriers to designing effective
strategies for prevention and treatment. The report continues
the common lack of understanding of the complexities of obesity
and thereby contributes to the uncertainty of how to treat.
Cox JSA., Hewlett B. (2000) Attitudes and opinions towards
some weight related-issues. International Journal of Obesity,
24, (suppl. 1), pS58.
Department of Health (1992). The Health of the Nation. HMSO.
Department of Health (1999). Saving Lives: Our Healthier
Nation, The Stationery Office.
Department of Health (2000). National Service Framework for
Coronary Heart Disease: Modern Standards and Service Models.
Department of Health (2000). The NHS Plan: A Plan for Investment,
A Plan for Reform. The Stationery Office.
Ministry of Agriculture, Fisheries, and Food (1992). Household
food consumption and expenditure. London: HMSO.
NHS Centre for Reviews and Dissemination (1997). Effective
Health Care: The Prevention and Treatment of Obesity, Vol 3, No.