1. With quite astonishing rapidity, an epidemic of
obesity has swept over England. To describe what has happened
as an epidemic may seem far-fetched. That word is normally applied
to a contagious disease that is rapidly spreading. But the proportion
of the population that is obese has grown by almost 400% in the
last 25 years. Around two-thirds of the population are now overweight
or obese. On present trends, obesity will soon surpass smoking
as the greatest cause of premature loss of life. It will bring
levels of sickness that will put enormous strains on the health
service, perhaps even making a publicly funded health service
2. Dr Sheila McKenzie, a consultant at the Royal
London Hospital which recently opened an obesity service for children,
offered a powerful insight into the crisis posed to the nation's
health. Despite only being in existence for three years, her service
had an eleven-month waiting list. Over the last two years, she
had witnessed a child of three dying from heart failure where
extreme obesity was a contributory factor. Four of the children
in the care of her unit were being managed at home with non-invasive
ventilatory assistance for sleep apnoea: as she put it, "in
other words, they are choking on their own fat."
3. A generation is growing up in an obesogenic environment
in which the forces behind sedentary behaviour are growing, not
declining. Most overweight or obese children become overweight
or obese adults; overweight and obese adults are more likely to
bring up overweight or obese children. There is little encouraging
evidence to suggest that overweight people generally lose weight;
there is ample clear evidence that being overweight greatly increases
the risks of a huge range of diseases, and that the more overweight
people are, the greater the risks. Yet paradoxically, the phenomenal
increase in weight comes at a time when there is an apparent obsession
with personal appearance. There are more gyms than ever, more
options presented as 'healthy eating', and the Atkins diet dominates
the best seller charts.
4. Little has been done to reverse trends in obesity.
According to Professor Sir George Alberti, President of the International
Diabetes Federation, this is partly because the phenomenon has
"insidiously crept in" and partly because it raises
politically sensitive issues.
Dr Geof Rayner, then Chair of the UK Public Health Association,
suggested that another issue was the sheer difficulty in knowing
how to combat obesity: "when you have big explanations which
you cannot pinpoint exactly then it is very difficult to see what
you can do about it."
For Professor Julian Peto, Head of Epidemiology at the Institute
of Cancer Research, another reason for the neglect was the fact
that some of the health risks of obesity had not been known for
long. In particular, the extent of the link with cancer had only
recently emerged following a major US cohort study.
Professor Hubert Lacey, for the Royal College of Psychiatrists,
argued that part of the problem was stigma and prejudice against
the obese, both within society at large and within the medical
profession: "as a group clinically they are not liked
[they are seen as having] brought it on themselves."
5. So rapid has been
the rise in obesity that there is a danger it will overtake the
population to the extent that what used to be considered 'overweight'
starts to become 'normal'. Moreover, as Professor Peto pointed
out, "the NHS cannot provide detailed clinical services or
intensive clinical services" for the 20% of the population
who are obese, and amongst whom two-thirds of the excessive mortality
6. Society is rapidly changing to absorb the trend
in weight. One American airline has started charging obese passengers
for two seats. A woman
was recently awarded £13,000 compensation from Virgin Atlantic,
after developing a large bruise, and muscle and nerve damage which
made her bedridden for a month, caused by being wedged next to
an obese female passenger for an 11 hour flight.
A recent study in Leeds suggested that schoolchildren now require
trousers two sizes larger than did their counterparts only 20
years ago. Another report
has concluded that 23.6% of British children under four are overweight,
compared with 14.7% ten years earlier. A major re-insurance firm
has just completed a study concluding that the obese will soon
have to pay larger premiums.
In America, super-size coffins are now available, and burial plot
sizes are increasing.
7. It is often said that Britain lags behind America
by a few years in cultural patterns. Trends in obesity in Britain
do indeed follow, albeit with a delay of a few years, those in
America. And such are the trends in obesity in that country that
it is now predicted that one in three American children will eventually
become diabetic, which in itself will pose an almost unimaginable
disease and cost burden on that country.
8. The Chief Medical Officer has referred to obesity
as "a health time bomb" that needs defusing.
He noted the World Health Organization (WHO) prediction that the
world 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."
9. The WHO itself describes an escalating global
epidemic of overweight and obesity"globesity"that
is taking over many parts of the world. In their view, "If
immediate action is not taken, millions will suffer from an array
of serious health disorders."
10. Should the gloomier scenarios relating to obesity
turn out to be true, the sight of amputees will become much more
familiar in the streets of Britain. There will be many more blind
people. There will be huge demand for kidney dialysis. The positive
trends of recent decades in combating heart disease, partly the
consequence of the decline in smoking, will be reversed. Indeed,
"this will be the first generation where children die before
their parents as a consequence of childhood obesity."
Scope and nature of our inquiry
11. We announced our intention of holding an inquiry
into obesity on 28 March 2003 with the following terms of reference:
The inquiry will cover:
The health implications of obesity
What are the health outcomes of obesity
in society? What are the economic and social costs? What efforts
is the Government making to evaluate these?
Trends in obesity
What are the trends in obesity (including
trends among particular groups, by social class, age, gender,
ethnicity and lifestyle)? What is the relationship between obesity
and other health inequalities? What are the international comparisons
(EU, OECD, USA)?
What are the causes of the rise in obesity
in recent decades?
What has been the role of changes in diet? To what extent have
changes in lifestyle, particularly moves to a more sedentary lifestyle,
been influential? How much is lack of physical activity contributing
to the problem?
What can be done about it?
What is the range of 'levers' and drivers
(food industry, marketing, education, family life, genetics, drugs,
surgery)? Within that range, what role can the food industry,
marketing and advertising, transport and schooling play? What
are the responsibilities of the food industry in respect of marketing?
How influential is the media? How can the amount of physical activity
being undertaken be increased? To what extent can and should Government,
at central and local level, influence lifestyle choices? How coherent
is national and local strategy? What is international best practice?
Are the institutional structures in place to
deliver an improvement?
What is the role of the Department of Health (DoH) and of the
NHS, including that of primary care, hospitals and specialist
clinics? How effective are the structures for health promotion?
Can health promotion compete with huge food sector advertising
budgets? To what extent can the food industry be part of a solution?
To what extent is the Food Standards Agency influential? How well
is the DoH liaising with, and what is the role of, other central
and local government departments and bodies? What is the role
of schools, including sport in schools? Who should 'own' and drive
delivery? Have we the appropriate institutional structures, budgets
Recommendations for national and local strategy
How can the Government's strategy be improved?
What are the policy options? Can they be better integrated? What
are the priorities for action?
12. Since 12 June 2003 we have taken oral evidence
on no fewer than 14 occasions making this the most comprehensive
inquiry the Health Committee has ever undertaken. We have heard
from: Ministers and officials in the Departments of Health (hereafter
'the Department'), Culture, Media and Sport (DCMS), and Education
and Skills (DfES); officials from the Food Standards Agency (FSA),
the Office of the Deputy Prime Minister (ODPM), the Department
for Environment, Food and Rural Affairs (DEFRA) and the Department
for Transport; representatives of fast food, carbonated drinks,
breakfast cereals and confectionery companies and the advertising
agencies representing them; major supermarkets; epidemiologists;
experts on obesity, the food industry and physical activity; health
professionals; Mr Barry Gardiner MP (who has pioneered a scheme
extending the school day to incorporate greater physical activity);
and Professor Marion Nestle, Chair of the Department of Nutrition,
Food Studies and Public Health, New York University.
13. We received around 150 memoranda from health
professionals, representatives of the food industry, academics,
advertisers, commercial slimming organizations, those working
in sport, recreation and physical activity, and members of the
14. We are extremely grateful to all those who submitted
written and oral evidence to our inquiry. We are also very grateful
to our five specialist advisers: Dr Laurel Edmunds, Senior Researcher
for the Avon Longitudinal Study of Parents and Children, University
of Bristol; Professor Ken Fox, Department of Exercise and Health
Sciences, University of Bristol; Professor Gerard Hastings, Director,
Centre for Social Marketing and Centre for Tobacco Control Research,
University of Strathclyde; Professor Phil James, Director of the
Rowett Research Institute, Aberdeen and Chair of the International
Obesity Taskforce; and Tim Lang, Professor of Food Policy, City
University. This has been a contentious inquiry, with powerful
interest groups carefully watching our work. We are grateful for
the objective and expert support we have received from our advisers.
We are also very grateful to the Clerk's Department Scrutiny Unit,
who provided us with an extremely helpful analysis of the economic
costs of obesity, which is annexed to this report. We should also
like to thank Liz Powell-Bullock and Adriana Rodriguez for supplementary
research for this report.
15. The USA is experiencing particularly disastrous
trends in obesity and we wanted to see at first hand what the
scale of the problem was and what measures were being taken to
address it. Accordingly, in October 2003 we visited the USA. In
New York, we met Dr Xavier Pi-Sunyer, a world expert in diabetes
at the Obesity Research Center; we visited the Strang Cancer Prevention
Center; we met doctors at the New York Presbyterian Hospital,
including a representative from the Comprehensive Weight Control
Center; we received a presentation from Dr Christine Ren and Dr
George Fielding, bariatric surgeons;
we met representatives of the New York City Parks Department;
finally, we held discussions with Fleishman-Hillard Marketing
and Professor Marion Nestle.
16. In Atlanta, Georgia we held discussions with
a range of experts from the Centers for Disease Control; we met
senior representatives of Coca-Cola; and then met Dr David Satcher,
the former Surgeon General of the United States and Director of
the Morehouse School of Medicine.
17. Finally we visited Denver, Colorado which leads
the national strategy to counter obesity through physical activity,
and is the leanest state in America. Here we met representatives
of the Colorado Physical Activity and Nutrition Program, the Department
of Education, the Healthy Foods/Five-a-day project and the Department
of Transportation. We also met Dr James Hill, Director of the
America on the Move project, and representatives of Colorado on
18. Since the EU has a locus in public health in
member nations we visited Brussels in December 2003. Here we met
David Byrne, EU Commissioner for Health and Consumer Protection,
and officials, Mr Andrew Hayes from the International Union against
Cancer and the Association of European Cancer Leagues, representatives
of the Confederation of the Food and Drink Industries of the EU,
and representatives of the European Heart Network.
19. We also visited Finland and Denmark in connection
with this and other inquiries. Although Finland experienced substantial
growth in obesity in the 1980s and 1990s it has been successful
in greatly reducing death through coronary heart disease and has,
as a nation, altered its diet and boosted its exercise levels.
Although Finland has not managed to reverse the overall growth
of obesity, it has managed to reduce the steepness of the curve
in trends in obesity in men, and flatten it entirely in women.
Finland now has obesity rates lower than England for both males
and females. We wanted to see at first hand how it had succeeded
in doing that. Denmark has recently agreed a national obesity
strategy which could offer many parallels to England.
20. In Finland, we met the Minister for Public Health
and officials in the Ministry of Social Affairs and Health, staff
and pupils in Pikku Huopalathi school, the National Public Health
Institute, Professor Aila Risannen and staff at Helsinki University
Central Hospital, and members of the Parliamentary Social Affairs
and Health Committee.
21. In Denmark we met officials from the Ministry
for the National Board of Health, including the Chief Medical
Officer; we also visited the town of Odense which has a particularly
advanced transport system, integrating cycle and pedestrian travel.
22. Within England, we undertook a visit to Leeds
to witness a specialist obesity clinic, and went to a range of
primary and secondary schools to look at physical activity and
sport in schools and school meals. We also held informal discussions
there with a wide range of health and education professionals.
We also visited Bradford Bulls Rugby League Football Club, which
has an excellent community outreach scheme, involving children
in health education and physical activity.
23. We are extremely grateful to all those, including
the Foreign and Commonwealth Office staff, who facilitated these
visits which offered crucial evidence to our inquiry, on which
we have drawn considerably in formulating this report.
24. According to the Faculty of Public Health, obesity
is "an excess of body fat frequently resulting in a significant
impairment of health and longevity."
Body fatness is most commonly assessed by body mass index (BMI)
which is calculated by dividing an individual's weight measured
in kilogrammes by their height in metres squared. We annex, at
Annex 2, a chart which will allow readers of this report to calculate
their own BMI. Overweight is generally defined as a BMI greater
than 25; individuals with a BMI greater than 30 are classified
1: Classification of Body Mass Index and Risk of Co-morbidities
||BMI (kg/m2 )
||Risk of co-morbidities
||<18.5||Low (but risk of other clinical problems increased)
|Class III severe (or 'morbid obesity' or 'super obesity')
Source: International Obesity Task Force
25. It is important to recognise that obesity is
both a medical condition and a lifestyle disorder and both factors
have to be seen within a context of individual, family and societal
26. There is no generally agreed definition of childhood
obesity but two widely favoured indicators are based respectively
on percentiles of UK reference curves (85th centile for overweight,
95th centile for obesity) and on reference points derived from
an international (six country) survey.
27. The correlations between BMI and the risk of
co-morbidities in the table above offer a good summary of the
situation but also oversimplify it. For example, individuals of
South Asian descent have an increased risk of obesity-related
disorders, triggered at lower BMI ratios than those above, but
this is not taken into account in the current guidelines for obesity
management. A BMI of 27.5 or more in an Asian person has been
estimated to be associated with comparable morbidities to those
in a Caucasian person with a BMI of 30.
28. Central obesity, that is to say a high waist:hip
ratio, is another measurement used to define obesity. Central
obesity is sometimes defined as a waist:hip ratio greater than
0.95 in men and 0.85 in women. A simpler indicator used in a WHO
report is that increased risk is present when the waist circumference
exceeds 37 inches for men or 32 inches for women.
How prevalent is obesity?
29. Professor Terence Wilkin, of Peninsula University
Plymouth, pointed out that over the past 30 years the median body
mass of the population has risen as fast as the mean, "suggesting
that society is getting fatter, not just those who are already
30. The Health of the Nation targets in 1992 were
for fewer than 6% of men and 8% of women to be obese by 2005.
The latest figures make disturbing reading, and the trend data
show how obesity has more than trebled in the last two decades.
These figures are from the Department's own memorandum, updated
to take account of data taken from the Health Survey for 2002:Table
2: Prevalence of obesity in England 1980-2002
|Body Mass Index
|| 2000|| 2002
|Healthy weight: 20-25
|Obese: Over 30||6
|Morbidly obese: Over 40
|Body Mass Index
|| 2000|| 2002
|Healthy weight: 20-25
|Obese: Over 30||8
|Morbidly obese: Over 40
Source: Department of Health (Ev 3) and Health
Survey for England 2002
31. Amongst children, one study found that obesity
and overweight showed little change between 1974 and 1984, but
between 1984 and 1994 overweight increased from 5.4% to 9% in
English boys and from 9.3% to 13.5% in girls; the prevalence of
obesity reached 1.7% in boys and 2.6% in girls.
The 2002 Health Survey for England noted a substantial deterioration
in the decade subsequent to this study:
About one in 20 boys (5.5%) and about one in 15 girls
(7.2%) aged 2-15 were obese in 2002, according to the International
classification. Overall, over one in five boys (21.8%) and over
one in four girls (27.5%) were either overweight or obese. In
comparison with the International classification, obesity estimates
derived by the National BMI percentiles classification were much
higher (16.0% for boys and 15.9% for girls). The difference between
the two estimates is small for girls when the combined overweight
including obesity category is considered (30.7% vs 27.5%), but
remains more marked for boys (30.3% vs 21.8%). About one in ten
young men (9.2%) and women (11.5%) were obese, while about one
in three young men (32.2%) and young women (32.8%) were overweight
32. Projecting these figures forwards by 15 years
simply by assuming a steady growth suggests that around one-third
of adults will be obese by 2020. However, "if the rapid acceleration
in childhood obesity in the last decade is taken into account,
the predicted prevalence in children for 2020 will be in excess
33. The following table lists the prevalence of obesity
(defined as BMI above 30) in various European countries:
34. Not only does England have some of the worst
figures in Europe but it also demonstrates some of the worst trends
in the acceleration of obesity: in the majority of European countries
the prevalence of obesity has increased between 10-40% in the
last ten years, but in England it has more than doubled.
35. In 1995, according to the WHO, there were an
estimated 200 million obese adults worldwide and another 18 million
children aged under five classified as overweight.
However, by 2000, the number of obese adults had increased to
over 300 million.
36. Contrary to conventional wisdom, the obesity
epidemic is not restricted to industrialised societies. Some 115
million people suffer from obesity-related problems in the non-industrialised
world. For example:
- Over three-quarters of men
living in cities in Samoa are obese;
- There are as many overweight as underweight adults
- 44% of women in the Cape Peninsula of South Africa
37. There is enormous variation in obesity rates
even within countries with the highest GDPs. The USA is near the
top of any table of obesity rates but Japan is nearer the bottom.
Despite the entry of US-style eating chains in Japan, its food
culture has proved sufficiently robust so far to resist some of
the global trends in obesity. This cultural dimension is important:
obesity should not be seen as an inevitable result of economic
advance. However, it is true to say that, as countries develop,
there is a marked shift in the proportion of the population who
are overweight as opposed to underweight. Ironically, in many
countries the problem of malnutrition is being superseded or complemented
by the problem of obesity.
Obesity and health inequalities
38. In common with most public health problems the
impact of obesity mirrors many other health inequalities. Men
and women working in unskilled manual occupations are over four
times as likely as those in professional employment to be classified
as morbidly obese.
The Health Survey for England has shown that in 2001 amongst professional
groups 14% of men and women were obese, compared to 28% of women
and 19% of men in unskilled manual occupations.
Children who are Asian are four times more likely to be obese
than those who are white.
Pakistani, Indian and Bangladeshi men have relatively low levels
of obesity measured by BMI, but 41% of Indian men are classed
as centrally obese compared to 28% of men in the general population.
39. 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.
What are the potential health
risks of obesity and what are the costs of these?
40. There is a nine-year reduction in life expectancy
amongst obese patients, the risk being markedly amplified if they
also smoke. Generalised obesity (fat distributed around the whole
body) results in alterations in the blood circulation and heart
function, while central/abdominal obesity (fatness mainly around
the chest and abdomen) further restricts chest movements and alters
breathing function. Fat around the abdomen is also a major contributor
to the development of diabetes, hypertension, and alterations
in blood lipid (fat and cholesterol) concentrations.
41. Overweight and obesity are associated with a
wide range of conditions as the table below shows:Table
3: Relative risks of health problems associated with obesity
|Greatly increased (relative risk much greater than 3)
||Moderately increased (relative risk 2-3)
||Slightly increased (relative risk 1-2)
|Type 2 diabetes||Coronary Heart Disease
||Cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer)
||Hypertension||Reproductive hormone abnormalities
||Polycystic ovary syndrome
||Hyperuricaemia and gout
||Low back pain|
|Fetal defects associated with maternal obesity
Source: WHO (1998)
42. According to the 2002 WHO World Health Report:
"Overweight and obesity lead to adverse metabolic effects
on blood pressure, cholesterol, triglycerides
and insulin resistance. Risks of coronary heart disease, ischaemic
stroke and type 2 diabetes mellitus increase steadily with increasing
BMI." Raised BMI also "increases the risk of cancer
of the breast, colon, prostate, endometrium, kidney and gallbladder."
43. In non-smokers, the relative risk of death has
been estimated to rise in relation to increased body weight by
the following factors:Table
4: Classification of Body Mass Index and Relative Risk of Death
|BMI||Relative risk of death
Source: RCGP (Appendix 18)
44. Overweight and obesity are regarded as amongst
the main modifiable risks associated with coronary heart disease
(CHD) and cardio-vascular disease generally. The British Heart
Foundation estimates that around 5% of CHD deaths in men and 6%
in women are due to obesity as such
and a higher proportion if the large number of overweight adults
is also considered.
45. Perhaps the most dramatic impact has come in
the area of diabetes. Already there are over two million
diabetics living in the UK (only around half of whom will have
had the disease diagnosed); that figure is projected to rise to
three million by 2010.
Worldwide, the number of diabetics is projected to rise from 200
to 300 million over the period 2000 to 2020.
The prevalence of diabetes has increased by 65% in men and 25%
in women since 1991.
It represents a massive and growing threat to public health, given
that typically the gap between onset and diagnosis of the disease
is 9-12 years. Already, some 20% of the South Asian population
is diabetic and 25% are glucose-intolerant, a precursor condition
for diabetes. On some projections, by 2025 diabetes could account
for a quarter of the health budget.
46. Obesity triggers a state of insulin resistance.
Professor Terence Wilkin, from Peninsula University, Plymouth,
and Director of the Early Bird Study which seeks to establish
the factors in childhood that lead to insulin resistance and diabetes,
suggested that hyperinsulinaemia drives a host of metabolic disturbances
[these are known as:] the metabolic syndrome, and
include hypertension, hypercholesterolaemia, hypertriglyceridaemia,
hypercoagulation, hyperviscosity and hyperuricaemia. Each in itself
is a risk factor for coronary artery disease, but together they
are catastrophicthe so-called syndrome X [or metabolic
47. Professor Wilkin concluded that, rather than
being a "complication" of diabetes, premature cardiovascular
disease is an "inevitable association" of the condition.
48. Whereas type 2 diabetes was hitherto normally
associated with diabetes developing in adults over the age of
35it was often termed "late onset" or "adult
onset" diabetesit is increasingly being diagnosed
in children. One
estimate suggests that up to 45% of cases of diabetes diagnosed
in children in the USA are now type 2.
As Professor A H Barnett, Clinical Director for Diabetes and Endocrine
Services at the University of Birmingham, noted: "figures
from the USA
indicate a very serious long-term outlook
for these children, with significant numbers dying from heart
attack or being on kidney dialysis and/or blind before the age
of 40 years."
Dr Tim Barrett, a paediatrician at Birmingham Children's Hospital,
told us that it was only since about the year 2000 that the medical
profession had started seeing children with type 2 diabetes in
England, but that this disease now accounted for about 6% of the
children attending his clinic with diabetes. The youngest patient
he had seen, who had developed some symptoms, was a super-obese
eight year old girl.
49. The progress of diabetes is so closely entwined
with that of obesity that in America it has produced the coinage
Diabetes leads to cardio-vascular problems, and can also entail
blindness following damage to the small blood vessels of the eye,
kidney failure, stroke, osteoarthritis, and damage to the nervous
system which can lead to leg ulcers and limb amputation. A long-term
study of 51 Canadian patients aged 18-33 years diagnosed with
type 2 diabetes before the age of 17 years found that:
Seven had died; three others were on dialysis; one
became blind at the age of 26; and one had had a toe amputation.
Of 56 pregnancies in this cohort, only 35 had resulted in live
50. Children contracting type 2 diabetes will also
have a life-time to develop the severe sequelae of the disease
and their diabetes is much more difficult to control than those
children developing the classic form of type 1 diabetes with insulin
51. It is crucial to realise that for diabetesand
indeed many of the conditions listed hereit is not necessary
to be obese to increase the risk of morbidity. Risks rapidly
accelerate as people become overweight. As Professor Andrew
Prentice, Head of the Medical Research Council's International
Nutrition Group at the London School of Hygiene and Tropical Medicine,
noted, "If you look at the risks for diabetes
people with a BMI that does not classify them as clinically obese
(a BMI of around 28 in women) the increased risk of diabetes is
risks continue to accelerate as BMI grows. According to Professor
Sir George Alberti, President of the International Diabetes Federation,
a study of nurses in the USA has revealed that those with a BMI
of 35 had "a 92-fold increase in risk of diabetes" compared
with those with a BMI of 22.
52. Diabetes is also associated with health inequalities:
diabetes is three to five times more common in people of African
and Caribbean origin living in the UK.
53. Professor A H Barnett estimated that diabetes
"now costs the Exchequer around 9% of the total healthcare
budget of the UK, with projections that by 2025 that this could
reach 25% of the total healthcare budget."
54. End-stage renal failure is a complication
of diabetes. According to the National Kidney Federation, renal
failure is set to increase massively: yet already services in
the UK are "overwhelmed" in terms of capacity and financial
55. Around 14% of cancer deaths in men and
20% in women are attributed to obesity.
Obesity is associated with breast, endometrial, oesophageal
and colonic cancers.
According to Professor Julian Peto, for the Institute of
Cancer Research, obesity is "far and away the most important
avoidable cause" of cancer in non-smokers.
Cancer Research UK suggested that 1 in 7 cancer deaths in men
and 1 in 5 in women in the USA, are attributable to overweight
and obesity. This implies that 1 in 8 UK cancer deaths are thus
caused. The clear association between obesity and cancer, in the
view of the charity, is "poorly acknowledged outside the
A recent survey showed that only 3% of the population was
aware of the link between overweight and cancer even though this
factor is the main preventable risk factor after tobacco use,
and will eventually become the main risk factor.
Professor Peto cited a Framingham study which suggested that in
female non-smokers who are obese life expectancy is seven years
56. The National Obesity Forum presented evidence
to suggest that around 20 different cancers have been linked to
obesity. They also noted that in the morbidly obese, death rates
from cancer were 52% higher for men and 60% higher for women.
57. Osteoarthritis, a joint disorder which
typically affects the joints in knees, hips, and lower back, is
exacerbated by overweight. Weight gain appears to increase the
risk of osteoarthritis by placing extra pressure on these joints
and wearing away the protective cartilage. Back pain, one
of the commonest health problems caused or exacerbated by overweight
and obesity, leads to more than 11 million lost working days each
year in Britain.
58. Psychological damage caused by overweight
and obesity is a huge health burden. In childhood, the first problems
caused are likely to be emotional and psychological.
Moreover, the psychological consequences of obesity can
range from lowered self-esteem to clinical depression. Rates of
anxiety and depression are three to four times higher among obese
women are around 37% more likely to commit suicide than women
of normal weight.
59. The seminal 2001 National Audit Office (NAO)
Report, Tackling Obesity in England, noted:
are more likely to suffer from
a number of psychological problems, including binge-eating, low
self-image and confidence, and a sense of isolation and humiliation
arising from practical problems.
60. Professor Hubert Lacey, for the Royal College
of Psychiatrists, told us that depression tended to be caused
by obesity, rather than obesity by depression:
There is not a clear link between massive obesity
and a pre-existing psychological problem; rather there is evidence
of psychological sequelae from the massive obesity itself.
This professional analysis is the opposite of that
held by the public and indeed by many doctors.
61. Excess weight
is also likely to lead to prejudice in the workplace, lower self-esteem
and reduced job opportunities. According to Professor Jane Wardle,
of the Health Behaviour Unit at University College London, a recent
study has demonstrated that teachers underestimate the IQ of overweight
62. One recent study has concluded that "Mortality
attributable to excess weight is a major public health problem
in the EU. At least one in 13 annual deaths in the EU are likely
to be related to excess weight." However, in that figure
the UK has the highest individual percentage of all, with 8.7%
of deaths being attributable to excess weight.
What are the economic costs?
63. The NAO estimated that the direct cost of treating
obesity and its consequences in 1998 was £480 million (1.5%
of NHS expenditure) and that indirect costs (loss of earnings
due to sickness and premature mortality) amounted to £2.1
billion, giving an overall total of £2.58 billion. A total
projected figure of £3.6 billion was given for 2010. Although
these figures have been widely quoted in much subsequent work
on obesity, the authors consistently acknowledge the conservative
nature of their estimates.
64. We asked the House of Commons Clerk's Department
Scrutiny Unit to revisit the NAO calculations and analyse them
so as to produce a more up-to-date and comprehensive analysis
of the costs of obesity. Their work is annexed to this report
at Annex 1.
65. However, in summary the findings of the Scrutiny
Unit were as follows:
- The calculations of the cost
of obesity made in the NAO report Tackling Obesity in England
are said to be conservative and underestimates by its authors.
- Estimates of the cost of obesity from other
countries are nearly all well above those for England, as a proportion
of healthcare spending, even though obesity levels were generally
- The direct cost of treating obesity in England
in 2002 is estimated at £46-49 million.
- The costs of treating the consequences of obesity
are an estimated £945-1,075 million.
- The indirect costs of obesity in 2002 are estimated
at £1-1.1 billion for premature mortality and £1.3-1.45 billion
for sickness absence.
66. The Clerk's Department Scrutiny Unit has recalculated
the total estimated cost of obesity is therefore £3.3-3.7 billion.
This is £0.7-1.1 billion (27-42%) more than the NAO
estimate for 1998. The difference between the two figures occurs
for a number of reasons including higher NHS and drug costs, more
accurate data that have been produced recently, the inclusion
of more co-morbidities and the increased prevalence of obesity.
This figure should still be regarded as an under-estimate. We
note that these analyses are for the 20% of the adult population
who are already obese. If in crude terms the costs of being overweight
are on average only half of those of being obese then, with more
than twice as many overweight as obese men and women, these costs
would double. This would yield an overall cost estimate for overweight
and obesity of £6.6-7.4 billion per year.
1 Appendix 33 Back
Q172, 185 Back
The Times, 24 Feb 2004 Back
Sunday Times, 20 October 2002 Back
M.C.J. Rudolf et al, "Rising obesity and expanding waistlines
in schoolchildren: a cohort study", Archives of Disease
in Childhood, 89 (2004), pp 235-37 Back
The Guardian, 7 April 2004 Back
Scotland on Sunday, 5 October 2003 Back
Centers for Disease Control Report presented to 63rd
Annual Society, American Diabetes Association Back
Annual Report of the Chief Medical Officer 2002 Back
See www.who.int/nut/obs.htm. Back
Appendix 4 (Dr Mary Rudolf); this point was recently echoed by
the Chair of the Food Standards Agency. See The Observer,
9 November 2003. Back
Bariatric surgery is surgery on the stomach and/or intestines
to help patients with extreme obesity lose weight. Back
Ev 46 Back
In 1990 a nationally representative sample of children had their
heights and weights measured. The resulting BMIs were used
to generate the UK standard reference charts. The range of BMIs
for each sex and age was divided into 100 parts or centiles. For
example the 50th centile represents the average BMI, the 3rd centile
provides the level at which the thinnest 3% of the population
would be identified and similarly, the 97th centile identified
the most overweight 3% of the population. Therefore the 85th centile
identified the top 15% overweight in the population and 95th the
top 5% as obese. Back
World Health Organization expert consultation cited in Royal College
of Physicians, Storing up problems: the medical cure
for a slimmer nation (2004), p3. Back
Cited in National Audit Office (NAO), Tackling Obesity in England
(2001), p11. Back
Appendix 37 Back
Cited in Appendix 18 (Royal College of General Practitioners). Back
Susan Chinn and Roberto Rona, "Prevalence and trends in overweight
and obesity in three cross sectional studies of British children,"
1974-94, British Medical Journal 322 (2001), pp 24-26 Back
Department of Health, Health Survey for England 2002 Back
RCP, Storing up problems, p4 Back
International Obesity Taskforce-see www.iotf.org . Back
Appendix 5 (British Medical Foundation) Back
Chief Medical Officer's Report, 2002 Back
Appendix 29 (Medical Research Council) Back
Ev 115 Back
Storing up problems, p 7 Back
All relative risk estimates are approximate. The relative risk
indicates the risk measured against that of a non-obese person.
For example, an obese person is two to three times more likely
to suffer from hypertension than is a non-obese person. Back
Triglycerides are blood fats. Back
WHO, World Health Report 2002, p 60 Back
Appendix 5 Back
Appendix 23 (Diabetes UK) Back
Appendix 3; Q216 (Professor Alberti) Back
Ev 115 (National Heart Forum) Back
Appendix 3 (Professor A Barnett) Back
Appendix 37 Back
Type 1 diabetes used to be known as "juvenile diabetes".
It is an auto-immune disease, now representing less than 10% of
diabetes world-wide. Back
A Pagota Campagna, "Emergence of type 2 diabetes mellitus
in children: epidemiological evidence", Journal Paediatric
Endocrinology and Metabolism 13 (2000), supplement 6, pp 1395-1402 Back
Appendix 3 Back
The Guardian, 10 May 2003, "Food: The way we eat now",
H Dean and B Flett, "Natural History of type 2 diabetes diagnosed
in childhood: long term follow-up in young adult years",
Diabetes 2002:51 (suppl 2) A24-25, cited in RCP, Storing
up problems: the medical case for a slimmer nation, 2004,
p 8; Q195 (Dr Barrett) Back
Appendix 23 (Diabetes UK) Back
Appendix 3; see further C J Currie et al, "NHS acute sector
expenditure for diabetes: the present, future and excess in-patient
cost of care,"Diabetic Medicine, 14 (1997), pp 686-92 Back
Appendix 1 Back
Appendix 11 (UK Association for the Study of Obesity) Back
Q174; Q178 Back
Ev 57 Back
NOP poll for Cancer Research UK. See BBC News UK, 5 April
Ev 318 Back
BBC health website at www.bbc.co.uk Back
Appendix 20 (Royal College of Paediatrics and Child Health) Back
IOTF website at www.iotf.org Back
Appendix 6 (Roche) Back
Tackling Obesity in England, p 56 Back
See J R Banegas et al, "A simple estimate of mortality attributable
to excess weight in the European Union", European Journal
of Clinical Nutrition, 57 (2003), pp 201-8. Back
Tackling Obesity in England, para 2.27; see also appendix
6 paras 17-18, 22, 25, 28 and 33-34. Back