Select Committee on Health Third Report

1 Introduction

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 unsustainable.

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."[1]

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.[2] 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."[3] 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.[4] 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]

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 occurs.[6]

6. Society is rapidly changing to absorb the trend in weight. One American airline has started charging obese passengers for two seats.[7] 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.[8] A recent study in Leeds suggested that schoolchildren now require trousers two sizes larger than did their counterparts only 20 years ago.[9] 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.[10] In America, super-size coffins are now available, and burial plot sizes are increasing.[11]

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.[12]

8. The Chief Medical Officer has referred to obesity as "a health time bomb" that needs defusing.[13] 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."[14]

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."[15]

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 and priorities?

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 public.

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;[16] 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 the Move.

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.

Defining obesity

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."[17] 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 as obese:Table 1: Classification of Body Mass Index and Risk of Co-morbidities
Classification BMI (kg/m2 ) Risk of co-morbidities
Underweight <18.5Low (but risk of other clinical problems increased)
Normal range 18.5-24.9Average
Overweight 25.0-29.9Mildly increased
Obese >30.0 
Class I 30.0-34.9Moderate
Class II 35.0-39.9Severe
Class III severe (or 'morbid obesity' or 'super obesity') >40.0Very severe

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 functioning.

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.[18]

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.[19]

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.[20]

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 fat."[21]

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.[22] 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 1980 1993 2000 2002
% %% %
Healthy weight: 20-25 37.8 29.929.6
Overweight: 25-30 44.444.5 43.4
Obese: Over 306 13.221.0 22.1
Morbidly obese: Over 40 0.2 0.60.8

Body Mass Index 1980 1993 2000 2002
% %% %
Healthy weight: 20-25 44.3 39.037.4
Overweight: 25-30 32.233.8 33.7
Obese: Over 308 16.421.4 22.8
Morbidly obese: Over 40 1.4 2.32.6

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.[23] 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 or obese.[24]

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 of 50%."[25]

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.[26] 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 in Ghana;
  • 44% of women in the Cape Peninsula of South Africa are obese.[27]

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.[28] 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.[29] Children who are Asian are four times more likely to be obese than those who are white.[30] 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.[31]

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.[32]

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[33]
Greatly increased (relative risk much greater than 3) Moderately increased (relative risk 2-3) Slightly increased (relative risk 1-2)
Type 2 diabetesCoronary Heart Disease Cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer)
Gallbladder disease HypertensionReproductive hormone abnormalities
DyslipidaemiaOsteoarthritis (Knees) Polycystic ovary syndrome
Insulin resistance Hyperuricaemia and gout Impaired fertility
Breathlessness Low back pain
Sleep apnoea Anaesthetic risk
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[34] 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."[35]

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
BMIRelative 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[36] 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.[37] Worldwide, the number of diabetics is projected to rise from 200 to 300 million over the period 2000 to 2020.[38] The prevalence of diabetes has increased by 65% in men and 25% in women since 1991.[39] 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.[40]

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 besides diabetes:

[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 catastrophic—the so-called syndrome X [or metabolic syndrome].[41]

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 35—it was often termed "late onset" or "adult onset" diabetes—it is increasingly being diagnosed in children.[42] One estimate suggests that up to 45% of cases of diabetes diagnosed in children in the USA are now type 2.[43] 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."[44] 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.[45]

49. The progress of diabetes is so closely entwined with that of obesity that in America it has produced the coinage "diabesity".[46] 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 births (62.5%).[47]

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 deficiency.

51. It is crucial to realise that for diabetes—and indeed many of the conditions listed here—it 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 … [in] 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 18-fold."[48] But 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.[49]

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.[50]

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."[51]

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 resources.[52]

55. Around 14% of cancer deaths in men and 20% in women are attributed to obesity.[53] Obesity is associated with breast, endometrial, oesophageal and colonic cancers.[54] 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.[55] 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 scientific community".[56] 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.[57] Professor Peto cited a Framingham study which suggested that in female non-smokers who are obese life expectancy is seven years shorter.[58]

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.[59]

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.[60]

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.[61] 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 individuals.[62] Obese women are around 37% more likely to commit suicide than women of normal weight.[63]

59. The seminal 2001 National Audit Office (NAO) Report, Tackling Obesity in England, noted:

Obese people … 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.[64]

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.[65]

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 children.[66]

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.[67]

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.[68]

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 lower.
  • 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

2   Q170 Back

3   Q172 Back

4   Q172 Back

5   Q172, 185 Back

6   Q195 Back

7   The Times, 24 Feb 2004 Back

8   Sunday Times, 20 October 2002 Back

9   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

10   The Guardian, 7 April 2004 Back

11   Scotland on Sunday, 5 October 2003 Back

12   Centers for Disease Control Report presented to 63rd Annual Society, American Diabetes Association Back

13   Annual Report of the Chief Medical Officer 2002 Back

14   See Back

15   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

16   Bariatric surgery is surgery on the stomach and/or intestines to help patients with extreme obesity lose weight. Back

17   Ev 46 Back

18   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

19   World Health Organization expert consultation cited in Royal College of Physicians, Storing up problems: the medical cure for a slimmer nation (2004), p3. Back

20   Cited in National Audit Office (NAO), Tackling Obesity in England (2001), p11. Back

21   Appendix 37 Back

22   Cited in Appendix 18 (Royal College of General Practitioners). Back

23   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

24   Department of Health, Health Survey for England 2002 Back

25   RCP, Storing up problems, p4 Back

26   www.who/int/nut Back

27   International Obesity Taskforce-see . Back

28   Appendix 5 (British Medical Foundation) Back

29   Chief Medical Officer's Report, 2002 Back

30   Appendix 29 (Medical Research Council) Back

31   Ev 115 Back

32   Storing up problems, p 7 Back

33   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

34   Triglycerides are blood fats. Back

35   WHO, World Health Report 2002, p 60 Back

36   Appendix 5 Back

37   Appendix 23 (Diabetes UK) Back

38   Appendix 3; Q216 (Professor Alberti) Back

39   Ev 115 (National Heart Forum) Back

40   Appendix 3 (Professor A Barnett) Back

41   Appendix 37 Back

42   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

43   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

44   Appendix 3 Back

45   Q195 Back

46   The Guardian, 10 May 2003, "Food: The way we eat now", p17 Back

47   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

48   Q362 Back

49   Q174 Back

50   Appendix 23 (Diabetes UK) Back

51   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

52   Appendix 1 Back

53   Appendix 11 (UK Association for the Study of Obesity) Back

54   Q174; Q178 Back

55   Q210 Back

56   Ev 57 Back

57   NOP poll for Cancer Research UK. See BBC News UK, 5 April 2004. Back

58   Q212 Back

59   Ev 318 Back

60   BBC health website at Back

61   Appendix 20 (Royal College of Paediatrics and Child Health) Back

62   IOTF website at Back

63   Appendix 6 (Roche) Back

64   Tackling Obesity in England, p 56 Back

65   Q182 Back

66   Q189 Back

67   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

68   Tackling Obesity in England, para 2.27; see also appendix 6 paras 17-18, 22, 25, 28 and 33-34. Back

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