Obesity is one of the most visible, but most neglected, public health problems facing the UK today. A quarter of the UK’s adult population are now obese and nearly 2% are morbidly obese.
The comorbidities associated with obesity include type 2 diabetes, sleep apnoea, cancer, depression and arthritis. The impairment to quality of life and the disability caused by these conditions carries an enormous human, social and financial cost. In 2007, such costs to the wider health economy were estimated to be in the region of £3.2 billion, predicted to rise to £6.3 billion by 2015.
Obese patients are proven to have a higher prevalence of limiting, long-standing illnesses, and obesity is also known to decrease life expectancy by seven years in a 40 year old, increasing incrementally up to the age of 75 years. There is also a bidirectional relationship between obesity and disability among adults. Evidence of the higher economic and social burden of obesity in primary care is additionally reflected in the higher prescribing costs across a wide range of drugs.
Genetic predisposition
The 2007 Foresight report ‘Tackling Obesities: Future Choices’ demonstrated numerous causes of obesity. Certainly, modern theories suggest that contemporary lifestyles and environmental factors, coupled with the easy availability of palatable and cheap food that is not nutritionally beneficial, all contribute to expanding waistlines.
Genetic predisposition and epigenetic factors are being increasingly studied. Gut microbes are implicated due to their influence on bile and cholesterol metabolism, which affects gut transit time and food choices, thereby predisposing some to obesity. Pancreatic peptides, including amylin and glucagon-like peptide (GLP-1), also modulate eating. Since nutrients stimulate efferent signals to reduce food intake, a dip in circulating glucose levels followed by a rise in insulin precedes the onset of eating. Rising insulin resistance and predisposition to metabolic syndrome are further contributing to the global rise in obesity across every section of society.
More recently, it has been suggested that humans were designed to exist in a state of ‘high energy flux’ with a high intake of calories and, in turn, a large number of calories expended; sedentary lifestyles and the lack of physical activity so typical of more urban lifestyles are therefore contributing to modern-day weight gain.
The roots of the current crisis lie in the contemporary obesogenic environment. The numbers of those with obesity may be rising, but the condition is not new. About 30,000 years ago, those with the ‘thrifty genotype’ were more likely to survive the feast-or-famine existence of hunter-gatherers, whereas their slimmer counterparts were more likely to die more quickly, succumbing to the ravages of the hostile environment due to their metabolic inheritance.
Human evolution is such that our bodies have mounted a good response to times of famine by not losing weight so rapidly. Times of high energy flux and low intake were balanced by periods of rest accompanied by lower energy. Now, with the ubiquitous arrival of 24-hour access to calories in all their permutations, including fast food and high-energy soft drinks, those periods of low energy intake are no longer so apparent in our diets. Food consumption is predicated on hunger in resource-poor societies, but in consumer-driven societies, hunger can be manipulated by the environment.
And those with the ‘thrifty gene’ fare even worse in the weight gain stakes – as a result, society starts to gain weight.
Perception of obesity in society
Obese patients continue to be the target of unfavourable opinion. A qualitative study conducted on 200 patients undergoing bariatric surgery revealed that obese patients feel misunderstood and are mistreated by those around them, including medical and non-medical personnel. Although there are laws designed to prevent discrimination based on appearance, there is much work needed to make sure that the correct equipment is provided to accommodate patients of a certain weight, and that negative attitudes surrounding obesity are corrected.
In more affluent countries, and in certain Asian countries, slenderness is now favoured medically and cosmetically. As people, particularly women, gain weight, they feel increasingly unacceptable and can adopt undesirable obsessive behaviours in an attempt to lose it.
Poor motivation is seen as more of a problem than lack of information in some sections of society. In a large study of nurses’ behaviour, these professionals were deemed to have an advanced knowledge of the health-associated obesity risks and a reasonable understanding of how to manage obesity; however, 40% recognised that they were overweight, but felt powerless to address their own risks. This study highlights the need, reflected elsewhere, for healthcare professionals to be properly educated with regard to how to treat obesity.
A slippery slope
Obesity is the precursor to many other disabling conditions, the principle ones being type 2 diabetes and ischaemic heart disease. There is a tendency, however, for patients with obesity to also have significant undiagnosed morbidity; healthcare professionals can be slow to realise the complex interplay of metabolic syndrome and the toxic effects of visceral obesity.
As an example, obstructive sleep apnoea, an illness largely driven by obesity, is a major and largely unrecognised cause of road traffic accidents, as well as a powerful driver of diabetes, hypertension and heart disease. There exists treatment, but this is not available to the undiagnosed, and many patients, aware that their snoring may be indicative of an underlying disease, do not come forward for a diagnosis to be made because they are – correctly – concerned that they could lose their driving licence and – incorrectly – of the belief that there is no treatment. Continuous positive airway pressure (CPAP) is an effective, if intrusive, treatment for this disabling condition.
Treatment for obesity can only be offered, it cannot be forced upon patients. Respect for a patient’s autonomy can sometimes be lacking, particularly when patients seem to deliberately refute all advice to eat more healthily and increase their physical activity. Consideration must be given, though, to the patient’s physical and cognitive abilities: what are they capable of doing for themselves? Many lack the social or educational skills necessary to undertake the massive task of changing their lifestyle and losing weight, and they must always be treated with dignity and respect.
The costs of obesity
Treating obese patients in the NHS is a complex and costly undertaking, and outside of bariatric surgery departments, many hospitals are ill-equipped to provide care for severely obese patients. Obese patients have longer and more frequent hospital stays, equating to an increased use of hospital services. Obesity is associated with four of the most disabling conditions in the UK, namely learning disability, arthritis, mental health issues and back pain. Mobilising patients after trauma presents particular issues, and failure to provide adequate and appropriate equipment can lead to suboptimal treatment of, and injury to, patients and staff. Manual handling of high-risk patients can carry higher risks; 10% of claims reported to the NHS litigation authority in 2012 were related to injuries sustained while caring for obese patients.
Moving and handling obese patients requires particular skills, but there are also medical difficulties to surmount. Peripheral IV access is more difficult in an obese patient and even taking a blood pressure reading becomes a more complex procedure for which the equipment is not always available. Larger blood pressure cuffs; reinforced ambulances, scales, wheelchairs, commodes and beds that take extra weight; and extra-large dignity gowns are not standard throughout the NHS. Imaging techniques such as ultrasound and MRI are more challenging and less informative. Training is also an issue because staff need to experience the problems they may encounter as realistically as possible, but with minimal risk. Safety is always paramount when considering the moving and handling of any patient or client, but especially one who is considered to be morbidly obese.
If patients do not understand the consequences of perpetually making a series of poor lifestyle choices, they may make personal decisions that do not maximise their welfare. The biggest strain on financial resources is that incurred by the morbidly obese. Treating obesity is dependent on assessment; identifying a patient’s level of motivation and ability to manage treatment plans is paramount.
Obesity occurs when energy intake exceeds energy expenditure; in many people this takes place over a long period
of time. The complex interplay of the contributory mechanisms affecting this include environmental and biopsychosocial factors. Inactivity, expressed as increased sedentary behaviour and lack of structured exercise, contributes to the obesity epidemic. Increasing physical activity as well as following a decrease in energy intake leads to far greater fat loss than either treatment on its own.
Translating intention and even motivation into an actual change in behaviour remains a challenge, as obese and non-obese patients tend to overestimate the amount of exercise taken and underestimate the amount of calories eaten. Inactivity affects more people in England than the combined total of those who drink alcohol, are obese or smoke. The health consequence of inactivity was also estimated to cost each local area health team in the UK as much as £5 million a year.
Treatment options
Exercise has many benefits, from psychological to physical, including decreasing insulin resistance, even independently from the effect on weight loss. The presence of physical exercise in the life of people today has been greatly reduced, with many now leading lives devoid of any meaningful energy expenditure. The required total energy output of 60-90 minutes a day, or 10-15,000 pedometer-measured steps, is hard to achieve in individuals unused to exercise, but crucial in order to encourage and maintain weight loss.
Behavioural therapy for decreasing total energy input involves improving cognitive control of intake. Calorie counting can be perceived as onerous and difficult, with patient and doctor unable to work out either true energy requirements or content of food. The tied relationship between sedentary behaviour and obesity is beginning to be unravelled. A map of research undertaken by the University of London demonstrated that sedentary behaviour can affect obesity due to the increased energy intake that occurs when one is snacking or grazing while watching TV or using the computer.
The use of a food diary is a simple and effective tool that – coupled with explicit guidance on low-energy-dense diets, portion control and regular monitoring – can prove effective. Low-calorie diets have also proved popular recently, with many patients able to use these diets to aid their efforts in consistently losing weight; modern evidence of the benefits of a low-carbohydrate diet is also accumulating.
Pharmacology offers little help with obesity; orlistat, a mildly effective lipase inhibitor that can precipitate diarrhoea and flatulence, is the only drug licensed for weight loss at present. Clinicians must be vigilant, however, that iatrogenic causes of obesity are kept to a minimum – certain atypical antidepressants, sulphonylureas, pregabalin, steroids and insulin itself are all known to precipitate weight gain and need to be carefully managed within the context of holistic patient care.
In cases where diet, exercise, pharmacology and talking therapies have failed to address weight issues, bariatric surgery is helpful, often offering the additional resolution of accompanying type 2 diabetes in up to 86% of gastric bypasses and 73% of gastric band cases. Body contouring surgery, which 80% of patients will need following bariatric surgery, is, however, rarely offered on the NHS.
Obesity is a long-term disabling and stigmatising condition that is becoming increasingly prevalent in the UK today. Human and financial costs are set to rise, affecting all sections of society and those who care for them. It is clear that education and empowerment are the keys to the management of this serious modern-day public health issue.
