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Weight Management

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  • It is one of the most serious global health challenges of the 21st century
  • It causes high incidence of morbidity, disability and premature mortality
  • It affects 30% of children and 62% of adults in the UK
  • It costs the UK £47bn a year
  • For 40 years official statistics have under-reported its main cause
  • Doctors have neither been able to reduce nor prevent it
  • Behavioural scientists are well positioned to reduce it
  
A major 21st century health challenge is under-reported for 40 years
 
A 2016 study by the UK’s Behavioural Insight Team (BIT) found that, for the past 40 years, official UK statistics have under-reported the main cause of it. The Office for National Statistics failed to pick up the fact that people consistently under-report the principal cause of it. “Such a large underestimate has misinformed policy debates, and led to less effective strategies to combat it,” says Michael Hallsworth, co-author of the study. Jamie Jenkins, head of health analysis at the Office for National Statistics, replied, “We are actively investigating a range of alternative data sources to improve our understanding of the causes of obesity”.
  
Obesity should be treated like terrorism

Although we know how to prevent obesity, it devastates the lives of millions and costs billions. In the UK obesity affects 33% of primary school children, and 62% of adults. Its prevalence among adults rose from 15% to 26% between 1993 and 2014. In 20 years, obese adults are expected to increase to 73%.
 
The UK spends £640m on programs to prevent obesity. Each year, the NHS spends £8bn treating it, and obesity has the second-largest overall economic impact on the UK; generating an annual loss equivalent to 3% of GDP. 
 
The World Health Organization warns that obesity is, “one of the most serious global public health challenges of the 21st century”. The UK’s Health Secretary says obesity is a “national emergency”, and the UK’s Chief Medical Officer argues that obesity should be treated similarly to “terrorism”.
 
Here we suggest how behavioural science rather than doctors can help to reduce and prevent obesity.
 

Vast, persistent and growing

Although we know how to address obesity, there are few effective interventions in place to reduce it. According to a 2014 McKinsey Global Institute study, the UK Government’s efforts to tackle obesity are, ''too fragmented to be effective'', while investment in its prevention is, ''low given the scale of obesity''. Being obese in childhood has both short and long-term consequences. Once established, obesity is notoriously difficult to treat. This raises the importance of prevention. Obese children are more likely to become obese adults, and thereby have a significantly higher risk of morbidity, disability and premature mortality. The global rise in obesity has led to an urgent call for action, but still its prevalence, which is significant, is rapidly increasing.
 

The incidence of certain cancers is significantly higher in obese people, and is expected to increase 45% in the next two decades. Professor Karol Sikora, a leading cancer expert, describes the association, but says we do not know the reasons why, and Dr Seth Rankin, Founder and CEO of the London Doctors Clinicsuggests that virtually every health problem known to mankind is made worse by obesity:

 

Prof. Karol Sikora - Cancer linked to obesity


Dr Seth Rankin - Can being overweight lead to health problems?
 
 The success and growth of Nudge Units

A previous Commentary drew attention to the fact that obesity is connected with a relationship between the gut and brain. Gut microbiota are important in the development of the brain, and research suggests that an increasing number of different gut microbial species regulate brain functions to cause obesity. Notwithstanding, the UK’s Behavioural Insight Team (BIT), which started life in 2010 as a government policy group known as the "Nudge Unit", revolutionized the way we get people to change their entrenched behaviours, and this has important implications for public policy strategies to reduce and prevent obesity.
 
Under the leadership of David Halpern, the BIT has been very successful and has quadrupled in size since it was spun out of government in 2014. Now a private company with some 60 people, the Nudge Unit permeates almost every area of government policy, and also is working with Bloomberg Philanthropies on a US$42m project to help solve some of the biggest problems facing US cities. The UK’s Revenue and Customs (HMRC) has set up its own nudge unit, and nudge teams are being established throughout the world.
 
The genesis of Nudge Units

It all started in 2008 with the ground-breaking publication on behavioral economics, Nudge: Improving Decisions About Health, Wealth and Happiness, written by US academics Cass Sunstein and Richard Thaler. Their thesis suggests that simply making small changes to the way options are framed and presented to people “nudges” them to change their lifestyles without actually restricting their personal freedoms. Politicians loved the thesis, not least because it was cheap and easy to implement, and ‘Nudge’ became compulsory reading among politicians and civil servants. “Nudge Units” were set up in the White House and in 10 Downing Street to improve public services and save money by tackling previously intractable policy issues.
 
Nudging people to change

The UK’s Nudge Unit has, among other things, signed up an extra 100,000 organ donors a year, persuaded 20% more people to consider switching energy provider, and doubled the number of army applicants. Now it is turning its attention to health and healthcare, and already has implemented behavior change strategies that motivate individuals to initiate and maintain healthier lifestyles. The Unit’s strategies that have demonstrated self-efficacy and self management are examples that can be further incorporated into lifestyle change programs, which help people maintain healthy habits even after a program ends and thereby be a significant factor in reducing and preventing obesity.
 
Takeaway
 
Doctors understand the physiology of obesity, but they do not understand the psychology of people living with it. Doctors are equipped to treat the morbidities and disabilities associated with obesity, but ill-equipped to reduce and prevent it. The sooner the Nudge Unit is tasked with reducing and preventing obesity the better.
 
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The UK's National Institute for Health and Care Excellence (NICE) recently recommended that primary care doctors should identify people eligible for state-funded slimming classes run by private companies, such as Weight Watchers, an American company that offers various products and services to assist weight loss and maintenance.

UK facts
Obesity costs NHS England £5.1bn a year
25% of adults in England are obese
42% of men & 32% of women are overweight
A BMI of 30-35 cuts life expectancy by up to four years
A BMI of 40 plus cuts life expectancy by up to 10 years

Lose weight and save millions
NICE suggests that health professionals should raise the issue of weight loss in a "respectful and non-judgmental" way, by measuring their body mass index (BMI) to identify people who are eligible for referral for lifestyle weight management services. BMI is a person's weight in kilos divided by their height in meters squared.

About 25% of UK adults are obese with a BMI over 30 and 74% are overweight with a BMI above 25. Just a 3% reduction in weight could extend life expectancy, and reduce the risk of Type2 diabetes, high blood pressure and heart disease.

NICE argues that the cost of funding private weight loss programs for overweight people would be outweighed by the benefits. For example, preventing just a 1% increase in obesity would save the UK government nearly £100 million a year.
 
Lifestyle change rather than yo-yo dieting
In a recent study published in The Lancet Diabetes and Endocrinology, researchers suggest that weight loss at any age in adulthood is worthwhile and even transitory weight loss is beneficial to health.
 
The research examined the impact of lifelong patterns of weight change on cardiovascular risk factors in a group of 1,273 British men and women, followed since their birth in March 1946. It concluded that the longer a person is overweight the greater their propensity of cardiovascular problems in latter life and the greater risk of diabetes.
 
According to the lead author Professor John Deanfield from University College, London, "Our study is unique because it followed individuals for more than 60 years, and allowed us to assess the effect of modest, real-life changes in adiposity. . . .  Losing weight at any age can result in long-term cardiovascular health benefits, and support public health strategies."
 
Professor Mike Kelly, the director of the centre for public health at NICE, said the guidelines were about lifelong change rather than yo-yo dieting, when the weight is piled back on after initial success.

He stressed the importance of achievable goals: "We would like to offer an instant solution and a quick win . . .  but realistically it's important to bear in mind this is difficult. It's not just a question of 'for goodness sake pull yourself together and lose a stone'; it doesn't work like that. People find it difficult to do  . . it takes resolve, it takes encouragement."
 
mHealth proven support for weight management
Scott Lonnee, a bariatric dietitian at St George's Hospital, London echoes Kelly's sentiment, "Sensible lifestyle changes, which include sustained dietary changes and physical exercise can have significant healthcare benefits. Planning is important, and there are simple techniques to help individuals lose weight, which include, setting realistic and achievable targets, keeping diaries of what you eat and what exercise you take."
 
Research commissioned by Weight Watchers, and recently published in the American Journal of Medicine, suggests that losing weight is significantly easier and more effective when individuals have access to online support, compared to weight loss among those who tried to lose weight on their own.
 
Takeaways
Pro-active mHealth strategies can help to change the way health professionals interact with patients. Information, guidance and support regularly sent to the mobiles of overweight individuals to help them lose weight and engage in lifestyle changes would save lives, prevent the onset of disease and save NHS England millions of pounds. Why is it not being done?   
 
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Scott  Lonnee

Scott Lonnee

Specialist Bariatric Dietitian
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Are we addicted to foods that make us obese and kill?

Why is it hard for obese people to lose weight despite the social stigma and health consequences associated with being overweight? Is it similar to cigarette smokers who continue to smoke even though they know smoking will give them cancer and heart disease?

Is processed food the new tobacco?

Large growing global epidemic
Over the past 25 years the prevalence of obesity in England has more than doubled and today, most English people are either overweight or obese. Similarly, in the US more than a third of individuals are obese.

It’s estimated that each year, obesity costs the NHS more than £5bn and the US economy about $150bn.

Global epidemicOnce considered a problem only for rich countries, obesity is a rising worldwide challenge. In 1997 the World Health Organization (WHO) formally recognized obesity as a global epidemic and in 2008, claimed that 1.5 billion adults were obese. 

Experts say a couch potato lifestyle and overindulgence in junk food is creating an overweight and obese generation prone to heart disease, diabetes and cancer. In rich countries people have easy access to cheap, high-energy food that is often aggressively marketed.

Call for parents and local authorities to help
The press refers to the “obesity time-bomb” and suggests that misguided parents are bringing up a generation of overweight children who gorge on junk food and sugary treats and rarely get any exercise. UK policy makers say that more should be done to support families to help them tackle the obesity crisis in children and young people.

In January 2014, Professor Philip James told the European Congress on Obesity in Antwerp: “Unless we can act firmly and decisively, we will be condemning a huge number of children . . . to becoming a ‘lost generation’.”

Where should we target our concerns? Parents? Municipal authorities? Or, the food and drinks industry?

Changed environment
Contrary to popular belief, people have not become greedier or less active, but what they eat has changed. Everyday, people are bombarded by food industry adverts to eat more food. New scientific evidence suggests that industrial processed food is biologically addictive.

The tobacco industry
In 1954, the tobacco industry paid to publish a “Frank Statement to Cigarette Smokers” in hundreds of US newspapers. It stated that the industry was concerned about peoples’ health and promised a number of good-faith changes.

What followed were decades of deceit and actions that cost millions of lives. During that time the tobacco industry emphasised personal responsibility and paid scientists to deliver research that triggered doubt and criticised science that found harm associated with smoking.

The food and drink industry

Similarly today, some large food and drink companies fund scientific research to establish health claims about their products.


A 2013 report suggests that scientific research sponsored by the food and drink industry is five times more likely to conclude that there are no links between consumption of sugary drinks and weight gain.

In March 2014, Dame Sally Davies, the UK’s Chief Medical Officer told a committee of MPs that, "research will find sugar is addictive" and that the government, “may need to introduce a sugar tax".

For years the tobacco industry made self-regulatory pledges, aggressively lobbied to stifle government actions and denied both the addictive nature of tobacco and their marketing to children.

Takeaways
Food and tobacco industries are different, but there are significant similarities in the actions they have taken in response to concerns that their products can harm.

Because obesity is now a pandemic the world cannot afford to make the same mistake it did with the tobacco industry.

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