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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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  • Obesity is common, serious and costly
  • Obese adults in the UK will soar by a staggering 73% to 26m by 2030
  • Obesity generates an annual loss equivalent to 3% of the UK’s GDP
  • Obesity cost NHS England £8bn in 2015
  • The obesity epidemic will only get worse unless we take effective action
  • Innovative research to control appetite could provide a cheap and scalable answer to the obesity epidemic
  • The UK’s obesity crisis should learn from the way AIDS was tackled 

Can the obesity epidemic learn from the way Aids was tackled?
 
Obesity is a common chronic health challenge, which is serious and costly.It is one of the biggest risk factors for type-2 diabetes (T2DM) and together - obesity and T2DM - form a rapidly growing global diabesity epidemic, which today affects some 9m people in England.
 
Experts forecast the incidence rate of obesity will rise sharply, and bankrupt the NHS. Conventional strategies to reduce obesity and prevent T2DM have failed. According to the Mayo Clinic it is common to regain weight no matter what weight loss treatment methods you try, and you might even regain weight after weight-loss surgery. This Commentary suggests that extra resources are urgently needed to accelerate and broaden innovative obesity research.
  
Efforts to tackle obesity are low priority and fragmented
 
Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. Risks of coronary heart disease, ischemic stroke, and T2DM increase steadily with raised body mass index (BMI). High BMI also increases the risk of osteoarthritis; sleep apnoea, gallbladder disease, and some cancers. Cancer Research UK predicts that obesity related cancers are expected to increase 45% in the next two decades, causing 700,000 new cases of cancer. Mortality rates will increase with increasing degrees of obesity. It is therefore important that obesity is treated aggressively. According to a 2014 McKinsey Global Institute study, the UK’s Government efforts to tackle obesity are ''too fragmented to be effective'', while investment in obesity prevention is ''relatively low given the scale of the problem''.
 
A multi-generational problem
 
The 2014 Health Survey found that 61.7% of adults in England (16 years or over) are either overweight or obese, and the prevalence of obesity among adults rose from 14.9% to 25.6% between 1993 and 2014. The number of obese adults in the UK is forecast to soar by a staggering 73% to 26m over the next 20 years.

In 2014-15, there were 440,288 hospital admissions in England due to obesity: 10 times higher than the 40,741 recorded in 2004-5. In England one in five children in their first year at school, and one in three in year 6 are obese or overweight. Also, in the past 10 years there has been a doubling of children admitted to hospital for obesity. Over the past three years 2,015 overweight youngsters needed hospital treatment, and 43 of these have had to undergo weight-loss surgery to reduce the size of their stomachs. Today, diabesity is a multi-generational problem, which suggests that far worse is still to come.
 
Costs and spends
 
The UK spends less than £638 million a year on obesity prevention programs - about 1% of the country's social cost of obesity. But the NHS spends about £8bn a year on the treatment costs of conditions related to being overweight or obese and a further £10bn on diabetes.
 
Obesity is a greater burden on the UK’s economy than armed violence, war and terrorism, costing the country nearly £47bn a year, the 2014 McKinsey study found. Obesity has the second-largest economic impact on the UK behind smoking, generating an annual loss equivalent to 3% of GDP. The current rate of obesity and overweight conditions suggest the cost to NHS England alone could increase from £8bn in 2015 to between £10bn and £12bn in 2020.

 
19th century technologies for a 21st pandemic
 
A year after the publication of the McKinsey study, the UK government launched a national Diabetes Prevention Program (DPP) led by NHS England, Public Health England (PHE), and the charity Diabetes UK (DUK). The program offers people at risk of T2DM an intensive personalised course in weight loss, physical activity and diet, comprising of 13 one-to-one, two-hour sessions, spread over nine months, and is expected to significantly reduce the estimated five million overweight and obese people in England, and thereby prevent them from developing T2DM. A previous Commentary predicted that the DPP would fail because it is using a 19th century labour intensive method to address a 21st epidemic.
 
This suggests that the diabesity epidemic will only get worse unless we take more urgent and effective action. A view supported by Majid Ezzati, Professor of Global Environmental Health at Imperial College, London, and the senior author of the most comprehensive review of obesity ever undertaken, and published in The Lancet in April 2016. According to Ezzati, “The epidemic of severe obesity is too extensive to be tackled with medications such as blood pressure lowering drugs or diabetes treatments alone, or with a few extra bike lanes”.

 
Radical action: weight loss surgery
 
The gravity of the UK’s obesity epidemic is demonstrated by the National Institute for Health and Care Excellence (Nice) 2016 suggestion to lower the threshold at which overweight people are offered weight loss surgery. The UK lags behind other European countries in this regard, and experts argue that lowering the threshold would mean the number of people who qualify for weight loss surgery would increase significantly.

According to a report prepared by English surgeons, weight-loss surgery would make people healthier and save the NHS money. The report concluded that after weight loss surgery obese people are 70% less likely to have a heart attack, those with T2DM are nine times more likely to see major improvements in their condition, and also the surgery has a positive effect on angina and sleep apnoea. If all the 1.4m most severely obese people in the UK had weight loss surgery, which costs the NHS around £6,000 per operation, the total cost would be £8.4bn.

 
Weight loss surgery and the brain
 
Initially it was thought that weight-loss surgery worked by reducing the amount of food that can be held by the stomach. However, some patients were found to have elevated levels of satiety hormones, the chemical signals released by the gut to control digestion and hunger cravings in the brain. Patients who had undergone surgery were also found to prefer less fatty foods, which supports the thesis that the hormones also change the patients’ desire to eat, and reinforce the gut brain relationship. This finding reinforces the important link between the gut and the brain on which some of the most promising obesity research is predicated.
 
Gut brain relationship
 
Dr Syed Sufyan Hussain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism at Imperial College London describes the gut-brain relationship and explains why we eat and why we stop eating:
 

 
Cheap, safe and scalable treatment for obesity
 
The person who has spent most of his professional life searching for cheap, safe and scalable alternatives to weight loss surgery and ineffective weight loss therapies is Professor Sir Steve Bloom, Head of Diabetes, Endocrinology and Metabolism at Imperial College London. Bloom believes that the answer to the UK’s obesity epidemic lies in the gut-brain relationship, and is working on two innovative methods of appetite control, which he and his colleagues believe could significantly reduce the burden of obesity.
 
Method 1: an implantable microchip
 
One method is comprised of a small implantable microchip attached to the vagus nerve to suppress appetite in a natural way. The chip reads and processes both electrical and chemical signatures of appetite within the vagus nerve, and then sends electrical signals to the brain to either reduce or stop eating. Bloom has proven the method’s concept, and in 2013 was awarded €7m from the European Research Council to continue his research. Early findings suggest that chemical rather than electrical impulses are more selective and precise, and the chip reduces both consumption and hunger pangs. All things being equal, it will take another 10 years before this treatment gets to market.
 
Method 2: naturally occurring hormones
 
Bloom is also working on another method to treat obesity, which uses naturally occurring hormones that reduce appetite. Early clinical studies suggest that people will consume 13% fewer calories when they eat a meal after taking the hormones. In 2013 Bloom received £2m from the Medical Research Council to develop this research. One of the significant challenges he faces is hormones normally last only a few minutes in the human body. To overcome this Bloom and his colleagues have had to develop versions of the hormones that can last up to a week before they start breaking down. This suggests that patients could take a single weekly injection to control their appetites. Another approach would be to develop a device, which delivers the hormones continuously. While promising, this method too will take 10 years to get to market.
 
Takeaway: treat obesity the same as Aids
 
Bloom believes that if we approached obesity as we did Aids, the time to develop a cheap, effective and scalable drug for weight control could be cut by half. "The obesity pandemic is the biggest disease that has hit mankind ever in terms  [of] numbers. It is killing more people than anything else has ever killed, . . . . . . . in terms of disease [there are] more deaths from obesity than anything we have known about. The time needed to develop an effective drug could be cut by more than half if conservative checks and balances were loosened. I think we might need to treat obesity in a hurry, and we are being held up. The Aids lobby forced Aids’ drugs on to the market before they had finished testing, but they turned out to be useful and lives were saved. Something similar should be considered for obesity,” says Bloom.
 
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