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The UK is the most overweight nation in Western Europe, with levels of obesity growing faster than in the United States, according to a 2017 report from the Organisation for Economic Co-operation and Development (OECD). The report said Britain was the sixth-worst country in its 35 member states, coming behind Mexico, the US, New Zealand, Finland and Australia.
One problem when it comes to tackling obesity in the UK is that people who are obese do not think of themselves as obese or even very overweight. A survey published in BMJ Open involving 657 adults whose self-reported weight and height in 2007 and 2012 put them in the obese (BMI ≥30) category found that the proportion describing themselves as ‘obese’ was low for both women (13 and 11 per cent in 2007 and 2012) and men (4 and 7 per cent in 2007 and 2012) and did not change significantly.
Recognition of a substantial degree of overweight declined substantially in women, from 50 to 37 per cent between 2007 and 2012 but was not significantly changed in men (down from 27 to 23 per cent between 2007 and 2012). This lack of recognition of weight status may hamper attempts to help people manage their weight effectively.
Becoming overweight or obese is often described as an individual’s ‘fault’. While our eating and physical activity habits may not be as healthy as they could be, the easy availability of inexpensive, energy-dense, palatable foods, the higher costs of – and insufficient access to – more healthy foods, a reduced need for physical activity during everyday life and plentiful opportunities to engage in sedentary behaviour have all created an ideal environment for obesity to emerge.
Weight management is a challenge but care should be taken neither to criticise nor stigmatise people who are overweight and obese. The often-used phrase ‘eating less and moving more’ is sometimes described in the media as a myth but, to lose weight, people need to burn off more calories than they consume. Studies show that people may eat more than they need without realising it and may therefore value guidance around diet and nutrition. Even losing 10 per cent of body weight can reap dividends for health.
Reversing the obesity trend, however, requires a major shift in thinking, not just by Government, but also by individuals, families, business and society in general.
For Government and businesses, it means creating an environment that encourages healthier eating and physical activity. For individuals and families, it means thinking about eating less and moving more and how they can do that.
Currently, no country in the world has a comprehensive, long-term strategy to deal with the challenges posed by obesity. The only country to have successfully reversed its obesity problem was Cuba, although it was the unexpected consequence of an economic downturn in the early 1990s.
This caused severe food and fuel shortages, which resulted in an average weight loss per citizen of 5.5kg over the course of the five-year economic crisis. During this time there was a significant drop in the prevalence of, and deaths due to, cardiovascular diseases, type 2 diabetes and cancers. That said, no one would wish for a national crisis to solve our own weight problem.
Pharmacy teams have an opportunity to help people at an individual level with their weight management by engaging them concerning the health risks of excess body fat and providing consistent advice to help them maintain a healthy weight. NICE has produced a clinical guideline on the management of obesity in children, young people and adults as well as guidelines on obesity prevention, maintaining a healthy weight and lifestyle weight management services.
Most of us may think we can tell if a person is overweight or obese, but the 2015 social attitudes survey by Public Health England found that only 54 and 39 per cent of people can correctly identify when a woman or man is obese.
Measurement using body mass index (BMI) is therefore valuable. A BMI of 25-29.9 means the person is considered to be overweight, while a BMI of 30 or more means that the person is obese. According to a report by NHS Digital, 58 per cent of women and 68 per cent of men were overweight or obese in 2015. Obesity prevalence increased from 15 per cent in 1993 to 27 per cent in 2015, while prevalence of morbid obesity (BMI>40) has more than tripled since 1993 to reach 2 per cent of men and 4 per cent of women in 2015.
Obesity varies by age for both men and women, with the highest obesity levels in the 55-64 age group – many of whom may be visiting pharmacy with prescriptions for long-term conditions. Obesity also varies by region with higher prevalence in the north of England and the Midlands than in the south.
NICE recommends that BMI is used in conjunction with waist circumference (see panel overleaf) as abdominal obesity better characterises health risk (e.g. type 2 diabetes, hypertension). BMI does not distinguish between mass due to body fat and mass due to muscular physique, or the distribution of fat.
The link between obesity and increased risk of serious conditions such as type 2 diabetes and cardiovascular disease, especially hypertension, is well known. In 2015, prevalence of diabetes (diagnosed and undiagnosed) was 2 per cent among adults with a desirable waist circumference and 11 per cent in those with a high waist circumference.
Hypertension is twice as common among obese adults as those of normal weight (43 per cent of obese men and 37 per cent of obese women compared with 21 per cent of men and 18 per cent of women with a BMI in the normal range).
In England, obesity is estimated to be responsible for more than 30,000 deaths each year. On average, obesity deprives an individual of an extra nine years of life, preventing many individuals from reaching retirement age. In the near future, obesity could overtake tobacco smoking as the biggest cause of preventable death.
Waist circumference is measured by finding the bottom of the ribs and the top of the hips, then wrapping a tape measure around the waist midway between these points. The person should be asked to breathe out naturally, then the measurement taken. Waist circumference is categorised into desirable, high and very high, by sex-specific thresholds (cm):
Men: Desirable = Less than 94cm; High = 94-102cm; Very high = more than 102cm
Women: Desirable = Less than 80cm; High = 80-88cm; Very high = more than 88cm.
Medical treatment for obesity involves prescription medication (i.e. orlistat) or bariatric surgery. These treatments should be considered only after dietary, exercise or behavioural approaches have been started and evaluated.
While there is a continuing downward trend in the number of items being prescribed for obesity, as well as a falling net ingredient cost, 449,000 items were still prescribed at a cost of £9.9 million in England in 2016 – so, there are still savings to be made and, most importantly, healthier lifestyles to be encouraged.
Bariatric surgery comprises a group of procedures that facilitate weight loss, including stomach stapling, gastric bypasses, sleeve gastrectomy and gastric band maintenance. In general, such surgery is used in the treatment of obesity in patients with a BMI above 40 or those with a BMI of 35-40 who have health problems such as type 2 diabetes or heart disease.
In 2015/16, there were 6,438 finished consultant episodes (FCEs) in NHS hospitals with a primary diagnosis of obesity and a main or secondary procedure of bariatric surgery. Over three-quarters of bariatric surgery patients were aged between 35 and 54 years, and over three-quarters were women.
Bariatric surgery has been found to help or resolve many obesity-related conditions such as type 2 diabetes and CVD and reduce the need for medication for these conditions.
The main requirement in the dietary and nutritional management of obesity is to reduce energy (calorie) intake below energy expenditure. Diets that provide 600kcal a day less than the person requires are recommended for sustainable weight loss.
Many people find it difficult to eat healthily, mainly because of the ready availability of energy dense food and perhaps their long-term eating habits. Less healthier choices are the default, which encourages weight gain and obesity.
The increasing consumption of out-of-home meals – that are often cheap and readily available at all times of the day – has been identified as an important factor contributing to rising levels of obesity.
Public Health England (PHE) estimated in 2014 that there were over 50,000 fast food and takeaway outlets, fast food delivery services and fish and chip shops in England. More than one quarter (27.1 per cent) of adults and one fifth of children eat food from out-of-home food outlets at least once a week. These meals tend to be associated with higher energy intake; higher levels of fat, saturated fats, sugar and salt; and lower levels of micronutrients.
Eating out contributes just over 10 per cent of total energy intake. Preparing and cooking from scratch can be healthier and lower in calories as it is easier to control what goes onto the plate.
Portion sizes have increased during recent decades. Evidence collated by the British Heart Foundation in 2013 showed that curry ready meals, for example, had expanded by 20 per cent in the past 20 years. An individual shepherd’s pie ready meal grew by 98 per cent, chicken pies were 40 per cent bigger and a meat lasagne ready meal for one had increased by 39 per cent. For weight management it is very important to stay in control of portion sizes and it is worth weighing out portions of foods such as pasta and rice.
Four in five obese school pupils are destined to remain dangerously overweight for life, according to a report by the Royal College of Paediatrics and Child Health.
“Four-fifths of obese children will remain obese as adults; that will reduce their overall life expectancy by up to 10 years and their ‘healthy life’ expectancy by up to 20 years,” says Neena Modi, president of the college, with later years increasingly likely to be spent battling heart problems and diabetes.
“We need the kind of hard-hitting campaigns we used to have for HIV and for smoking, as well as firm action to curb the power of industry. Instead, what we are seeing is cuts to public health budgets.”
The royal college is calling for a ban on advertising foods high in saturated fat, sugar and salt on television before 9pm and action to stop fast food outlets opening near schools. In 2009 there were 9,700 fast food outlets within five minutes’ walk of a school gate – a number that has risen dramatically to 16,160 in England, Wales and Scotland, according to Allmapdata (an increase of 67 per cent).
Fruit and vegetable intake is important for good health and for reducing the overall energy density of the diet but only 26 per cent of adults ate the recommended five or more portions a day in 2015. Women (27 per cent) were more likely to do so than men (24 per cent). Average adult intakes were 3.9 portions. Youngsters in their mid-teens did better – in 2014, 52 per cent of 15-year-olds reported they consumed five or more portions of fruit and vegetables a day.
Higher intakes of fruit and vegetables – seven or 10 a day – have been associated with better health in terms of reduced risk of obesity, cardiovascular disease and diabetes. However, given that only a quarter of adults consume five-a-day, this advice might appear impractical. Yet there is no doubt from the research data that eating plenty of fruit and vegetables, particularly vegetables, is good for overall health, and a good strategy for weight management.
People may think it is more expensive to eat a healthier diet with more vegetables and fruit – but meat and fish are typically the most expensive part of a meal. Adding more vegetables to meat dishes can make meals go further and pulses, such as beans and lentils, are some of the cheapest foods on the supermarket shelves.
A few vegetarian meals during the week will also help to keep costs down. In short, a diet based more on plants should help to keep costs down and improve health, provided the plant-based foods are mainly whole and unprocessed.
Physical activity contributes to a wide range of health benefits and regular physical activity can improve health outcomes irrespective of whether the individual loses weight.
In 2015/16, 26 per cent of adults were classified as inactive (fewer than 30 minutes’ physical activity a week). Sixty-one per cent of adults were classified as active (150 minutes or more a week). Inactivity increases with age. One in six 16-24 year-olds are inactive compared with 54 per cent of those aged over 75 years.
People who are obese in the UK do not think of themselves as obese or even very overweight.
The British Dietetic Association (BDA) has the following recommendations for losing weight and keeping the weight off:
• Keep a diary and stay more aware of habits and problem areas
• Have regular meals, starting with breakfast
• Choose lower fat foods (e.g. lean meat and lower fat dairy products)
• Fill up on vegetables and fruit at meals and choose these as snacks and for desserts
• Watch your portion sizes
• Get active, aim for at least 30 minutes daily of moderate activity
• If you can manage more than that even better – ideally aim to build up to 60 minutes a day
• Be realistic about weight loss – aim to lose 1-2lbs (0.5-1kg)
The BDA has also devised a NHS 12-week diet and physical activity plan, which promotes safe and sustainable weight loss at a rate of one to two pounds each week. See nhs.uk/LiveWell/weight-loss-guide/Pages/weight-loss-guide.aspx.
Encouraging people to change sometimes well-entrenched behaviours is a hard task. Working in the community, the pharmacy team often has the big picture of the locality, the food available and the rational for the lifestyles of their customers. Teams also know what medication for obesity-related conditions regular patients are taking.
In this broad context, community pharmacy can contribute hugely to the management of this seemingly intractable problem.
Every year sees a list of recommended ‘diets’ for weight loss. Some, such as the Mediterranean Diet or a Flexitarian Diet can be healthy – but many more are not. Pharmacy customers may ask about these diets, so it is important the pharmacy team is aware of the pitfalls. Customers should be advised to stay away from diets that:
• Promise a magic bullet to solve a weight problem without having to make a change
• Promise rapid weight loss of more than two pounds of body fat each week
• Recommend ‘magical’ fat burning effects of foods (e.g. grapefruit)
• Promote the avoidance or severe limitation of a whole food group, such as dairy products or a staple food such as wheat
• Promote eating mainly one type of food (e.g. cabbage soup, chocolate or eggs) or avoiding all cooked foods (the raw food diet)
• Recommend eating foods only in particular combinations based on genetic type or
• Suggest being overweight is related to a food allergy or yeast infection
• Recommend ‘detoxing’ or avoiding foods in certain combinations such as fruit
• Offer no supporting evidence apart from a celebrity with a personal success story to tell.