Action to reverse the trend of obesity
A chance conversation in a clinic corridor changed the direction of my specialty practice.
The clinical problem concerned a 21 year old woman with severe obesity and poorly controlled type 2 diabetes mellitus. The diabetologist had tried various strategies to keep the blood sugar under some control. However, nothing seemed to have the desired effect and so, as a last resort, a surgical solution was considered.
My practice at the time was focussed on surgical gastroenterology and oncology and a departure into a very different surgical ideology seemed like a major stretch. The long and short of it, however, was that we agreed to take on this patient for metabolic surgery – a foreign concept in the mid-1990s.
Following the surgery, the woman lost a dramatic amount of weight and her diabetes was virtually eliminated. This pattern has underpinned the transition from bariatric surgery to metabolic surgery. In my view there is a place for both although only in highly specific circumstances. Surgery ought always to be a last resort.
It seems self-evident that the lifestyle related problem of obesity requires an adjustment to the well-established aetiological factors in order to address the trend. This applies at both an individual and a population level. The problem is, and it is all too clear to see, whatever we are doing, isn’t working!
The statistical trends appear to follow a relentless path. Globally, obesity has more than doubled since 1980. According to the World Health Organisation, 39% of adults over the age of 18 were overweight in 2014; 13% were obese. The UK Government’s National Child Measurement Programme found that one in five children starting school in England is overweight or obese. By year six (10-11 years of age), it is over a third. The prevalence of obesity among children living in the most deprived areas is more than double that of those living in the least deprived areas, indicating a clear health/wealth divide. In Scotland, the Scottish Government claim that, in 2015, 65% of adults over the age of 16 were overweight, including 29% who were obese. The time trend graphs have followed the same trajectory since the 1990s.
Successive governments have made promising statements about how important it is to have a strategic approach to help reverse the trend. In 2010, a Scottish national obesity strategy was published, rather hopefully entitled ‘Preventing Overweight and Obesity in Scotland’. Unfortunately, this has proved, so far, to have had little effect. The best of intentions have failed to achieve meaningful results.
It must surely now be time to do something more radical. A radical approach was required to deal with the evident health effects and costs of tobacco smoking, which had an impressive effect on the resultant disease profile. Scotland led the way with its smoking ban introduced in March 2006. The ban received a high level of public support. The effects were dramatic: A 17% reduction in admissions for myocardial infarction, a 10% drop in the country’s premature birth rate. There was also a substantial drop in the proportion of people who smoked – down by 8-10%.
What radical adjustments could potentially result in a similar change to the national obesity crisis? There are several elements which might form part of a co-ordinated attempt to discourage some of the root causes.
Our College has strongly promoted the remarkable health benefits which can accrue from regular physical activity. That approach needs to be advanced in new and imaginative ways.
Even more important is the need to deal with the high calorie intake characteristic of the contemporary western diet. It would make perfect sense to fully implement the Soft Drinks Industry Levy (SDIL), actively discourage price promotions of high fat, sugar and salt junk foods and drinks, and restrict the advertising of these products which is unashamedly targeted at children.
There is also now plenty of evidence to support a concerted effort to encourage manufacturers to reduce the sugar and fat content in a wide range of food products.
During the recent Health and Sport Committee hearing at the Scottish Government, Obesity Action Scotland, who are based in our College, strongly recommended brave and bold fiscal and regulatory measures to change our food environment.
The time has come to stop tinkering at the edges of the problem and really make some decisive moves. Without doubt there will be a storm of protest. I can already hear the naysayers revisiting the nanny state arguments. However the effects of obesity are so serious and so far reaching that we must not be swayed from taking the steps required to change direction. Clinicians across the specialty spectrum are well placed to drive this message home. Let us resolve to take every opportunity to try to turn this dangerous tide.
We need to act with conviction to reverse the trend.