SUMMARY

  1.  Although effective weight control is simply about eating differently and getting more exercise, actually achieving this is far from simple. Such lifestyle change requires massive and sustained effort in our present society where food is everywhere and sitting for much of the day is normal for most people.

  2.  Weight Watchers wishes to be seen as a key source of support for overweight and obese people wanting to lose weight.

  3.  Weight Watchers would like to work in partnership with the health care system, especially general practitioners, to ease the clinical burden of obesity-related ill-health. We have reported evidence of our success compared with other approaches to weight management and we are confident that our structured support, through weekly meetings, offers scope for many obese and overweight patients presenting in the primary health care system.

1.   Health implications, trends and causes of obesity prevalence

  1.1  Trends: An alarming 55% of adults in England are carrying excess weight, of which 21% are clinically obese and this leaves around 40% at best in the "normal", healthy weight range (Department of Health 2002). The unquestionable scale of concern about obesity and its rising prevalence, are well established and have been fully reported elsewhere (National Audit Office 2001, WHO 2000).

  1.2  Health implications: Weight Watchers is concerned about health and well-being. The rising obesity prevalence will be causing concern for the health budget because an increase in body fatness leads to increased insulin resistance and Type II diabetes with such predictability that medical experts have now coined the term "diabesity". Our major killer diseases such as coronary heart disease and some cancers, along with conditions that are the source of much suffering and disability such as raised blood pressure (leading to strokes) and osteo-arthritis, are also very strongly linked with obesity.

  1.3  Causes of obesity: The escalating trend in obesity prevalence is clearly caused by an imbalance in energy: from both overeating the wrong sorts of foods (and not getting enough of the right ones) and low energy expenditure, as passive lifestyles are now the norm. Genetically we are programmed to survive at times when food is scarce and our physiology is not well equipped to adjust to the opposite scenario: a lifestyle based on too much energy from food and exceptionally low physical activity levels, now typical in the UK and across the developed world.

2.   What can be done about it?

  2.1  Do nothing?: Without any intervention at all, research shows that overweight and obese people gain more weight with time. Thus our population will simply get fatter and fatter and the prevalence of diabetes, as well as the other obesity related conditions will soar. Doing nothing is not an option, unless we are prepared to continue sliding further down the slippery slope of obesity prevalence in the same way as our cousins in the USA.

  2.2  Government supported massive all-round effort required: Weight Watchers believes the Government should tackle the treatment and prevention of obesity simultaneously. A wide variety of strategies at multiple levels will be needed to steer the whole population towards eating appropriate types of food in appropriate amounts and to be physically active on most days. But such changes are not simple and will require a massive effort. Our food supply is abundant, overeating is so easy, inactivity is ingrained and fatness is met with prejudice and discrimination rather than understanding and support.

  2.3  Lifestyle change with behavioural support: Evidence shows that weight loss in people who are overweight or obese is best achieved not only by changes in diet and exercise but also with behavioural support to guide people's health-related behaviour (Health Development Agency 2002, National Institutes of Health 1998, NHS Centre for Reviews and Dissemination 1997, Thorogood 2001). Even with the use of anti-obesity drugs, which have only a modest effect, lifestyle change remains an absolute necessity.

  2.4  National policy: There is presently no national strategy for obesity prevention or management and international best practice does not lead us to any obvious simple or quick solutions. Despite this, central Government should create national policy across all Government departments, not just health, to move the whole population towards a healthier lifestyle.

  2.5  Local policy: Government should take action at local level to influence lifestyle choices. Local health services for example are required to identify obesity as a public health risk in their Health Improvement Programmes and have dedicated obesity prevention and treatment strategies in place yet evidence suggests activity in this respect is patchy (National Audit Office 2001).

  2.6  Legislation: Ultimately the removal or alteration of laws that currently act as a barrier to healthy eating and/or increased activity and the introduction or extension of laws which facilitate these changes are, in our opinion, the only way to make any real impact on the obesity epidemic in the UK. Such changes in law would add leverage to any national and local obesity policies.

3.   Are the institutional structures in place to deliver an improvement?

  3.1  DH and NHS requirements: Weight Watchers feels the National Health Service should be responsible for the overall management of those who are overweight and/or obese, especially people with associated clinical conditions. Central Department of Health policy guidance on both the prevention and management of obesity and a National Service Framework on Obesity would help the NHS put the necessary systems and resources for obesity management in place.

  3.2  General practice—partnership working?: Within the NHS most contact with overweight and obese people occurs in general practice (National Audit Office 2001). It is clear, however, that despite best efforts, the impact health professionals have on obesity prevalence is small. An obesity counselling and support role has been suggested for healthcare providers (Noel and Pugh 2002), but unfortunately present evidence suggests that health professionals have limited time, finite resources and inadequate skill to deliver effective interventions for weight loss (Harvey 2002). They are therefore neither best placed to give detailed advice about diet and exercise, nor to offer proper behavioural support, nor to provide frequent monitoring. Current clinical guidance for obesity management suggests all of these are essential (National Obesity Forum, 2000, Prodigy 2002).

  3.3  General practitioners are best placed to raise the importance of the health benefits of modest weight loss, and the need for lifestyle change. They then need to refer obese patients on. Dietitians could play a key role not just with patient care, but also with the development of local and practice obesity policy together with skills training. However dietitians are, and will continue to be, in very short supply.

  3.4  Weight Watchers welcomes the Health Development Agency's recent suggestion that the exploration of partnerships between commercial slimming organisations and general practice should be considered as an effective approach to obesity management (HDA 2002). Indeed we are initiating work with several Primary Care Trusts and general practice teams to offer just such partnership arrangements for supporting obese patients.

  3.5  Clinical guidance—options: Following current clinical guidance (National Obesity Forum, 2000, Prodigy 2002), there are four first line treatment options for weight management of obese patients:

—  primary care

—  dietitian

—  commercial slimming group

—  self-help group

  Although it is perhaps obvious that different things will suit different patients, guidance documents are hesitant to rank these four options in any way. One states that "it can be difficult to advise the individual on which group to attend as none have been formally evaluated—getting the practice nurse to look into these may be useful".

  3.6  Weight Watchers is very confident in the quality and appropriateness of its structured group support for obese people and feels they represent some optimism amidst the hopelessness presently felt by health and medical practitioners in the primary care system (Hunt, in press). The outcome of a multi-centre randomised controlled trial over two years suggests that Weight Watchers is more likely to be effective for managing overweight patients than brief counselling and self-help (Heshka 2000, Heshka 2003). Another study, reporting an initial evaluation of only short term results, showed greater improvements for participants attending the Weight Watchers programme than self-help participants, on all measures: weight loss, eating behaviour and mood (Lowe 1999). These Weight Watchers results represent real success compared with other studies examining the impact of different approaches to weight management.

  3.7  NICE guidance welcomed: Weight Watchers particularly welcomes the recent announcement that the National Institute of Clinical Excellence (NICE) in conjunction with the Health Development Agency is commencing work to develop guidance for the identification, prevention and management of obesity. NICE is in a unique position to judge the relative effectiveness of different approaches and make authoritative recommendations for good practice.

  3.8  Commercial slimming groups

  To our knowledge, Weight Watchers is one of the only commercial slimming organisations to publish scientific data in peer-reviewed medical journals showing its efficacy as described in 3.3. (Heshka 2000, 2002, Lowe 1999). Perhaps the most encouraging data from Weight Watchers relates to the maintenance of weight lost. Among participants in Weight Watchers who had reached their goal weight five years previously, just under 30% had remained within five pounds of goal weight since becoming lifetime members (Lowe 2001). Almost half of lifetime members had maintained a weight loss of 5% or more after five years and a substantial majority (70%) were still below their starting weight five years later. As scientific review evidence indicates that most lost weight is regained within five years (National Institutes of Health 1998), again these data from Weight Watchers represent real success.

4.   Recommendations for action by Government

  Many suggestions for national strategy and policy are made throughout the National Audit Office report of 2001, "Tackling Obesity in England". We feel this provides an excellent starting point for Government action and will not duplicate those suggestions here. We have made a number of other suggestions throughout this paper.

  We believe that the level and scope of effort Government would need to take to have an impact on obesity prevalence in the UK is vast. It would inevitably require significant financial resources, committee support and energy from the centre (Department of Health) alongside ultimate legislative change.

April 2003

REFERENCES

  Department of Health (2002) Health Survey for England 2000. DH: London

  Harvey EL, Glenny A-M, Kirk SFL, Summerbell CD (2002) Improving health professionals' management and the organisation of care for overweight and obese people (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.

  Health Development Agency (2002) Reducing overweight and obesity: features of effective interventions. In: Cancer Prevention: A resource to support local action in delivering The NHS Cancer Plan. HDA: London.

  Heshka S et al. (2000) Self help weight loss versus a structured programme after 26 weeks: a randomised controlled study. American Journal of Medicine. 109: 282-287.

  Heshka S et al (2003) Weight loss with Self-help compared with a Structured Commercial Programme: A randomised trial. Journal of the American Medical Association 289 (14): 1792-98.

  Hunt (in press) Weight control through group support: optimism amidst hopelessness. NHS Journal for Health Professionals.

  Lowe M R et al (1999) An initial evaluation of a commercial weight loss programme: short term effects on weight, eating behaviour and mood. Obesity Research, 7: 51-59.

  Lowe M R et al (2001) Weight-loss maintenance in overweight individuals one to five years following successful completion of a commercial weight loss programme. International Journal of Obesity Related Metabolic Disorders, 25: 325-331

  National Audit Office (2001) Tackling Obesity in England. Report by the Comptroller and Auditor General. London: The Stationery Office.

  National Institutes for Health (1998) Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults—the evidence report. Obesity Research: 1998; 6 (suppl 2): S51-209 (Published erratum appears in Obesity Research 1998 Nov; 6 (6): 464. Executive summary in: Arch Intern Med 1998; 158: 1855-67.

  National Obesity Forum (2000) Guidelines on Management of Adult Obesity and Overweight in Primary Care. Nottingham: National Obesity Forum.

  NHS Centre for Reviews and Dissemination, University of York (1997) The prevention and treatment of obesity. Effective Healthcare Bulletin. April 1997, Volume 3, No 2.

  Noel P H, Pugh J A (2002) Management of overweight and obese adults; clinical review. British Medical Journal 2002; 325: 757-761 (5th October)

  Thorogood M, Hillsdon M and Summerbell C (2001) Changing Behaviour. Clinical Evidence 6, 31-49.

  World Health Organisation (2000) Obesity: preventing and managing the global epidemic. Geneva: WHO (WHO Technical Report Series: No 894).

  Wyatt H R, Wing R R, Hill J O (2002) The National Weight Control Registry in "Evaluation and Management of Obesity" by Bessesen D and Kushner R: from The Centers of Obesity Research and Education. Hanley&Belfus: Philadeplhia.

WEBSITES

  National Obesity Forum www.nationalobesityforum.org.uk

  PRODIGY (2002) Guidance on Obesity: Practical Support for Clinical Governance in the NHS www.prodigy.nhs.uk/Clinical Guidance

  National Weight Control Registry in the USA. www.lifespan.org/services/bmed/wt-loss/mwcr