SUMMARY

  It must be recognised that at least two problems exist. One is to find strategies that will assist the obese and overweight to lose weight and maintain that weight loss, and the other is to prevent the increase in obesity by a prevention strategy.

  Currently the government is trying to kill two birds with one stone and misses both.

  Concentrating on the promotion of a healthy diet, containing adequate amounts of fruit and vegetables has neither halted the increase in overweight and obesity nor resulted in a decline.

  It must be recognised that tackling obesity is a complex problem. The obese do not need more advice on what is healthy eating; they do not need telling that they must eat less, and they do not need yet another diet sheet.

  Because obesity is seen by many as simply a lifestyle issue and not itself the cause of death, the co-morbidities are treated, not the eating disorder itself. Whereas, anorexia is seen as a direct cause of death the eating disorder is treated. Those suffering from obesity are told to just eat less; those suffering from anorexia are not told to just eat more.

  Obesity continues to be on the back burner of healthcare.

  How much is lack of physical activity contributing to the problem?

  A cheese sandwich is 500 Calories—it can be eaten in one minute. A pound of fat is 3,500 Calories. Overeating seven sandwiches or their equivalent will add one pound of fat. A total of seven minutes a day, or spread over a week, a leisurely one minute per day. It can take someone following the one-a-day sandwich regime 14 weeks to gain a stone. Total eating time taken to gain that stone—98 minutes.

  A five mile run or walk burns up the 500 Calorie sandwich; 35 miles to burn up one pound of fat. To walk off that extra stone they would have to walk from Lands End to John o' Groats on top of normal day to day living. And, that's assuming they stop eating that extra sandwich. This takes quite a bit longer than 98 minutes.

  In the light of the pressures put on the public to buy high calorie convenience foods, we propose a tax on their advertising and marketing spend used to market the healthy unprocessed options would go someway to counteract that influence.

  General Practices are where 95% of patient contacts with the NHS occur and are often the first port-of-call for persons seeking help and they obviously have potential to tackle overweight and obesity issues.

  Our research suggests that 90% of obese questioned thought that GPs did not, or only occasionally, provide the right kind of support. Similarly, 90% thought dieticians did not either. The GP may not be the first port-of-call but rather the last, when people are so desperate they feel they have nowhere to turn.

  Most obese people are confused by the contradictory nutritional messages that have been proposed over recent decades.

  The food pyramid as was known, with carbohydrates eaten in larger quantities than fats, is to be turned on its head, as reported in the Telegraph on Friday the 11 April 2003 following research by Professor Walter Willetts of Harvard University, published in the Scientific American. He recommends that carbohydrate be restricted and proteins and fats are increased.

  It is not so much about strategies being coherent, rather patchy. Different initiatives are available in different areas. There are no national initiatives for local strategy, local initiatives are poorly funded, poorly marketed and at best, inconsistent.

  However, although acknowledging the power of the individual, with 50% of the population overweight or obese we, society, industry must take responsibility for the very strong pressures that are exerted and work together.

  What the individual needs to make good choices is appropriate education, information, availability of healthy food at an affordable price.

  Obesity is not only a health concern but also a social problem.

  It is not unusual for explanations of the increase in obesity to focus on environment, behaviour and genes. Whilst not denying the power of environmental changes, it is important not to ignore the role the individual has in their interaction with their environment.

  The food choices of all human beings are made for a variety of reasons, ranging through appropriate "dinner time" hunger, stress leading to under eating, stress leading to overeating, a scrumptious looking dessert trolley to celebratory meals. As well as looking at the observable behaviour, such as how much is eaten; it's useful to look at what drives food choices, the cognitions and emotions that lie behind.

  For treatment programmes to be effective there needs to be more understanding of the complexity of the problem. Many programmes are too short-term and pay little attention to the skills of weight maintenance.

  TOAST is concerned that local and national schemes will not include effective programmes and will "fail" and obesity and obese people will be labelled as hopeless and once again put on the back shelf of health care.

  Increased exercise can be important in a healthier lifestyle. When combined with a lower energy intake can be part of a weight loss programme. However, focussing on healthy eating and physical activity (HEPA) as the main (if not only) solution to the obesity epidemic will not alter the course of the pandemic of overweight and obesity.

  We need to stop treating obesity at the simplest level. There are many influences on an individual's obesity development. If the government involves only organisations that advocate healthy eating and physical activity, they will be missing the many other strategies that could help. If an individual looks only to food and lack of activity as the cause of their obesity they are less likely to find their solution.

  A 5% to 10% weight loss produces valuable health improvements, but such a small reduction is not acceptable as the only goal of treatment. The health benefits increase as the weight loss increases.

  There has been a tendency for all obese people to be grouped together as one homogenous lump. A "one size fits all" treatment approach will not work.

  Overweight and obesity have a wide range of different causes, and tackling the problem requires those living with these problems to have access to a wide range of different solutions.

  For many types of obese there are strong links to the aetiology of those with a drink problem. Observing effective addiction treatment programmes would provide useful insights.

  The "whole practice" approach enables good use of skills and resources. Counsellors within primary care and in the private sector are seldom discussed. For instance they are not mentioned in the National Audit Office Report. Again the general psychological and emotional well-being of the patient is not discussed in the National Audit Office Report. There is a lack of differentiation of possible approaches.

  The Department of Health can have little impact acting in isolation, and joined up approaches are required. However, it is important that the "chain" does not just consist of Healthy Eating and Physical Activity links. The NHS could engage more constructively with the private and commercial sectors. It alone cannot manage a problem that will soon afflict a quarter of the population.

  Working with young people is vital. Along with promoting a healthy school environment it is also necessary to distinguish the different needs between the overweight child and the child who is already obese.

  TOAST would research programmes that provided a wider selection of evidence based prevention and treatment data to enable the development of local and national cost-effective strategies both in the NHS, private and commercial sectors.

  Prevention is important but it must not be the only focus. Costs will also increase if the incidence of obesity stays the same because the existing obese population is aging.

  Weight maintenance is rarely mentioned as in the case of the National Audit Office Report, with no mention at all in the Executive Summary. The point that often gets missed is that it is not weight loss skills that are the most difficult, but rather weight maintenance skills.

  The National Audit Office Report frequently acknowledges its underestimation of the costs of obesity. NICE estimations suggest a much higher cost, quoting a figure of £1.9 billion. With such a cost it is not acceptable that the NHS is investing only £9.4 million. We understand from the Audit Office that most of the funding used by hospital obesity clinics is actually obtained via other departments. There is obviously a need for greater investment.

  The current system isn't working. The message that the government puts out needs to be simple and initiatives need to be co-ordinated.

  1.  Health Outcomes—Economic and social costs—What efforts is the Government making to evaluate these

  1.1  What are the health outcomes of obesity in society?

  The health outcomes of obesity are well documented elsewhere; type II diabetes and hypertension being the most prevalent. Reducing weight reduces both the risk of developing these conditions and enables 80% to 85% of those already medicated to reduce or cease medication. Predictions are that if the epidemic continues the medication costs for these two conditions alone will bankrupt the National Health Service (NHS).

  To compound the problem, diabetic medication increases appetite, which often increases weight, which means medication needs to be increased and so the cycle continues.

  1.2  What are the economic and social costs?

  Refer NAO

  Obesity is not only a health concern but also a social problem. Many obese experience life as an outsider in a society that frequently rejects them. We all live in a culture in which "thin is in". When shown pictures representing various disabilities, both children and adults indicate that obesity is the type of disability they would least prefer (Richardson et al 1961). Obesity creates obstacles to marriage (Elder 1969) and to employment and promotion.

  In the National Audit Office report (NAO) note is made of the stigmatisation, prejudice and discrimination of obese children and adults;

"Obese people, and the severely obese in particular, are more likely to suffer from a number of psychological problems, including binge-eating, low self-image and confidence, and a sense of isolation and humiliation arising from practical problems." and "It is difficult to separate cause from effect in the relationship between obesity and psychological disorders. Whilst mental well being may suffer as a result of the pressures associated with being obese, psychological problems may equally contribute to the type of behaviours, such as emotional and binge-eating, that can result in the onset of obesity." The "thin is in" society contributes to increasing the stress levels of many obese which in turn increases comfort eating.

  1.3  What efforts is the Government making to evaluate these?

  The NAO ( 2001) report reported on many of the economic costs of obesity, although confirmed to us that the figures quoted were grossly underestimated. For example only direct health costs were included; no figure was included for days off work due to back pain due to obesity.

  Up until the publication of The Health of the Nation Report in 1992 overweight and obesity had had little attention from the government, being seen primarily as the problem of the individual who was implicitly judged to be a gluttonous, weak willed creature who should "just eat less".

  The Health of the Nation Report identified the co-morbidities and therefore some of the financial costs of obesity and set targets to reduce the incidence from 12% back to the 1980 level of 8%. Around the same time the World Health Organisation labelled obesity an epidemic.

  Following the report, the government organised a "one-day" symposium on obesity to implement strategies to reduce obesity. The symposium was held under the joint auspices of the Health of the Nation Nutrition and Physical Activity Task Forces. Its subsequent report focused, not surprisingly, on healthy eating and physical activity alone as "the" solutions to the epidemic. This "cure" is still the main focus of recommendations today.

  The "Health of the Nation: A Progress Report" published in 1996 identified that obesity targets were actually moving in the wrong direction and that the proportions of obese men and women in the population aged 16 to 64 had risen to 13% and 16%; whereas the target was to reduce the proportion of obese men from 7% in 1986-87 to 6% in 2005, and obese women from 12% in 1986-87 to 8% in 2005. Following the failure of the government to meet the targets they had set in 1992, the 1999 publication "Saving Lives: Our Healthier Nation" set no targets at all. With the obesity epidemic raging, obesity had been dropped, with no strategy being pursued to reduce or limit it. There was a feeling amongst those living and working with obesity that the government hoped that if they ignored obesity, and the obese, then it, and they, would go away.

  For decades, obesity research had shown there to be virtually no measurable medical explanation for the problem. Obesity had been dismissed as an issue of gluttony and sloth and the obese person labelled as greedy, stupid and lazy. Doctors had been giving out diet sheets for years and most of their patients just didn't "try hard enough". The perceived solution was simple, they just had to eat less and get on their bikes. In the early 1960s there was a similar attitude to people with drink problems. At that time the alcoholic had little support from the NHS and was seen as a sinner, at best to be pitied.

  The National Service Framework for coronary heart disease was published in March 2000 giving the following milestones to primary care;

  By April 2001 HAs, LAs, PCGs/PCTs, and NHS Trusts will:

—  Have agreed and be contributing to the delivery of the local programme of effectiveness on reducing overweight and obesity

  By April 2002

—  Have quantitative data no more than 12-months old about the implementation of the policies on reducing overweight and obesity

  Our concern is that GPs haven't even found the milestones deep within the Framework—never mind actioned them. We have asked for, but not received evaluation of the milestones.

  2.  Trends—among particular groups; class, age, gender, ethnicity and lifestyle.

  2.1  What are the trends in obesity?

  The epidemic continues and it is well documented that obesity is more prevalent amongst C,D,E social groups, although by no means exclusive to these groups. Childhood obesity on the increase and the gap between genders is narrowing.

  2.2  What is the relationship between obesity and other health inequalities?

  Because obesity is seen by many health authorities as simply a lifestyle issue and not itself the cause of death, the co-morbidities are treated, not the eating disorder itself. Whereas, anorexia is seen as a direct cause of death and that eating disorder is treated. Those suffering from obesity are told to just eat less, those suffering from anorexia are not told to just eat more.

  Obesity continues to be on the back burner of healthcare.

  2.3  What are the international comparisons?

  The WHO and IOTF have documented the world wide spread of the obesity epidemic.

  3.  Causes of Rise—Changes in diet, lifestyle

  3.1  What has been the role of changes in diet?

  The findings of the National Food Survey suggested that energy intake increased from the late 1950s to a peak in 1970, and since then has decreased. Their results are often quoted. As the NAO report says "On this basis, the major increase in the prevalence of obesity in England, since 1980, has occurred at, a time when the energy consumed from food appears to have been decreasing."

  A lot of research has used the data that showed that home consumption of food had decreased to argue that the main reason for the obesity epidemic is lack of exercise. One example of this is the "Effective Healthcare Bulletin" mentioned in the NAO report as "The main source of guidance to health care professionals"". The Bulletin, although acknowledging that eating outside the home "may also contribute to this trend," states "[The increase in obesity] has occurred despite a reduction in the total average energy consumption, suggesting that sedentary lifestyles are the most important factor."

  But as the NAO report points out. "However, it is important to note that the falling trend in energy intake suggested by the National Food Survey does not take account of alcoholic, soft drinks and confectionery brought home, or food and drink purchased and eaten outside the home."

  Food consumed outside the home has in fact steadily increased, from under 600 million meals served in UK restaurants in 1995, to nearly 680 million in 2000 (Foodservice Intelligence 2001).

  Look at any high street and see that there is no longer the butcher, the baker and the candlestick maker, but an increasing number of restaurants and takeaways.

  In the 1950s families ate their "meat and two veg" together. Today, there is a much wider range of high calorie, processed foods and less structured eating. Much obesity is not caused by food eaten with a knife and fork.

  3.2  To what extent have changes in lifestyle been influential?

  Stress levels have increased over recent decades and many obese people use food as a coping mechanism in the same way that some use cigarettes, alcohol and other substances and behaviours. Some other addictions have also increased over recent years.

  At the simplest level obesity is caused by eating more than a body needs. The food choices of all human beings are made for a variety of reasons, ranging through appropriate "dinner time" hunger, stress leading to under eating, stress leading to overeating, a scrumptious looking dessert trolley to celebratory meals. We have asked a variety of groups why they think obese people over eat. The following list is typical of the answers given:

Boredom		Guilt
Anger		Shame
Stress		Because it's there
Loneliness		Pressure from other people
Happiness		Going to start a diet tomorrow
Revenge		Frustration
Depression		It's Sunday
Addiction		Pleasure
Habit		Unloved
Not appreciated		Unfulfilled
Tired		Unsatisfied
Unhappy		To celebrate
Comfort		Holidays

  As well as looking at the observable behaviour, such as how much is eaten, it's useful to look at what drives food choices; the cognitions and emotions that lie behind.

  Paragraph 13.2 of the NHS Plan states "The worst health problems in our country will not be tackled without dealing with their fundamental causes." We have to stop treating obesity at the simplest level.

  Many people have higher levels of disposable outcome than in previous decades and although food bills now form a smaller part of overall expenditure, more money is available for socialising and food is frequently part of such events.

  As obesity has increased so has TV and car ownership.

  3.3  How much is lack of physical activity contributing to the problem?

  A cheese sandwich is 500 Calories—it can be eaten in one minute. A pound of fat is 3,500 Calories. Overeating seven sandwiches or their equivalent will add one pound of fat. A total of seven minutes a day, or spread over a week, a leisurely one minute per day. It can take someone following the one-a-day sandwich regime 14 weeks to gain a stone. Total eating time taken to gain that stone 98 minutes.

  A five mile run or walk burns up the 500 Calorie sandwich; 35 miles to burn up one pound of fat. It takes, bearing in mind we're talking about the obese population—one hour, two hours or impossible to run/walk five miles.

  To walk off that extra stone they would have to walk from Lands End to John o' Groats on top of normal day to day living. And, that's assuming they stop eating that extra sandwich. This takes quite a bit longer than 98 minutes.

  Exercise has many benefits to health and burning up more Calories is one of them. But it's important that the committee realise the limitations of typical exercise regimes to the management of obesity.

  Frequently, the emphasis on exercise and level of exercise required can be misleading and lead to a sense of failure in the obese person, which they typically deal with by overeating:

  Because losing weight reduces the risk of coronary heart disease (CHD), obesity has a mention in the National Service Framework for Coronary Heart Disease (2000). However, because the focus of this document is on reducing the risk of CHD, the levels of activity recommended are also focused on how much exercise an individual needs to do to reduce that risk. And, unfortunately, the level of activity required to be fit and the level required for weight loss are different. Thirty minutes a day is for prevention of CHD; in order to lose weight this needs to be substantially increased.

  The NAO report, along with many others, states that the Framework is one of the key initiatives to demonstrate the importance attributed by the Department of Health to the prevention of obesity, providing guidelines for levels of exercise.

"focuses on local action designed to prevent coronary heart disease, such as by promoting healthy eating and physical activity and reducing overweight and obesity." Many obese think that going to the gym three times a week will sort their obesity problem. When it doesn't they become disillusioned and often stop exercising altogether, missing out on the benefits to health.

  Whilst thirty minutes a day reduces CHD risks, this regime, if followed to the letter and assuming no overeating, in a year will result in about one stone of weight loss.

  4.  What can be done—levers and drivers—food industry, marketing, education, family life, genetics, drugs, surgery, transport.

  4.1  What is the range of levers and drivers?

  When considering the range of levers and drivers it is necessary to look both at the internal and external forces at work.

  Why do human beings make the choices they do? At some level of consciousness they weigh up the pros and cons of the results of the choices open to them. Some choices at first glance seem to be destructive; the man or woman who, again, chooses to stay within a violent relationship; the man or woman who has extramarital affairs despite the risk to their careers, the man or woman who uses their credit cards to the point of financial ruin, the man or woman who has one drink too many and loses their driving license, the new year's resolution that disintegrates on January 2nd, the decision to have "just one" cigarette after a month of abstinence. Human beings are capable of making choices which at one moment seem to be the right choice only to be regretted later. People can make change, however, any agency involved in helping others to achieve change needs to understand the process of change.

  However, although acknowledging the power of the individual, with 50% of the population overweight or obese we, society, industry must take responsibility for the very strong pressures that are exerted and work together.

  What the individual needs to make good choices is appropriate education, information, availability of healthy food at an affordable price.

  Even though human beings are ultimately responsible for their choices, the pressures from others are an integral part of individuals' choices.

  4.2  What are the responsibilities of the food industry in respect of marketing?

  There is no question that the increase in easily available high fat foods is an important contributor. The "epidemic" of fast food outlets and 24-hour petrol stations (where it's often impossible to find anything that isn't high in fat) has occurred in parallel with the obesity epidemic.

  One of their responsibilities is to "say it how it is", not mislead the consumer with misinformation.

  Not to price healthy options out of the range of those living on a low budget.

  TOAST fully understands that the purpose of marketing is to optimise sales but believes this need not be compromised and that solutions can be found to benefits of the food industry and the obese.

  Those involved in solving the obesity epidemic could benefit from observing industries such as advertising and food who understand what makes their customers tick.

  4.3  How influential is the media?

  The media promotes overeating in cooking programmes, few of which focus on low fat eating, soap operas are based around people eating, food advertising between programmes. Newspaper articles in cooking in high fat ways. On the other hand there are weight loss programmes following celebrities or general public losing or failing to lose weight. The media contradicts itself, on the one had they promote thinness, on the other hand they promote eating and food.

  4.4  How can the amount of physical activity being undertaken be increased?

  Exercise on Prescription was received well by obese people.

  City keep fit programmes, such as that which took place in New York are good motivators.

Encouraging physical activity in the schools, and then a system where this can be carried on after school leaving age, and using school facilities for the community.

  Safe exercise facilities. TOAST does not believe a safe cycle route is created by putting a line on the road. For cycle routes to be valuable they need to be physically separated from other road users.

  People need to be encouraged to stop using sport as a spectator sport, and join in. In Norway, every town has a walk in on a Sunday morning. Socialising sport, making it a socially acceptable recreation.

  4.5  To what extent can and should Government, at central and local level, influence lifestyle choices?

  Government needs to recognise Obesity is a complex issue, they need to look at the underlying causes, rather than assume it is simply a healthy eating and exercise issue. The healthy eating and physical activity message has been advocated for some time, and the obese know that because it is a complex issue, eating five bits of fruit a day, is not going to sort the issue. If you want to know how many calories are in any food, ask an obese person.

  It is important for policy makers to understand that more is needed.

  For many types of obese there is a strong link to the problems of those with a drink problem; many talk of sometimes feeling out of control around food. The experiences of those working with alcoholics have led to an understanding that the alcoholic is not "cured" because they have not had a drink for weeks, months or even years. They also don't think the problem drinker is going to stop misusing drink by teaching them how to read the labels on bottles in the supermarket to find the one with the lowest alcohol content. The alcoholic doesn't drink too much because they are abnormally thirsty.

  All the alcohol treatment programmes we know of use some form of counselling within their treatment profile. They recognise that the alcohol is often used as a coping mechanism, to drown sorrows, for swallowing anger, blotting out the pain, to be part of the crowd. Many overeaters will recognise these behaviours and reasons for over consuming. Alcohol treatment programmes help people to recognise why they have been over consuming and to find other coping mechanisms, helping clients build belief in them.

  What other health problem effecting almost a quarter of the population would have this question asked of it. It is important to stop seeing obesity as simply a lifestyle issue.

  We are not suggesting that the government create a nanny state, however, the management of public health risks such as obesity falls within the Department of Health's strategic objective "to reduce avoidable illness, disease and injury in the population". Where the behaviour of industries affects people's health and well being, government intervention is both commonplace and justified. As is the case with individual behaviour, as exemplified by car seatbelt regulations.

  The NHS Plan proposes "a major expansion in smoking cessation to give England a world-leading service" including "focus on heavily dependent smokers needing intensive support"

TOAST is concerned that there is no such proposals for dealing with overweight and obesity. . . There are similarities with overeating and other addictions, including smoking.

  The NAO report says; "We carried out this study. . .to make recommendations that might help to create a climate in which individuals are aware of the consequences of obesity, and can make informed decisions about their lifestyle. In this we draw a parallel with another serious lifestyle issue—smoking—where such an approach has been successful in reducing prevalence within the population as a whole, if not in all sections of it."

  4.6  How coherent is national and local strategy?

  Most obese people are confused by the contradictory nutritional messages that have been proposed over recent decades.

  The food pyramid as was known, with carbohydrates eaten in larger quantities than fats, is to be turned on its head, as reported in the Telegraph on Friday 11 April 2003 following research by Professor Walter Willetts of Harvard University, published in the Scientific American. He recommends that carbohydrate be restricted and proteins and fats are increased.

It is not so much about strategies being coherent, rather patchy. Different initiatives are available in different areas. There are no national initiatives for local strategy, local initiatives are poorly funded, poorly marketed and at best, inconsistent.

  4.7  What is international best practice?

  The WHO and IOTF have documented the world wide spread of the obesity epidemic. TOAST recommends we look to their work to identify and use best practice from these.

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

  With just twelve specialist obesity clinics, the vast majority of Primary Care Teams unaware of their obese patients and frankly uninterested and unaware of the aetiology of the problem, no national treatment guidelines and one obese person dying every seventeen minutes it is safe to say that the institutional structures are not only not in place to deliver an improvement but are not even waiting in the wings to be put in place.

  Secondary and tertiary care

  Where specialist clinics do exist the majority are highly constrained by resources and therefore the number of patients they can treat. We understand from the Audit Office that most of the funding used by hospital obesity clinics is actually obtained via other departments.

PRIMARY CARE

  General Practices are where 95% of patient contacts with the NHS occur and are often the first port-of-call for persons seeking help and they obviously have potential to tackle overweight and obesity issues.

  Our research suggests that 90% of obese questioned thought that GPs did not, or only occasionally, provide the right kind of support. Similarly, 90 per cent thought dieticians did not either. The GP may not be the first port-of-call but rather the last, when people are so desperate they feel they have nowhere to turn.

  General Practices provide healthy living information leaflets in their surgeries, but the NAO report identified that "None of the general practitioners or practice nurses we interviewed had evaluated the extent to which material was used by patients or its impact on lifestyle. However, given the rate at which the prevalence of obesity is increasing in England, there may be benefits for all general practices, rather than around half as at present, to make information available to all patients on the risks of obesity and how to manage one's weight."

  Or maybe not! There is a danger that a national leaflet campaign will be instigated, based on no evidence of effectiveness, perhaps just to be seen as "doing something".

  The NAO report commented that "Some patients listen better to the nurse than to the doctor" Rather than only thinking about how to get patients to "listen better" we suggest there is a role for counsellors to "listen to the patient". It's not unusual to hear an obese person say that "no one listens or understands". Appropriately trained counsellors are also the obvious professionals to help the patient to understand why they use food in the way that they do and help people motivate themselves towards change.

  Exercise on prescription is an initiative that allows general practitioners to refer patients for free or subsidised exercise programmes under the supervision of a qualified trainer. We have had positive feedback from patients who have been using this scheme. They felt helped by their GP.

Exercise on prescription cares for the body. It is important to remember that humans are not just "the kidney in bed 63" and are also thinking feeling creatures too, with a set of beliefs, thoughts and habits that need changing.

THE DEPARTMENT OF HEALTH

  The NHS cannot manage a problem that will soon afflict a quarter of the population. TOAST welcomes the NHS Plan's call to engage more constructively with the private sector as well as the commercial sector.

  The DoH can have little impact acting in isolation, and joined up approaches are required including liaising with the key representatives of other Government departments in order to advise on policies and initiatives to improve health, in particular to diet and nutrition, health education, transport and physical recreation.

  The NHS Plan states the intention to tackle obesity and physical activity, informed by advice from the Health Development Agency. Initiatives with the food industry planned over the next few years to improve diet, including increasing fruit and vegetable consumption and reducing salt, fat and sugar intake, although important for improving health this will not solve the obesity problem.

  An NHS investment of 9.4 million to deal with a problem costing upwards of 1.9 billion is not acceptable.

FOOD INDUSTRY

  The DoH can learn a lot from the food industry and their marketing departments who understand their customers well and know how to fulfil their needs.

  A fat tax has been suggested. In the light of the pressures put on the public to buy high calorie convenience foods, we propose a tax on their advertising and marketing spend used to market the healthy unprocessed options would go someway to counteract that influence.

TOAST is concerned about the recent industry sponsorship activities and the inconsistent message this gives to children. There is a great need to explore the positive contributions that business can make to education and to obesity in general.

  5.5  To what extent is the Food Standards Agency influential?

  An important aspect of the work of the Food Standards Agency in relation to overweight and obesity is to ensure that information provided to consumers about the food they buy is accurate, adequate and not misleading.

  Government advice is that only 25%-30% of our Calorie intake should be from fat. Firstly, this level of fat intake is a guideline for healthy eating, based on a consensus opinion by European officials, some of whom also have an interest in protecting export markets of various fat products. Secondly, the guideline is a recommendation for healthy eating, not for weight loss. The overweight and obese would benefit from a lower intake to help achieve a negative energy balance.

  Thirdly, the current labelling information does not easily allow people to choose their fat intake. Fat has nine calories per gram and protein and carbohydrate have four calories per gram. Currently labels show fat weight. Most people would need a calculator to find the percentage of fat in the product.

  Many, knowing that the low fat version is healthier, think they are buying a product that complies with the guidelines when in fact they are not. An example of this is:

  Currently, to work out what is the percentage of fat calories in a product, the following computation needs to be undertaken:

1.  Multiply the fat grams (weight) by nine

2.  Divide the answer by the total calories per 100 grams

3.  Multiply by 100 to give percentage fat calories

  This is a complicated enough process given a quiet place and a calculator let alone in a supermarket, in a hurry and perhaps with an anxious child.

  Clear, readable labels showing percentage from fat calories would also stop misleading claims about a product being % fat free. Some products carry a banner on the front of the packaging declaring the product to be, for example, 85% fat free. Most people interpret this as meaning only 15% of the calories in the product are from fat. In reality the percentage of calories from fat can be twice as much.

  Even the Food Standards Agency in their labelling initiative Sanco/1341/2001 paragraph 28, state that "80% fat free is a product with 20% fat content, quite a high fat content for most products, but the claim 80% fat free can lead consumers to assume that the product is low in fat."

  5.7  What is the role of schools, including sport in schools?

  Working with young people is vital. Along with promoting a healthy school environment it is also necessary to distinguish the different needs between the overweight child and the child who is already obese: if a child is asked to pick fellow team members for a match, the obese child will be one of the last picked, along perhaps with "four eyes". This is where, for the obese child, the psychological pain of obesity has its roots. When after school sports events take place no wonder the fat child chooses not to join in and spends time alone with a packet of crisps. If they are bullied they are more likely to over consume food, finding some solace in that substance in the same way that adults do; food is the easily accessible substance of comfort for all children. Older children and adults also have alcohol, cigarettes, drugs, gambling, sex, shopping etc.

  Confusion is created when considering anorexia. Because there is a strong suggestion of a link for some between dieting and anorexia, putting any child on a diet is seen as negative. There is no question that too much emphasis is placed on slimness for children and that this contributes to negative self-images. However, children are not a homogenous group and the severely obese child needs different advice from normal weight or anorexic children. Obese children need specialist support as just putting them on a diet is inappropriate.

  The Department for Education and Employment's general objective is to ensure that all young people reach 16 with the skills, attitudes and personal qualities that will give them a secure foundation for lifelong learning, work and citizenship in a rapidly changing world."

  This objective encompasses some of what TOAST feels is important in helping people to learn about and change to a healthier lifestyle when it identifies the "skills, attitudes and personal qualities" that lie behind "learning". Before somebody is able to learn they need to have the right attitude.

  6.  Recommendations for national and local strategy—Recommendations for action for consideration by the Committee

  6.1  How can the Government's strategy be improved?

  By recognising that that at least two problems exist. One is to find strategies that will assist the obese and overweight to lose weight and maintain that weight loss, and the other is to prevent the increase in obesity by a prevention strategy.

  Currently the Government is try to kill two birds with one stone and misses both.

  Concentrating on the promotion of a healthy diet, containing adequate amounts of fruit and vegetables has neither halted the increase in overweight and obesity nor resulted in a decline.

  It must be recognised that tackling obesity is a complex problem. The obese do not need more advice on what is healthy eating, they do not need telling that they must eat less, and they do not need yet another diet sheet.

  If you want to know the calorific value of any foodstuff; ask someone who is obese. Most know more about healthy food and diet than most thin person.

  To halt the incidence of obesity it must be recognised that to make the lifestyle change required, there must be lots of support.

  The message to smokers used to be "it's not good for you, just quit". There has since been a realisation that it is easy to say, and not so easy to do and there are now some very good initiatives that recognise the problem for what it really is, and the big brother rhetoric has been replaced with understanding, support and recognition of the enormity of the task. The "Don't Give Up Giving Up" campaign shows that there is an understanding of how difficult it is to stop smoking.

  Obesity has to dealt with in the same way.

  We have to stop just telling people what they should do, and then blaming them when they can't do it.

  We need to recognise the enormity of the task on an individual basis, and give people the support, understanding and help that they need.

  Many obese talk of feeling out of control around food, experiencing cravings. Research still continues to look at the addictive aspects of some foods. Certainly the label "chocoholic" is commonplace.

—  Food presents a complex set of issues because nicotine is not required for health, whereas food is. For many types of obese there are strong links to the aetiology of those with a drink problem. Observing effective addiction treatment programmes would provide useful insights.

  We think the obese would benefit from a "Tsar" who would be responsible for bringing together all the different disciplines and departments to provide a "joined up approach to reduce obesity. This would not be the same person whose role it would be to implement an obesity prevention problem. We have to get away from the idea that the two problems are the same. They are fundamentally different and need a fundamentally different approach. A "one size fits all" treatment approach will not work.

  Roles and activities of government departments

"Overall, we found a substantial amount of co-operative and cross-departmental work related to obesity.

  Firstly those addressing the population as a whole:

(i)  promoting active transport;

(ii)  promoting more active recreation in society; and

(iii)  identifying and promoting healthy patterns of eating

  And secondly, those targeting children and young people:

(iv)  equipping young people for a healthier lifestyle;

(v)  promoting a healthy school environment;

(vi)  promoting healthy travel to schools; and

vii)  promoting healthy eating in schools."

—  Weight maintenance is rarely mentioned and the point that often gets missed is that it is not weight loss skills that are the most difficult, but rather weight maintenance skills.

  By treating obesity at the simplest level; advocating healthy eating and physical activity, many other strategies that could help will be missing.

  6.2  What are the policy options?

  There are no national guidelines for health authorities on the way in which their plans should address obesity. The most relevant guidance was published in March 2000 as part of the National Service Framework for coronary heart disease.

  By April 2001 HAs, LAs, PCGs/PCTs, and NHS Trusts will:

—  Have agreed and be contributing to the delivery of the local programme of effectiveness on reducing overweight and obesity

  By April 2002

—  Have quantitative data no more than 12 months old about the implementation of the policies on reducing overweight and obesity

  Our concern is having set the milestones in 2000 there is no follow up to see what has been done. The onus has been placed on the overstretched GP, many of whom are not even aware that they were supposed to be implementing these milestones and have nothing to report in April 2003 because they have done nothing.

—  TOAST would welcome funding to research programmes that provided a wider selection of evidence based prevention and treatment data to enable the development of local and national cost-effective strategies both in the NHS, private and commercial sectors.

  The current system isn't working.

  The message that the government puts out needs to be simple and initiatives need to be co-coordinated.

"The main source of guidance to health care professionals and the NHS on the effectiveness of interventions to treat obesity was published in 1995 in an `Effective Healthcare Bulletin'".

  Some of the findings of the research reported in this document suggest;

—  Progression of obesity in high-risk children may be prevented by family therapy

—  some behavioural interventions alone are effective

—  cognitive therapy (when effective) may have more impact when of longer duration

—  no evidence of a difference between long-term effects of individual and group therapy

—  the combination of diet and exercise appeared to more beneficial for weight loss than diet alone

—  very low calorie diets and standard behavioural therapy were more effective than diet alone

—  behavioural drug treatments and surgery have been shown to be effective

—  no evidence to suggest that behavioural therapy in conjunction with a prescribed diet is more effective in an inpatient than outpatient setting

  It also states that "No studies of alternative therapies and none evaluating the effectiveness of commercial weight loss programmes met the inclusion criteria" and that "the cost-effectiveness of commercial weight loss programmes and alternative therapies should be investigated".

  How much weight should be lost?

  Because many weight loss regimes can only reduce weight by 10%, this is in danger of becoming the bench mark for weight loss.

  A person who weighs 130Kgs (20 stone+) will gain health benefits from a 5—10% weight loss. However 10% loss would leave them weighing 117 Kgs (18½ stone). Our research (Cox 2000) suggests that the vast majority of people do not believe that a 10% weight loss is the whole answer.

  Although many treatments are only achieving a 5% to 10% weight loss, we agree with the government's National Service Frameworks coronary heart disease statement, "…but the goal which patients should be encouraged to aim is still a BMI in the average range".

  One of the disadvantages of ONLY focusing on the benefits of a small weight loss is that it becomes the expected norm and work does not continue to find ways of helping individuals to reach and maintain an even healthier weight. The greater the weight loss, the greater the health benefits.

Weight Maintenance

  Weight maintenance is rarely mentioned in the NAO report and has no mention at all in the executive summary and recommendations. Many obese have made many weight reduction programmes work for them. The point that often seems to be missed is that it is not weight loss skills that are the most difficult, but rather weight maintenance skills that are missing.

  The most frequently reported statistics are that 9 out of 10 women regain their lost weight within a year, and the statistics for men are not much better.

  Many of those who regain their weight end up fatter than before they started. This has lead to the concept "dieting makes you fat". According to Dr Hill (ASO Presentation 2000), this causal statement "refuses to die and needs to be chucked out of the window". Stice et al (1999) carried out a three-year prospective study that concluded that dieting makes you fat. But their study also showed that so did exercise and use of laxatives. People who have never been very overweight or obese are viewed as non-dieters—but these people are often "watching" their weight and are making diets work". They have weight maintenance skills that need to be passed on to the overweight and obese.

  Each time weight regain occurs the individual's belief in themselves, their self esteem takes a knock and many eventually reach a point where they can no longer make the weight loss solutions that worked before work for them again. They feel desperate, lost, trapped in a body they hate and doomed to a life of shame.

  In addiction treatments it is recognised that recidivism is part of that process, that the drinker, working at a healthier lifestyle, is not a failure. Alcohol programmes often identify the importance of someone to listen, someone who understands. Someone whose expectation at the start of treatment is greater than the expectation the alcoholic had of themselves after years of lies, self-destruction and seeing themselves as a failure. Obesity treatments need to take the same approach.

RECOMMENDATIONS FOR TREATMENT

  With many routes to becoming obese it seems realistic to assume that "one size fits all" is not a useful approach for treatment. One obese person may simply need more knowledge about low fat eating; another may be a dieting expert full of facts and figures but be unable to motivate her/himself to put that knowledge into action etc.

  The NAO report identified that "73% of general practitioners believed there was a lack of proven, effective interventions available to assist them in determining the most appropriate treatment pathway for their patients. And 64% believed the range of treatments available to them was of little or no effectiveness."

  TOAST understands general practitioners' concern about the lack of proven, effective treatment pathways, but believes this is an example of the confusion between effective weight loss interventions and weight maintenance interventions.

6.3 Can they be better integrated?

  With nearly a quarter of the population obese, primary care teams cannot deal with the problem alone. Other areas of healthcare also have a supply and demand problem. A model to consider is that of geriatric care. The GP and the commercial sector work together, medical issues are dealt with by the GP and the personal care and day to day management by the commercial sector.

6.4  What are the priorities for action?

  Setting up working parties with all interested parties from as many disciplines as possible. GPs, nurses, dieticians, counsellors, psychotherapists, commercial weight loss organisations, charitable organisations, patient representatives and policy makers at local and national levels. Unless there is a broader thought process to address obesity, TOAST is concerned that local and national schemes will not include effective programmes and will `fail' and obesity and obese people will be labelled as hopeless and once again put on the back burner of health care.

6.5  TOAST Proposals

  With all initiatives for treating obesity, it is important to realise that no "one size fits all." As already stated, obesity is a complex problem; one weight loss treatment may work well for one, but not for another. The condition is often classified by just the physical characteristic of "size". It is too simplistic a label. Just as treating in the same way all those with the physical characteristic of "a rash" would be. One specific initiative will not halt the epidemic, a mixed array of treatment options need to become available for all.

  TOAST held a Parliamentary Reception on the 22nd January 2003, hosted by David Amess MP, which was attended by 30 MPs: 15 representatives from the House of Lords and some 30 other delegates from industry etc.

  David followed the Reception by an Early Day Motion (number 577) which (as at 25 April 2003 has been signed by 53 MPs. The motion reads—

"That this House notes that the level of obesity in the United Kingdom has trebled over the last 20 years and that one in five adults are now obese and one in three children are overweight; further notes that overweight and obesity lead to dramatic increases in risk of heart disease, diabetes, high blood pressure and osteoporosis at an annual cost to the National Health Service of over £500 million and a total cost to the economy of £2.6 billion; commends the work of The Obesity Awareness & Solutions Trust (TOAST) in raising awareness of the problems of obesity and providing support for those who suffer from it further notes the proposed establishment of TOAST House, a new Centre of Excellence for work on all aspects of obesity through conference facilities, training courses and support programmes, counselling, healthy living and residential facilities, motivational support and research resources; extends to TOAST its very best wishes for every possible success with this project; and hopes that it will receive the financial support necessary to realise its vision."

TOAST PROPOSALS FOR THE WAY FORWARD

TOAST HOUSE Campaign—a National Centre of Excellence for the Prevention, Treatment and Management of Obesity working with all aspects of obesity in a supportive and non-judgemental environment:

—  To positively aid the reduction of obesity in the UK.

—  To hold conferences for health care professionals, food industry, teachers and other professionals.

—  To organise accredited courses in obesity for students.

—  To hold adult, child and family courses, to actively encourage healthy living routines.

—  To offer counselling.

—  To create a Healthy Living Centre.

—  To provide a Help/Information facility offering motivational support.

—  To offer Residential facilities for sufferers and carers.

  The National Centre will be supported by:

  10 Regional Centres:

  The Centres would to be open to anyone concerned with obesity and weight-related problems, ie personal, parent/carer or professional.

  The Centre to provide the following facilities:

—  Self-help Action Groups meeting on a regular basis.

—  Obesity Awareness and Solutions Courses:

These can be offered as distance learning modules, computer led or day & evening classes. They would include:

Motivational training.

Assertion training.

Lifeskills training.

Positive thinking training.

Self-defence training.

Understanding how your body works.

Understanding what your body needs.

How to understand food labelling.

Dispelling the myths around obesity.

Understand the process of change.

Setting goals and how to achieve them.

Other ways of coping.

Cognitive behavioural work.

—  A library/internet containing all the information surrounding weight-related problems.

—  A kitchen where hands-on-experience can be gained, offering nutritional advice such as the Government's "5 a Day" Scheme; the recommendations of the British Heart Foundation and the Diabetic Association.

—  Advice from visiting professionals, ie Childhood Obesity Specialists.

—  Help with job applications and the specific problems attached to getting over-weight people in work (ie sourcing employers who will employ the over-weight).

—  A programme specially tailored to overweight teenagers, those who have been bullied at school and, as a consequence, had very little schooling.

—  A nurse carrying out patient profiling—

1.  Identifying physical and psychological characteristics.

2.  Analyse profiling results.

3.  Patient/Professional designed Treatment Programmes.

  The 10 Regional Centres would be supported by:

  Local Community Walk-In Centres:

  A nationwide web of "drop-in" Centres, positioned in town centres, offering advice and information together with professional patient profiling:

  Patient profiling

  Firstly it is important to identify both the physical and psychological characteristics of the obese person. This will also help build further understanding of the different types of obesity.

—  BMI and waist circumference measured.

—  Patient's medical, dieting and family history to be taken by someone who understands the problem—although not ideal, this could be developed into a computerised system enabling large numbers of individuals to be processed.

—  Series of questionnaires to be self-administered where possible providing insight into the patient's relationship to food. This needs to include addiction profiling.

—  Series of questionnaires to be self-administered where possible, providing insight for both clinician and patient into such areas as motivation, strengths and weaknesses, mood, in what way they want to be involved in their treatment, in what way they prefer to work, eg written material, audio tapes, want to know all the facts and figures or just want to be told to follow a tight structure—again this could be a computerised system.

—  Medical examination where appropriate.

  Once the patient's characteristics are identified, possible future action can be discussed by the patient with someone who understands their specific problem(s).

  Patients can now be involved in designing a treatment profile to suit the characteristics of their obesity and their personal preferences. Treatment profiles need to be flexible over time to take into account the outcome of treatment options and changes in circumstances. Options that were once rejected need to be available at a later date if appropriate.

TREATMENT OPTIONS

Obesity Awareness and Solutions courses

  These can be offered as distance learning modules, computer led or day and evening classes. They would include—

Motivational training.

Assertion training.

Lifeskills training.

Positive thinking training.

Self defence training.

Understanding how your body works.

Understanding what your body needs.

How to understand food labelling.

Dispelling the myths around obesity.

Understand the process of change.

Setting goals and how to achieve them.

Other ways of coping.

Cognitive behavioural work.

Counselling

  One to one counselling and group counselling have been shown to be effective in helping people understand more about why they do what they do, identify what aspects they want to change and help support people through the change process. Group counselling and cognitive behavioural therapy have been shown to be especially effective in helping with addictive and obsessive compulsive problems. Counselling would help individuals to put into practice some of the knowledge gained on Obesity Awareness and Solutions courses such as motivation, assertion, life skills, positive thinking, change and goal setting.

Exercise

  It is generally recognised that three to five half hour sessions of exercise a week increases general fitness and in turn reduces the long-term risk of disease.

  These include coronary heart disease, strokes and some cancers. Immediate benefits include having more energy, feeling more relaxed, sleeping better, feelings of self-confidence and a general feeling of well being. Exercise best aids weight loss when combined with calorie restriction.

Computer led programmes—

  Internet sites providing the latest information on health services available.

Diets

  Much evidence suggests that "just" going on a diet may well produce weight loss but that many will regain the weight if they do not also work on the underlying causes of their weight issues. Just treating the symptoms alone will rarely produce a long-term solution. The dieter needs to change his or her inside, as well as their outside.

Low Calorie Diets

  Most restrict energy intake to between 1,000 and 1,500 calories. The lower the intake, the faster the weight loss. It is important for dieters to make sure they eat a nutritionally balanced intake and include the recommended daily portions based on The Balance of Good Health; seven portions of fruit and vegetables, seven portions bread, other cereals and potatoes, two portions of milk and daily foods, two portions meat, fish and alternatives and two portions of fatty and sugary foods. Someone whose total daily energy expenditure was 2,000 calories who was strictly following a 1,500 calorie a day diet would be burning 500 calories a day of her stored fat which would result in a 1lb loss that week. The same person on a 1,000 calorie a day diet would be burning 1,000 calories a day of her stored fat which would result in a 2lb loss that week. One of the benefits of a properly structured, properly followed low calorie diet is that an energy deficit is created in a nutritionally complete way.

Meal Replacement Diets

  These are another type of low calorie diet where some conventional are replaced with special formulae soups, drinks and bars. According to the Infant and Dietetic Foods Association "Formula slimming diets are nutritionally fortified balanced, calorie restricted products designed to help achieve an energy restricted diet without sacrificing nutritional requirements."

  One of the benefits of meal replacement diets is that the dieter ensures s/he is getting balanced nutrition for some of her meals in a simple format.

Very Low Calorie Diets (VLCDs)

  Complete replacement of conventional foods with nutritionally complete formulae soups, drinks and bars. They should contain at least 100% of RDA's and should contain no less than 400 calories per day for women and 470 calories per day for men. Someone whose total daily energy expenditure was 2,000 calories who was strictly following a 500 calorie a day VLCD would be burning 1,500 calories a day of her stored fat which would result in a three pound loss that week. One of the benefits of a VLCD is that the physical hunger mechanisms are interrupted enabling the dieter to lose weight without experiencing physical hunger.

Medical Intervention—Drugs—The prescription drugs currently available on the NHS are Orlistat and Sibutramine

  Orlistat (Xenical)—Prescription only drug. For use on patients of Body Mass Index (BMI) 30+ or with a BMI of 28+ with co-morbidities such as high blood pressure or diabetes. The drug is a fat eliminating chitosan, a product made from shellfish skeletons, which attaches itself to fat and blocks the action of the enzymes that break down fat in the gut. The fat is pulled through the digestive system and excreted. The side effects of the drug may lead to loose and urgent bowel actions and possible faecal leakage or oily spotting. This helps patients to become highly selective over the fat content of food.

  Sibutramine (Reductil)—Prescription only drug. Also for use on patients of BMI 30+ or with a BMI of 28+ with co-morbidities. It acts centrally to the brain helping people feel satisfied with smaller portions. It also speeds up metabolism. Possible side effects include tachycardia, insomnia, headache, anxiety and sweating. Users may also experience a slight increase in heart rate and blood pressure.

  Surgery—Procedures use various methods to create a feeling of fullness with a smaller intake and include gastroplasty (normally vertical banding), gastric bypass, gastric banding, jejunoileal bypass and biliopancreatic bypass. Surgical intervention is currently under investigation by the National Institute for Clinical Excellence. The purpose of surgery intervention aims either to alter the absorption rate of food or reduce the amount of food actually ingested. It is not common on the NHS, currently there are about 200 procedures a year.

  Listed below are some of the benefits which would result from the establishment of TOAST HOUSE, supported by Regional Centres and local community walk-in Centres—

—  Contribute to reductions in the NHS on the lists and times.

—  Prevent unnecessary hospital admissions.

—  Help to prevent the co-morbidities such as heart disease, hypertension, type 2 diabetes, etc.

—  Support people with chronic illness by helping them to participate actively in the management of their illness.

—  Help to reduce inequalities in healthcare in vulnerable groups.

—  Provide timely, relevant and accurate information to support patients and clinical relationships.

—  Help patients to manage their own care through locally established networks.

—  Educate patients and the public on issues relating to the disease, specifically with regard to rights and responsibilities.

—  Support carers and patients by offering respite facilities.

—  Train and educate healthcare professionals.

—  Provide a venue for healthcare conferences

—  To support research and analysis of the multifaceted problem.

—  To focus on obesity prevention and management strategies.

—  To encourage the increase of healthy lifestyles.

—  To encourage more physical activity.

BULLET POINT PAGE

—  The Government's current policy of "five a day" and exercise is manifestly not working.

—  Focussing only on obesity prevention results in the government failing 50% of the population and must be reviewed.

—  The NHS can not cope with treating the current obese population; the public, private and commercial sectors must be used to help solve the problem.

—  The government must commit to a National Weight Loss Strategy.

—  Obesity is a complex problem; a "one size fits all" solution doesn't work.

—  TOAST House Project will be a centre of excellence for education of health professionals, treatment and will provide the much needed multidisciplinary approach to tackling obesity needs funding.