FACING THE OBESITY EPIDEMIC

The UK obesity epidemic adversely affects both morbidity and mortality and is fuelled primarily by high calorie foods and reduced physical activity. Obesity damages individuals, highlights global inequalities and reflects bad stewardship of resources. But conversely the promotion of a responsible lifestyle must not be confused with the worship of physical perfection. The morbidly obese patient often has marked psychological problems around food and body image. The situation calls for compassion and empathy teamed with good practical solutions both for the individual patient and for society at large.

Obesity is an increasing problem in the UK, with over 60% of the population overweight and 20% obese. This results in an increase in risk of morbidity and mortality from type 2 diabetes, ischaemic heart disease, hypertension, cancer and stroke, amongst others.(1) Obesity is not confined to the UK. The obese US population is approaching 30%. Many parts of urban Africa are experiencing an increase in levels of obesity and the incidence of type 2 diabetes following adoption of a western lifestyle.(2)

Body Mass Index (BMI)

BMI is measure of body fat based on height and weight that applies to both adult men and women. It is calculated by dividing a person's weight in kilograms by their height in metres squared (BMI=kg/m2). The BMI categories indicate whether a person is over or under weight. There are limitations however, for example for those with a muscular build. Considering BMI with other factors such as waist circumference, levels of activity, and dietary intake will give a more complete picture of an individual's health. Racial factors should also be considered as patients of south-asian origin have a higher risk at a lower BMI.

BMI Categories:

• Healthy weight = less than 25
• Overweight = 25-29.9
• Obesity = 30 or greater

In considering a response to obesity we have to reflect on its causes. It is clear that obesity must result from an excess of energy intake over expenditure. Despite a common belief that we all eat more than we used to, energy intake in comparison with 40-50 years ago has actually declined. Therefore activity must have declined to a greater extent. Additionally certain factors impair our ability sensibly to adjust calorie intake to our needs, such as the increased energy density of processed and 'fast' foods.(3)

As physicians we see the consequences of excess weight in our daily practice: the relentless increase compounded by the individual's incapacity to achieve a significant weight loss, their own failure further compromising their impaired self-esteem. Worse still, the poorer sections of society experience the brunt of this disease.

Christians believe that individuals have responsibility for themselves and others. Therefore obesity in a world where people still suffer from hunger and scarce resources is wrong from a range of perspectives:

• It damages the individual
• It reflects a waste of food and money that could be used to address global inequities
• The consumption of pre-processed food requires a higher level of energy consumption (production and transport) and implies neglect of our duty as stewards of the earth

We are not called to judge but to show compassion, yet we must also be as 'salt' to the world in which we live.(4) This is best considered in three ways - the challenge we offer to society as a whole, how we deal with people as individuals and how we behave ourselves.

A response to society and obesity

A prominent UK diabetologist remarked that type 2 diabetes targets the rich in poor countries and the poor in rich countries(5) - this largely reflects the pattern of obesity in our world. Therefore in the UK, obesity is another inequality suffered by poorer members of society. The reasons behind this are complex, but cost of healthy food and the high energy density of cheaper foods (high in refined carbohydrate and added fats) are likely to be major factors.(6) In addition, our society prizes material possessions to the extent that people are spending a lower proportion of their income on food. Furthermore, many are less prepared to spend responsibly with regard to health and other factors such as free-range farming, consumption of fresh fruit and vegetables, and trade justice issues.

Currently, there is some media interest in the role of the food industry in promoting unhealthy eating, especially to children. Whilst this is a controversial area, we should seek the following changes:

• Availability of healthy eating options at a similar cost to processed foods to all sectors of society
• Cessation of high-profile promotion of foods with high energy density but little nutritional value

We can all contribute to these changes. You might ask your child's school to restrict use of vending machines, or write to a local supermarket suggesting they change their policy of displaying sweets at the checkout.

Barriers to increased physical activity also need to be addressed. Public transport is unviable for many, and few roads are truly safe for cycling. However, most people could make daily use of alternative forms of transport. When I suggested to an obese patient with diabetes and his wife that they might sell one car and walk 1.5 miles to work each day, he was shocked and it was clear that such a solution would not have crossed his mind. Our challenge should therefore be:

• Safe non-car transport options
• Challenge society's view that a two car family is the norm
• Access to cheap/free leisure facilities for all

Knowledge is a further part. As a physician with an interest in obesity, I am involved in education of patients, members of the public and healthcare professionals on a regular basis. People do not know the scale of risk. The risk of type 2 diabetes starts before a person even reaches a BMI of 25 and translating this into real-life figures for height/weight shocks many. People need to know the facts that relate to them and their families. Focussing on extremes leaves too many with a false sense of security.

There is a catch to all this. The promotion of a responsible lifestyle must not be confused with the worship of physical perfection and the self-obsessed pursuit of beauty. We want to promote responsible living without excess consumption of precious resources and glaring inequalities across society. A more fundamental change could be to seek a radical approach to poverty.

Dealing with our patients

Too often I see the obese patient come to clinic desperate for a hormonal explanation for their body weight. They have convinced themselves it cannot be related to food consumption. Faced with a 180kg, 35 year old woman who reports a calorie intake 2,000 calories lower than her predicted resting metabolic expenditure, I know that this cannot be true whether recognised by the patient or not. I have to take away this crutch holding up an already poor self-esteem if she is to accept a treatment that involves less food, whether through diet, surgery or drugs.

The morbidly obese patient often has marked psychological problems around food and body image, which we must deal with in a compassionate way whilst maintaining a sense of individual responsibility. There are effective treatments for morbid obesity; lifestyle modification prior to surgery with mean weight losses in excess of 35kg is one of them. Surgery for the morbidly obese is not an easy answer to a greedy person, but often a lifesaver to a profoundly disturbed and unhappy individual.

Personal responsibility

To deal with obesity in our world is to address excess consumption on many fronts, whether food or a luxurious lifestyle that would shock all but our richest forebears. The subject provokes some hard questions for Christians:

Are we guilty of excess in our lives or do we live simply without concern for what we eat and wear?(7)

• Have we taken too much interest in our bodies and the pursuit of physical beauty?
• Are we different from those around us?

Conclusions

Christ calls us to live to higher standards yet he gives us the means to achieve them. We must be salt for a society that needs to change from its rampant excesses. We need compassion and empathy for our patients teamed with practical solutions.

References

• National Audit Office. Tackling obesity in England: report by the Comptroller and Auditor General. HC 220 Session 2000-2001. Available online at www.nao.org.uk/publications/nao_reports/00-01/0001220.pdf
• Sobngwi E et al. Exposure over the life course to an urban environment and its relation with obesity, diabetes, and hypertension in rural and urban Cameroon. Int J Epidemiol 2004; 33(4):769-76
• Prentice AM, Jebb SA. Fast foods, energy density and obesity: a possible mechanistic link. Obes Rev 2003; 4(4):187-94
• Matthew 5:13
• Gale EA. Is there really an epidemic of type 2 diabetes? Lancet 2003;362(9383): 503-4
• Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr 2004; 79(1):6-16
• Matthew 6:25