The prevalence of obesity is on the rise with serious impact on the economy and the health of the nation. People who are obese are more prone to type 2 diabetes, some cancers, heart disease, liver disease, depression and mobility problems. Direct costs caused by obesity are now estimated to be £5.1 billion per year (Department of Health, 2011). The government has a role to play in reversing the tide of obesity. As suggested by the previous health secretary, organisations should work in broad partnership with local authorities, businesses, charities and healthcare professionals. One of the local authorities proposed that overweight people who refuse to attend exercise sessions could have their benefits reduced.
Local authorities are soon to take over public health provision from April 2013, and have an onerous task of looking after the health of their constituents, within a limited budget. So how will the local authorities do it? Will cutting benefits help motivate people to adhere to the exercise regime prescribed by their doctors? In the first instance, we will need to understand what the aim of this new proposal is. Is it about cost cutting, improving health, reducing weight, or all of the above?
Let us take the case of Mrs Smith, who has type 2 diabetes, osteoarthritis and hypertension, and a BMI of 45 kg/m2. Mrs Smith is receiving benefits, and her medications include insulin, metformin, anti-hypertensives and pain killers. She has been prescribed exercise in a local gym by her doctor and has been given a “smart card”. She finds it difficult to walk so she takes a taxi to the gym, paying a £4.50 taxi fare. Her trainer in the gym advises her on exercise, which she then tries to follow. She walks on a treadmill for 10 minutes and stops as she gets very tired. She spends the rest of the time sitting in chair and at the end of the hour, she leaves the gym to get a taxi. She tries to attend the gym regularly and has to spend £9 on each occasion. Her exercise tolerance improves and she is able to walk for 20 minutes.
On one of those days she falls down and loses consciousness. Paramedics arrive in time and find that she is hypoglycaemic. Her motivation to go to the gym has considerably reduced and her gym attendance declines. She is worried that her benefits may be discontinued, and becomes depressed, seeking help from her doctor. She is now on antidepressants. This increases her hunger and causes fatigue. She notices that she has gained weight since taking antidepressants. This may be due to a combination of “comfort eating”, depression and antidepressants. Her nurse has to now increase the dose of insulin, which was previously reduced following the hypoglycaemic episode.
This classic case highlights the complexity of the management of obesity, its comorbid conditions and the social problems that accompany people with weight problems. It is important for policy makers, health authorities and politicians to understand that the global obesity epidemic can only be tackled by understanding the problems encountered by obese people and organisations working together.
In my view, a single strategy adopted by one of the local authorities to save money and improve health would not help. Any decision should be consulted with the local healthcare providers. Other draconian measures that have been suggested, such as restricting electricity for heating, stopping bus services and having only cycle lanes, will be counterproductive. Restricting benefits based on one factor will lead us on to a slippery slope. Decision makers will need to answer more questions. How would people with drug addiction, smokers, alcoholics, reckless drivers or people with anorexia be treated?
Exercise on its own does not tend to help people lose weight in the long term. Councils, after discussion with public health departments and experts in obesity, should bring about innovative ways to improve physical activity whilst ensuring healthy food is easily available. Just recommending attendance at a gym can be boring and monotonous for some. Brisk walking tours, swimming, non-weight-bearing exercise and games organised in local parks may be more attractive alternatives.
However, before any recommendation, people have to be assessed for any underlying issues contributing to their obesity. Why do they eat more? What is there hunger pattern like? Do they have a hormone problem? Have they been through a traumatic childhood? Do they have suboptimally treated psychiatric illness? Unless the underlying problem is unravelled and addressed appropriately, I believe that people will not benefit from weight loss programmes in the long run.
