COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Inquiry into Obesity

26 March 2009

Members present for all or part of the proceedings:

Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mr John McCallister
Ms Sue Ramsey

Witnesses:

Dr Michael Ryan ) Northern Health and Social Care Trust

The Deputy Chairperson (Mrs O’Neill):

I welcome Dr Michael Ryan from the Northern Health and Social Care Trust. Members will recall that we met Michael at one of our informal discussions. A copy of his submission and other relevant papers are in Members’ papers.

Dr Ryan, thank you for sitting through our long business session. I invite you to lead off and members will ask questions when you have finished.

Dr Michael Ryan (Northern Health and Social Care Trust):

Thank you very much for your invitation to come back to the Committee. I will talk to my written submission. I have also submitted supplementary information. I emphasise that I am speaking as clinician in the front line: I am not an academic clinician. I see patients who are at a very high risk of cardiovascular disease, particularly diabetes and high cholesterol. My motivation to get involved in this topic is due to the fact that 90% of the patients that I see are either overweight or obese, and there is no specific service for them to avail of.

Although the Department has made many efforts in the community, there is a significant shortfall in the care offered to patients — unless they are children, which is laudable — in the primary or secondary health-care arena. That is my motivation for coming here today.

There is no comprehensive, strategically planned, service for dealing with overweight and obese adults, in particular. There is also no seamless stream of care packages available for those who suffer from overweight and obesity. According to the World Health Organization, about 7% of all disease, about one third of all coronary heart disease and stroke, and almost 60% of hypertension disease are secondary to overweight and obesity.

As I mentioned, 90% of the patients I see for diabetes; about 80% who attend cardiac clinics; 70% who attend our gastrointestinal clinics, and about 60% who attend respiratory clinics have significant co-morbidity that is linked to weight and obesity. The difficulty is that there is no service for those patients. A large proportion of the population needs professional help.

I have appended a table to my submission that puts the issue of weight and obesity in context by ranking its health-risk factor against the risk factors of other conditions that have considerable resources invested in them. For example, smoking will roughly quadruple a male or female’s risk of diabetes, which accounts for approximately 12% of total health-care costs. Some patients who have hypertension — for which treatment is expensive — take three or four hypertension agents on a regular basis.

Abdominal obesity is on a par with those risk factors as regards the risk of cardiac disease. However, as a proportion of that risk, the resources put in to deal with the problem are miniscule. The problem is that, unlike other issues, there is no “plug-and-play” approach to tackling obesity. No tablets or agents, such as those used to control cholesterol or deal with hypertension respectively, can be used to tackle obesity. A fundamentally different approach is needed to tackle obesity than those that are being used to address conventional risk factors.

Secondly, much of the morbidity and premature mortality linked to hypertension, diabetes and cardiac disease is underpinned by the co-existence of overweight and obesity among those patients. At a whole range of clinics, obesity is the common denominator in a high proportion of patients’ conditions. My contention is that a vast range of clinical services is being “silted up” with patients who attend with obesity-related co-morbidity, but who have nowhere to go.

A doctor might pick up on the fact that a patient has diabetes, hypertension, a respiratory problem or heart disease and send him or her to a specialist in the respective field. However, the patient’s fundamental problem will not go away until the obesity issue is addressed, because it underpins the primary presenting complaint. In the current structure, adults with a weight-related problem are being squeezed into other clinics.

As I said, about 90% of the patients that attend my diabetes clinic have weight-related issues. It is well established that more than 90% of diabetes is caused by overweight — too many calories in, too few calories out.

Fundamentally, the current approach lacks cohesion and an overarching strategy. It fails to produce objective and quantifiable outcome measures, such as the assessment of value for money and clinical effectiveness. I suggest that the current approach is inadequate; we see the evidence for that in that the obesity and overweight epidemic is now described in the medical literature as having reached a crisis point.

I suggest that we adopt best practice: the Counterweight programme in Scotland, for example, has been shown to be very successful in primary care and we can use that as a model framework for an obesity service in the Province. The interesting outcome of that is that for every unit of weight lost, the drug costs — the treatment of hypertension, diabetes, heart failure and cardiac disease — drops by 6%. Therefore, there is a cost-effective aspect to this proposal.

The managed clinical network model of service delivery is now well established and has been shown to be an effective means of delivering targeted services for specific reasons. The approach to weight management at all levels of intervention should be supported by the managed clinical network. Much of the cost of such a programme is already embedded in the system because we are already dealing with the consequences of overweight and obesity on people’s health, but it is unrecognised and unquantified because there is no specific weight-related programme targeted at the problem. Considerable resources have already been invested in tackling weight-related problems but, as a practising clinician at the front line, I see no evidence of their effectiveness. A managed clinical network model, specifically for obesity, would be able to evaluate programmes of care and produce solid evidence or otherwise of cost-effectiveness and clinical effectiveness.

I have submitted some slides as evidence to back up some of what I am saying. I am conscious of time. On the first slide, to which I have already referred, you can see that eating fruit and vegetables reduces risk, particularly in women, and that exercise will halve the risk, particularly in women. Cholesterol is very important and very expensive to tackle, but its threat to health is on a par with overweight and obesity. Obesity is, literally, the elephant in the living room.

I hope that the slides complement what I have said. I apologise for the small size of the writing, but otherwise it would run to 10 pages.

Obesity is reckoned to cost the Health Service £120 million per annum in Northern Ireland. We are already expending resources on the consequences of obesity: I propose that we invest in preventing that outlay on patient care. The impact of obesity on an adolescent or a young adult is equivalent to that of smoking and there has been a tremendous effort put into smoking as regards awareness and prevention. There are smoking cessation clinics and smoking cessation nurses: we do not have the equivalent for obesity and yet it poses the same threat to health. As we gain from the use of cholesterol drugs and blood-pressure drugs, and as the death rates from cardiovascular disease fall, the death rate from diabetes increases. A report in January 2009 showed that 55 patients died from diabetes 10 years ago in Northern Ireland. The figures from last year show 188 patients having died from diabetes.

Diabetes is an inevitable consequence of weight gain: our submission contains slides showing obesity as a risk factor for type 2 diabetes in women and men. For those of you who are not familiar with body mass index (BMI), I will give an example. A person who is 5 ft 6 in tall and weighs nine and a half stone would have a body-mass index of 25, which is fine. A person who was 5 ft 6 in tall and weighed around 12 and a half stone would have a body-mass index of 30. I see patients who weigh twice that, as does every doctor in the Province. It is a useful benchmark to know when a person is clinically obese.

When people develop diabetes, they may say that they have a mild form of diabetes. That is like saying that you have a slight touch of pregnancy. It is a serious and significant health threat. We can see mortality and glucose as a continuum. I draw your attention to mortality, as it is such a “hard” end point, and there is no coming back from it.

The tragedy of the shortfall in healthcare provision is that much of the diabetes cases can be prevented. There are three trials to show that, within three years, intervention can prevent about 60% of diabetes from occurring. I present a summary of those trials in the submission. Exercise and weight control can prevent at least that amount of diabetes, which is costing the healthcare system dearly. Once a person is diagnosed with diabetes, his or her life expectancy is reduced by approximately 10 to 15 years.

If we invest in weight loss and obesity, there are a number of benefits that will arise from a 10% loss in body weight — those benefits are detailed in the slides. Again, I draw your attention to mortality, because it is so dear to my heart. One can see that obesity-related cancer deaths will drop by 40%. Some cancers, particularly in women, are linked; about half of certain cancers in post-menopausal women are related to obesity, according to a recent report.

There is no drug or combination of drug therapies that would achieve those gains across the board globally. The absence of such an approach to weight and obesity is a serious shortcoming in healthcare provision. The fact that there is not a “plug and play” technology makes it a difficult area, and one that doctors conventionally tend to avoid, because it requires a different approach; repeated intervention and support at psychological, social, or physical levels.

I have provided a hypothetical example in the submission, which details the years of life lost for someone aged 40, who is 5 ft 6 in tall and weighs 12 and a half stone, with a body-mass index of 30. At age 40 they would lose approximately seven years of life. There are very few medical illnesses that, globally, across the population, achieve that level of compromise in relation to life expectancy.

The impact of obesity and overweight is worse than all the cancers put together, on an epidemiological basis, and yet we can intervene, and it can be prevented if caught early enough. If there were a structured programme that would involve as many impact points as possible, we could prevent very significant premature mortality and morbidity in the population.

In summary, I support the proposal for significant investment; from my perspective as a practising clinician, the research has gone on long enough. There is very good evidence that weight can be controlled, that weight gain can be mitigated, and that the consequences of weight loss are well established. We have effective means of intervening, with motivational analysis, behavioural modification from the Scottish Counterweight programme to show that such intervention is cost effective. However, political will is needed to make it happen, and that is why I am here today. Thank you very much.

The Deputy Chairperson:

Thank you for your presentation. It will be valuable to the Committee as it carries out its inquiry.

You talked about a managed clinical network, and the staff and training required for that. Will you give the Committee more information on the nature and extent of the specific training needed for staff to deliver such a programme, and how that programme would be delivered?

Dr Ryan:

A managed clinical network is a well-established model of healthcare delivery, and there are several in the Province. Fundamentally, it is protected time for a range of interventions under a structured programme. It has terms of reference, a management board, specific goals, and an audit programme to quantify its outcomes.

I do not feel that training is the problem. For example, in my job plan I have no time to deal with obesity. The scale of the problem lies mainly in the community — in schools, play areas, secondary schools, universities, etc — and that would be a major plank of a network. The difficulty is that the effort that we are putting into schools is not part of a strategic system: we are not measuring the outcomes. For example, there are many community groups — such as WeightWatchers — and there are many facilities for exercise. We are not harnessing those resources in a structured and managed way.

I cannot say how much I would need specifically. Many trusts have a managed network for diabetes. The expertise probably exists already, and much of the effort and expenditure exists. However, it must be released specifically for obesity. I cannot quantify that at this stage. The cost of not doing it now will be much higher five years down the line.

Mr Gardiner:

When I was reading your submission last night, the economy, the efficiency and the effectiveness jumped out at me, and you have referred to some of them. Do GPs need training in obesity? Can health visitors deliver information? How can we improve the system? You have talked about a programme, and getting it across to schools and various organisations. Please elaborate on that?

Dr Ryan:

The problem as I see it — from my perspective as a clinician with nowhere to send my patients — is that knowledge is not the problem. We are all aware of the need for reducing calories, and we are all aware of the need to exercise. The difficulty is the patient’s relationship with calories and food. It is a complicated issue: it is fundamental to a patient’s sense of well-being. Some specific training is required, and the most effective strategy used in Scotland and Wales contains motivational analysis and behaviour modification techniques, which is a branch of psychology — it is not knowledge. Patients know that they should not eat cream buns or whatever it may be.

Mr Gardiner:

I am not so sure that patients do know, and it would be better for them if their GPs told them so.

Dr Ryan:

You are absolutely correct.

Mr Gardiner:

Should someone in authority not get that message across?

Dr Ryan:

Yes; but the message must be approved and standardised. GPs seem to be delivering a slightly different message depending on the biases, their expertise, or the level of interest that they or their staff have. Some of those messages are neither appropriate nor effective, and that is where the managed network approach comes in. There would be a single message, approved and evidence-based. It is not a group hug.

Weight and obesity are well-established causal factors, in the same way as blood pressure and cholesterol. We need to become more scientific and rigorous in how we deal with weight issues. Having a group hug is not acceptable; we can no longer depend on well-meaning individuals doing their best. There is evidence that there are effective strategies, and, for the health of our population, we must implement them with a sense of urgency. We all need to be retrained.

Mr Easton:

It is good that you are enthusiastic. My feeling is that we force food retailers and producers to reduce the amount of fat, sugar and salt that goes into food, any measures that we put in place will not help much. I would appreciate hearing your comments on what we might do about that problem.

You touched on the subject of diabetic clinics. Do you think that a clinic should be developed specifically for obese people?

Finally, what is your opinion of the Norwegian nutrition policy and healthy-eating campaigns, which seem quite good?

Dr Ryan:

My answer is yes to all of the above. We do need to engage with the food industry, but only up to a point, because it will be led by market forces. Educated people make different choices than uneducated people. In our efforts to improve the health of the community, although it is important to engage with the food industry concerning salt, fat and sugar, the question is what can we do with a 35-year-old person who weighs 26 stone and cannot walk because he or she is so heavy? The cost of dealing with the health problems associated with such a patient is enormous; whereas, the cost of dealing with that person’s diet and getting him or her back to work is relatively small.

Two weeks ago, I saw a patient in my clinic — I am the only clinician who accepts obesity referrals — who carried her tummy in a modified shopping trolley. That lady cannot work because of her weight: her mobility and her social interaction are compromised — she is 52 years old. We need specialist clinics and services for such people — their lives are blighted. Suggesting that we ignore the problem, or just treat people’s blood pressure, is not dealing with the fundamental morbidity of what is an enormous social and personal problem. We must tackle it at a social, educational and individual level.

There should be adult obesity clinics to specifically target patients who fall through the community-level and primary-care-level filters, because cases involving overweight or obese people are silting up the vast majority of clinics in hospitals and GP practices. We need somewhere for those patients to go, so that they can receive the expert treatment and intervention that they require. The cost of not doing that will eventually be much greater than the cost of doing it.

The Surgeon General of the United States commented that this is the first generation of Americans whose life expectancy is less than that of their parents, specifically because of the obesity problem. An obese teenager is likely to be a cardio-vascular invalid in his or her 40s. We must do something about that problem as a matter of urgency, and that tone is reflected in the literature, which describes a tsunami of obesity.

When I was training, type 2 diabetes was called “maturity-onset diabetes”. Nowadays, I see 18 and 19-year-old people with that condition, and paediatricians are seeing it in the under 16s. That was unheard of. All I can say is that in my view, it is the single biggest health problem facing our community.

Dr Deeny:

Thank you, Michael. I am sorry that I missed the start of your presentation. As a GP, I am very concerned about obesity. I have two quick questions about the problem. First, I have my doubts about the BMI. One of the measurements is a waist-to-hip ratio. Last week, we saw the wonderful victory in Cardiff. Many of the guys who played in that rugby team would certainly have a BMI that, according to the charts in a GP’s surgery, would be classed as obese, yet they are big, strong and physical guys. I wonder whether the BMI needs to be discounted and replaced with a better measure of obesity. Some of those rugby guys are 18 stone and are built like the side of a house — they could run through you.

Secondly, as a doctor, I too think that it is our duty to get the message out and make it clear that this is a major epidemic that will have serious health consequences for the next generation, and those that follow, if it is not addressed.

As I said before, I am worried that we are perhaps going to extremes in being too alarmist. I say that for two reasons. You mentioned that, for about half of certain cancers in post-menopausal women, there is a link between obesity and cancer, and that is what made me ask the question. I was delayed because I had a surgery this morning. I called with a patient who is worried about cancer. Unless a statement such as yours is made more accurate — explaining how great the link is, as opposed to simply saying that there is a link — we are in danger of worrying a significant section of the population who are already starting to worry about cancer, particularly if there is a family history of it.

I will give you another example, which I mentioned a few weeks ago. There is an advertisement on the radio and on television, which is perhaps another example of going a little bit too far and almost terrifying people to force them to live a certain way. The advertisement is to do with breast cancer and drinking, and there is no doubt that there is a link there. However, that advertisement worries me. It shows a lady drinking and the drink going down the oesophagus, which is fair enough. It then states that drinking within the normal limits can reduce the risk of cancer. To me, listening to that, it sends out the message that even drinking sensibly and normally is associated with a link to breast cancer. On the one hand, people are being told that if they stick to the normal weekly units of alcohol — 14 units for women, 21 units for men — that that can have beneficial effects on health. Now we are hearing that if you stick within those limits, it will not get rid of you chances of breast cancer, it will only reduce them.

I am talking as someone who has been in general practice for some years. For doctors, and all medical people, getting the message out there to the community, strong and clear, is of absolute importance. However, I fear that we are going to extremes and terrifying people. Perhaps sometimes we get the wrong message across. Can you quantify the link between post-menopausal women who are obese and cancer?

Dr Ryan:

There was a recent editorial in the ‘British Medical Journal’ (BMJ) on that very topic, which stated that:

“Among postmenopausal women in the UK, 5% of all cancers (about 6,000 annually) are attributable to being overweight or obese. For endometrial cancer and adenocarcinoma of the oesophagus...half of all cases in postmenopausal women are attributable to overweight and obesity.”

I did not make that up. That is from the ‘BMJ’.

I accept that the BMI is an imperfect measure. I have been waiting for 20 years for the perfect measure. The difficulty is that meanwhile, patients are dying. We cannot wait for the perfect measure; however, I accept that the body mass index is not the ideal. You are quite right; it is a different kettle of fish if muscle weight is a contributory factor. However, at least it would sift out, on an epidemiological or population basis, those patients who might be targeted for lifestyle intervention.

In the literature on the issue, there is absolutely no doubt that the lighter that a person is — within reason — the longer he or she will live. I am convinced of that connection, and there is vast evidence to support it. Actuarial statistics from insurance companies will bear that out forcibly.

I have presented one or two of the best slides to show that even being moderately overweight will compromise life expectancy. I stand by that assertion. I accept that patients may not worry about losing two or three years from their lives, but that has the same effect on mortality of the whole population as all the cancers put together. To get the weight message into context, the Americans have a great phrase — “the soft stuff is the hard stuff”. Blood pressure is a plug and play; someone takes the tablets, and it goes away. Cholesterol is also easy to address. However, obesity is a much more tenacious and difficult problem. I can understand why we do not have a simple solution to obesity, but that does not mean that we can afford to ignore the problem — the cost of ignoring the problem will be enormous.

Dr Deeny:

I do not want to ignore the problem, but we must get across a message that is as accurate as possible. For example, I am concerned that the message about menopausal women will worry people more and affect their mental health. People who are obese and post-menopausal will read that message and think that they have a 50% chance of getting cancer. That is my concern.

Dr Ryan:

Knowledge is power. In my clinical practice, I use that type of knowledge all the time — the more that a patient knows about his or her condition, the more he or she is empowered to deal with it. In no situation is that more important than in a lifestyle-related problem. If a lady is obese and concerned about her cancer risk, perhaps she will be motivated to do something about it. There are very few cancers that people can address by changing their lifestyles. If a lady loses 10% of her weight, she will reduce her risk of obesity-related cancers by 40%. That is the epidemiological return on weight loss, which is well worth it. There are some serious threats to health, and putting the minds of patients at ease is important. However, it is equally important to give patients the hard and cold facts, and the literature on the issue supports that.

Ms S Ramsey:

I do not know whether I should thank you for your presentation. I am sitting here thinking that maybe I should just go home, go to bed and give up the ghost, because what I have heard is depressing. I agree that knowledge is power, but responsibility comes with that power.

In your presentation, you mentioned the importance of mindsets and attitudes in how we deal with the problem. Some people say that a sizeable percentage of those who suffer from obesity, some forms of cancer and diabetes come from socially deprived areas. That is an issue that we need to talk about. We also need to address the problem early, which means that we need to invest in schools.

Alex Easton said that food producers and manufacturers need to examine their ingredients, but we are not investing in school meals. A large percentage of the children who receive school meals come from socially deprived areas, and they are getting food that will create problems for them later in life. If we are going to be honest, we need to be brutally honest and admit that we — as a society and as the people who are supposed to be in charge — are feeding the problem; pardon the pun.

We also need to invest more in after-schools programmes, whether those are for recreation or study. The Assembly has debated the issue of whose responsibility it is to fund after-schools programmes. One Minister and Department are fighting with another Minister and Department, and the issue of neighbourhood renewal is getting lost because of that. Therefore, we need to be brutally honest about that.

Education is the key. We need to be honest about the advertisement and sponsorship of big events. A number of years ago, cigarette companies advertised at events, then it was the alcohol companies, and now it is either big fast-food companies or soft-drinks companies. We need to be clear about that.

Do you believe that other Departments and Ministers are playing an active role in trying to deal with and tackle this issue? A number of weeks ago, officials from the Department of Health, Social Services and Public Safety told us what they will do. However, we, as a Committee, have no control over the Department of Education, the Department for Social Development (DSD), or the Office of the First Minister and deputy First Minister (OFMDFM). I want you to be honest, because we need to tackle this issue as a collective problem. Do the Executive have a collective responsibility and mindset to deal with the issue of obesity?

Dr Ryan:

That is a difficult question for me to answer. I do not know what is going on in the Executive. I am simply addressing the issue from my perspective as a practising clinician. I see more and more patients with a primary problem that I have no authority to help them with; I have no means to help them. Obesity is a problem that I should and could help them with if I had the time. In running a diabetes clinic, I have an obligation to my employer to see diabetes as the primary focus. Although I do address all the other issues as best I can, obesity is such an intractable and deep-rooted problem that it needs specific, targeted intervention.

Obesity is a health issue; an education issue; a social policy issue; and a public transport issue. I agree with you, I do not know who should pay for this. All I know is that there are consequences that have yet to be realised. The difficulty is that I do not see the evidence to suggest that the provision of school meals produces fitter, lighter, healthier, smarter children with a longer life expectancy.

My primary measurement is death. If I intervene to help patients, I must be satisfied that there is evidence to show that they will live longer. That is my only justification for adding chemicals to their mix or for instructing, advising or guiding them to change their lifestyle. My concern is that resources are being expended and that there is no overarching infrastructure to weigh those in the balance in order to ascertain whether they are producing value for money.

Ms S Ramsey:

First, forget about the evidence about the value of schools meals. School meals are being provided, so we should ensure that those are of the highest standard. Secondly, I know loads of people who would love to be able to afford to buy free-range chicken. I use this example to show why people get caught in the trap. A free-range chicken can cost £8, £9 or £10; whereas a processed chicken costs approximately £2. Although we need to change the people’s attitude to food and lifestyle, we also need to ensure that they are able access healthier produce.

Dr Ryan:

I agree, but I do not know of any evidence to show that free-range chickens are any more nutritionally beneficial than processed chickens.

Ms S Ramsey:

We are led to believe that they are.

Dr Ryan:

If I were selling free-range chickens, I would lead you to believe that, too.

Mr Buchanan:

In your opening remarks, you mentioned the Counterweight programme in Scotland. How long has that been in operation, and how has it been evaluated? How much would it cost to set up a similar programme in Northern Ireland? Finally, how long would it take to roll out such a programme across all the health board areas?

Dr Ryan:

The Counterweight programme in Scotland is primary-care based and provides specifically trained staff to deal with obesity. It is rigorously evaluated by the University of York and the University of Aberdeen. Counterweight has produced credible evidence of the cost-effectiveness of that type of programme.

To implement a similar programme region-wide would require a significant amount of priming money, but that would be recouped through a reduction in drug costs, reduced levels of diabetes, fewer hospital admissions, and so forth. I can only hazard a guess that to roll out such a programme across the Province may cost approximately £500,000 a year for the first two or three years.

The Deputy Chairperson:

Dr Ryan, thank you for coming today. Your evidence has been most helpful to the Committee, and I will ensure that you receive a copy of the final report.