Who's to blame for Britain's obesity epidemic?

As newspapers last week descended on an Ipswich bungalow to chart the extraordinary life of the world's heaviest man, a fierce debate broke out about how to respond to the surge in obesity in Britain. How much is it a self-inflicted condition? Should the NHS bear the cost of dealing with its effects?
At the age of 48 Paul Mason is immobilised by his own fat. The 70-stone man needs an operation to save him from obesity-related death and the surgery will cost the NHS around £20,000 and require the hiring of special transport to take him across the country to a specialist unit.
It was discovered last week that the world's heaviest man was not in America, the junk food and obesity capital of the world, but in a housing association bungalow in Ipswich eating takeaways and playing computer games. Mason cannot work but needs a team of carers to wash, move and feed him as well as adapted doorways, strengthened furniture and other equipment inside his house. So over the past few years his condition has cost the state hundreds of thousands of pounds. Are we right to ask if this is a self-inflicted condition and question the cost to the taxpayer?
Like illnesses caused by smoking and excessive drinking, some people feel that obesity is not an illness but a lifestyle choice and therefore something for which the NHS should not pick up the bill. The lack of sympathy directed at overweight people is concerning many campaigners who feel that a new area of discrimination is opening up.
Mason's case was uncovered in the same week that a US research team at the Johns Hopkins University School of Medicine in Baltimore, Maryland, discovered that overweight people were treated with a contempt that increased directly in line with their weight. The fatter the patient, the less respect they got from their doctor.
Professor Mary Margaret Huizinga said that the idea for the research came from her experiences working in a weight loss clinic. Patients would come in and "by the end of the visit would be in tears, saying no other physician talked with me like this before. No one listened to me. Many patients felt that because they were overweight they weren't receiving the type of care other patients received," she said.
"If a doctor has a patient with obesity and has low respect for that person, is the doctor more likely to recommend certain types of weight loss programmes or to send her for cancer screening if the patient complains of feeling unwell? We need to understand these things better."
Ultimately, she said, doctors need to learn that obesity discrimination exists.
Obesity is more than a few extra pounds: it is the accumulation of fat in the body that damages health and knocks years off life, increasing the risk of strokes, heart disease, type II diabetes, cancers and arthritis.
The most common measure of obesity is the body mass index (BMI), a person's weight in kilos divided by the square of their height in metres. A BMI of 30 or more is considered obese, 25 or more is considered overweight. It is not a perfect system though because it does not differentiate between muscle and fat. International rugby players in prime condition would be classed as obese under this system. Morbid obesity is defined as a BMI of more than 40.
Once considered a problem only in high-income countries, obesity is now dramatically on the rise in low- and middle-income countries, especially in urban areas. Government statistics estimate that, by 2025, 41% of people in the UK will be obese and by 2050 it will be more than half.
NHS costs for treating the overweight are projected to double to £10bn a year by the middle of this century. The wider costs to business and other parts of society are estimated to reach £49.9bn a year. And the biggest fear is for children who, all the studies show, are far more likely to grow up into fat adults with all the health problems that extra weight brings if they are fat as children.
In Dundee this weekend one couple are waiting to hear if their newborn daughter can be returned to them after she became the seventh of their children to be taken into care over concerns for their welfare. The 40-year-old mother weighs 23 stone and the father is 18st and the council have been working with the family for some time to try to regulate their diet and exercise, but the parents' failure to comply is said to be a major, although not the sole, factor in the decision of social services that the children were not safe at home. The eldest of the children, aged 13, weighs 16st.
The family's lawyer, Katie Price, said they felt "victimised" and claimed that weight was 75% of the issues being held against them. "This whole case has been dreadful," she said. "Neither of these parents takes drink or drugs. They have a big, happy, noisy family which is prone to being overweight."
But it is a far more common situation in the US, where seriously overweight children are classed as having been abused. "Overweight and obese children become overweight and obese adults," said Amelia Lake, public health nutritionist at the Institute of Health and Society in Newcastle University.
She said it was very difficult to reverse the trend, but not impossible. "We did see this epidemic coming, experts have been talking about it for 30 years. We need to change behaviour and their environment.
"I gave a talk at a weight loss clinic recently and was at the bus stop and saw one of the women come out of the surgery and go straight into the fish and chip shop. Is that her fault or is it also in part the fact that the shop is there and the smell is irresistible? You can't be totally unsympathetic and there is certainly no reason to be nasty to the obese. We need to accept that there are things affecting behaviours."
Lake said the issue was complicated by factors such as food production and the environment: "Really the best word to describe obesity is 'complex'."
It is no surprise to experts that Paul Mason's parents, Janet and Roy, were both obese. His weight gain got so out of control that to take him to St Richard's hospital in Chichester, West Sussex, for surgery posed a logistical nightmare for the health authorities. After a military helicopter was ruled out, Keith Hotchkiss, transport manager at St John Ambulance in Suffolk, offered one of the country's four dedicated vehicles for obese patients.
"The last person we carried was 65st," said Hotchkiss, who commissioned the bariatric (field of medicine concerned with obesity) ambulances when he saw how overweight people were being transported in the back of vans or carried out on stretchers made of old doors.
"They were being treated in what was an unacceptable manner. We treat all our patients with care, compassion and dignity. People may criticise us for providing this service and say we shouldn't do anything to help these people because it's their own fault, but we at St John Ambulance are non-judgmental, and anyway we are taking them to treatment centres where they can lose weight and stop being a burden to the NHS or requiring people from the fire service to help them out."
Activists have started campaigning here to have discrimination against fat people made illegal, as it is in parts of the US. In legislation similar to UK disability access laws, cinemas and restaurants in San Francisco have to provide larger seats and doctors must "respect the wishes" of patients who do not want to discuss their weight.
"It took me a long time to persuade my own GP that my weight was not an issue we were going to be discussing," said Fatima Parker, the founder of International Size Acceptance Association UK.
"You can be healthy at any size. What we need to do is remove the stigma of the word fat and stop looking to this thin ideal that many doctors and diet companies and the fashion models are selling all over the place. I'm not overweight, I'm fat because I'm the right weight for me now, I'm not 'over' anything."
Parker said that when obese patients see their doctors they are told to lose weight, no matter the reason for the visit. "A lot of fat women get cervical cancer because they are too embarrassed to go and have tests done. The BMI test is flawed – it would class a muscle man as obese as it doesn't differentiate between muscle mass and fat, so it serves no one but the insurance companies. I am worried about fat people being discriminated against, and I think we should concentrate on that issue… where do you see fat women in positions of power or success?"
There have even been attacks on the obese. Marsha Coupe, 53, who weighs 22st, was assaulted while travelling by train from Charing Cross, London, to her home in Kent. "A woman sitting across from me started kicking me and said, 'Hey, fattie! You should not be on the train, you need two seats!' I had probably 30 to 40 bruises over my chest and my neck. I was terrified I was going to lose my eye," she said.
"London prides itself on being diverse, yet there is almost a zero-tolerance on anyone of size. You cannot walk down the street without being verbally or physically assaulted."
But Tam Fry of the National Obesity Forum believes fat people are a drain on the NHS and need to be more determined to lose weight. "I particularly regret that the fire service gets called to move these people about. This 70st man's surgery will tie up an operating table and I'd hate to be a family coming in with an emergency and a fat man is occupying the space.
"I sympathise with Paul Mason because he should have been picked up and helped by the NHS primary care years ago before it got so bad. But obese people need to dedicate themselves to losing weight through exercise and people who have a genetic predisposition towards weight gain have to double their efforts to combat that."
Fry says that the problem can be traced back to the 1970s. "Food became cheaper and faster and all the open spaces went, parks filled with winos and drug addicts and playing fields were sold off for housing. Then it was because of computers, because of television, junk food, a whole load of issues, and now big is about to become normal. We mustn't over-medicalise obesity either – in the case of our 70st man he has no medical problem, he has just eaten himself silly."
Fry believes Britain is 15 years away from turning the tide. "We are going to get fatter before we get thinner, because we have already missed a whole generation in schools, but now the government does seem determined to tackle the issues head-on and get into schools and educate the young."
The government has commissioned major studies on obesity. The largest was published two years ago, when Sir David King, then chief scientific officer, said the results showed "the current and likely future scale of the obesity problem is daunting".
The report blamed changes in work patterns, transport, food production and food-selling for the epidemic. In his introduction King said: "The technological revolution of the 20th century has left in its wake an 'obesogenic environment' that serves to expose the biological vulnerability of human beings." In other words, everything, from computer games to the way our houses and streets are designed is working against people staying fit, well and slim.
The experts and academics who co-operated to produce the study attacked an oversimplification of the problem.
The report's introduction says: "The project's findings challenge the simple portrayal of obesity as an issue of personal will power – eating too much and doing too little.
"Although, at the heart of the problem, there is an imbalance between energy intake and energy expenditure, the physical and psychological drivers inherent in human biology mean that the vast majority of us are predisposed to gaining weight.
The report said it is not surprising that the median body mass index in the UK is now above the "healthy" range. "We evolved in a world of relative food scarcity and hard physical work – obesity is one of the penalties of the modern world, where energy-dense food is abundant and labour-saving technologies abound.
"Creating an environment that better suits our biology and supports us in healthy eating and activity habits is a challenge for society and for policymakers. It's not simply a health issue, or a matter of individual choice."
But whether it's a medical, class, economic, psychological or feminist issue, the obesity epidemic shows no chance of slowing, and Hotchkiss is likely to find plenty of demand for his bariatric ambulances as Britain heads towards a fatter future.
Source  guardian.co.uk