Issue: 2015, Vol 1, No 1, Pages 1–40

The human cost of failing to address obesity

Val Bullen, Victoria Feenie

The costs of obesity and its related comorbidities to healthcare systems are well known, yet the effects on obese people individually are equally devastating. Obesity is now seen in people of all ages, even children, and it has widespread effects on physical health, reproductive health, employment, mental health, stigma and mortality risk. These effects are described in this article, and the urgent need to begin tackling the condition in primary care is highlighted.

We are all aware of the increasing cost to the NHS of treating obesity and its consequences, with headlines such as "Get serious about obesity or bankrupt the NHS" (NHS England News, 2014). This is not only due to the comorbidities associated with obesity, such as diabetes, cardiovascular disease and cancer, but also due to the costs of changes to operating theatres, ambulances, beds, wheelchairs, etc., that are required to cope with morbidly obese individuals. However, failure of obese people themselves to effectively address the problem, for whatever reasons, affects not only their health and wellbeing but also their social and work life. It is important for those healthcare professionals working with obese children and adults to be aware of all aspects of the condition, and to be prepared to make use of every encounter to address this issue, as detailed in the recent NHS England Implementation Guide and Toolkit (Varley and Murfin, 2014).

Impact on mortality and quality of life Globally, overweight and obesity comprise the fifth leading risk factor for mortality, resulting in some 2.8 million deaths annually (World Health Organization, 2009). Individuals with a BMI over 35 kg/m2 face an increase in mortality risk of 40% in women and 62% in men, as compared to individuals with a BMI in the normal range (Mehta and Chang, 2009). According to Dent and Swanston (2010), moderate obesity (BMI, 30–35 kg/m2) reduces life expectancy by an average of 3 years, while morbid obesity (BMI, 40–50 kg/m2) reduces it by 8–10 years, which is equivalent to the effects of lifelong smoking.

In addition to an overall increase in mortality, there are several studies linking a reduced quality of life (QoL) with obesity. In one, Jia and Lubetekin (2005) concluded that people with obesity had significantly lower health-related QoL (HRQoL) than people with a normal weight, and these lower scores were seen even in those who did not have chronic diseases known to be linked to obesity. This may be because obese individuals face a greater risk of mobility impairments, which will affect their QoL.

Obesity is a risk factor for functional decline in both genders, and the risk increases with body mass (Himes, 2000). Individuals with higher waist circumference and body mass demonstrate difficulty in bending, kneeling, stooping, lifting and carrying. Problems with executing these basic physical tasks creates limitations in maintaining strength and mobility, as well as in performing basic activities of daily living (Han et al, 1998). Furthermore, at the other end of life, we are seeing an impact of obesity on the QoL of children.

Effects in children

Figures from the latest National Child Measurement Programme for England show that over a fifth (22.5%) of children in Reception Year were either overweight or obese in 2013/2014, as were around a third (33.5%) in Year 6, with the prevalence of obesity higher in boys than in girls in both school years (Health and Social Care Information Centre, 2014). Recent figures from the Millennium Study showed significant variation in the different UK countries; 40% of 11-year-olds in Wales and Northern Ireland were overweight or obese, compared to 35% in England and 33% in Scotland (Centre for Longitudinal Studies, 2014). For 11–15 year olds, the prevalence of overweight and obesity is around 35% (Public Health England, 2014). This means that approximately 4.5 million children and young people in the UK are overweight or obese (Helping Overcome Obesity Problems, 2014).

Childhood and adolescent obesity confers an increased risk of adverse outcomes, including asthma, hypertension, cardiovascular problems, sleep apnoea, insulin resistance and other endocrine abnormalities, increased risk of fractures, and psychological effects such as low self-esteem and depression (Reilly et al, 2003). A recent study found that hospital admission rates for obesity and obesity-related health problems among children and young people have risen more than four-fold in the last decade, particularly among girls and teenagers (Jones Nielsen et al, 2013).

Obesity affects not only children’s health but also their academic performance (Booth et al, 2014), which may be partly explained by health issues and absenteeism (Wijga et al, 2010), and it may lead to bullying (Rees et al, 2011). A study by Schwimmer et al (2003) demonstrated that obese children and adolescents had an HRQoL that was similar to those diagnosed with cancer.

A decade ago, one of the most striking and sobering statements made by child obesity experts was that, because of the rising levels of obesity in children, the current generation may have a shorter life span than their parents for the first time in 200 years (Olshansky et al, 2005). This is because the majority of obese children become obese adults, with all the associated health issues that this brings (Singh et al, 2008). Yet progress in resolving the problem remains slow and has led GPs to call for a COBRA-style emergency taskforce to be set up in order to tackle the rising epidemic of childhood obesity. They warn that, unless urgent action is taken now, an entire generation will be "destroyed" by their diet (Royal College of GPs, 2014).

Reproductive health

Although obesity is becoming more acceptable and normalised, and with most parents failing to recognise their child as obese (Eli et al, 2014), there are consequences not only to the health of obese people but also to that of future generations, through transgenerational effects. However, obesity also has more direct effects on reproductive health. According to the Royal College of Obstetricians and Gynaecologists, the prevention of childhood obesity should be considered a priority given the impact of obesity on reproductive, obstetric and gynaecological health (Busby et al, 2012).

Obesity initially affects puberty, with girls entering menarche earlier (Kulie et al, 2011). Adipose tissues contain aromatase, an enzyme that can convert adrenal androgen precursors to oestrogen; thus, obesity may cause delay of puberty in boys, which in turn can cause psychological problems (Busby et al, 2012). Menstrual problems and polycystic ovary syndrome are more common in obese girls, affecting their fertility (Schulte et al, 2015), and obese pregnant teenagers are at greater risk of pre-eclampsia and eclampsia (Naver et al, 2014).

As obese children become obese adults and their fertility potential is adversely affected, although they are more likely to seek infertility services, they are less likely to receive help (Vahratian and Smith, 2009). Obesity decreases successful pregnancy rates in both natural and assisted conception cycles, and it increases the risk of miscarriage (Norman, 2010). Obese mothers are a risk both to themselves and to their children; maternal mortality rates are significantly higher in obese women when compared to their normal-weight counterparts (Wilkinson, 2011), and obesity confers an increased risk of adverse pregnancy and fetal outcomes, including gestational diabetes, fetal macrosomia, caesarian delivery and pre-eclampsia (Stewart et al, 2009). Although many conceptions will result in healthy live-born babies, these offspring will have increased lifetime health risks (Drake et al, 2010), and there is increasing evidence of an association between maternal obesity during pregnancy and childhood obesity in the offspring (Reynolds et al, 2010).

Obesity and work life

The effects of obesity extend to work life as well, with obese people less likely to be in employment than people of a healthy weight (NICE, 2013). Although the average employee takes 7 days off sick each year (Sainsbury Centre for Mental Health, 2007), obese employees from London Underground were found to take significantly more short- and long-term sickness leave than workers of a healthy weight, taking an average of four extra sick days per year (Harvey et al, 2010). For an organisation employing 1000 people at the average wage and working hours, this could equate to more than £126 000 per year in lost productivity (NICE, 2012). Such figures are likely to be an underestimate because of self-certification. Obesity can also result in workplace presenteesim. Unlike absenteeism, which is typically defined as health-related absence from work, presenteeism is defined as health-related limitations at work. Moderately or extremely obese workers (BMI, ≥35 kg/m2) experience the greatest degree of presenteeism, particularly in terms of the time needed to complete tasks and the ability to perform physical job demands. In fact, moderately or extremely obese workers have been shown to be significantly less productive than other workers; overall, moderately or extremely obese workers were found to have a 4.16% health-related loss in productivity, 1.18% greater than the combination of underweight, normal-weight, overweight and mildly obese workers (Gates et al, 2008).

The risk of suffering from a fall-related injury requiring medical treatment is 15–79% higher for overweight individuals than for normal-weight people. The greater the fat mass, the higher the risk of injury. Thus, compared with normal-weight individuals, someone with a BMI classed as overweight has a 15% greater risk and someone with a BMI of >40 kg/m2 has a 48% greater risk (Finkelstein et al, 2007). Falls and overexertion are the primary causes of sprains, strains and dislocations in people with obesity compared with non-obese people (Matter et al, 2007). It is, therefore, perhaps unsurprising that implementing a weight control programme in the workplace has been shown to reduce the frequency of several work-related injuries among obese individuals (Lemon et al, 2010).

Stigma

According to Puhl and Heuer (2009), in the US, obese individuals are highly stigmatised and face multiple forms of prejudice and discrimination because of their weight. Weight stigma is seen in the media, employment, healthcare and education, and seems to be growing in prevalence (Brewis, 2014). Obese individuals are considered to be lazy, unmotivated, lacking in self-discipline, less competent, non-compliant and sloppy (Puhl and Heuer, 2009). They are stigmatised and judged as though their condition is all their own fault, even though obesity is a complex, multifaceted condition. Weight stigma increases vulnerability to depression, low self-esteem, poor body image, maladaptive eating behaviours and exercise avoidance (Gatineau and Dent, 2011). Feeling stigmatised and discriminated against is very stressful and can lead to further weight gain and, in particular, an increase in visceral fat (Schvey et al, 2014). Thus, a vicious cycle is set up, compounding the problem.

Obesity and mental health

Psychological problems are a common feature of obesity. Individuals who suffer from psychological disorders (e.g. depression, anxiety and eating disorders) may have more difficulty controlling their consumption of food, exercising an adequate amount and maintaining a healthy weight. A recent review by Luppino et al (2010) found bidirectional associations between depression and obesity.

Up to 70% of obese individuals considering bariatric surgery suffer from a current and/or past psychiatric disorder, of which major depressive disorder (MDD) is the most prominent (Collins and Bentz, 2009). However, obesity and MDD are associated at all stages of life, including childhood, adolescence and adulthood. Adolescent girls are particularly at risk (Marmorstein et al, 2014). Obesity is strongly correlated to depression and other mood disorders, particularly in women, according to Gatineau and Dent (2011). Other psychological disorders, such as anxiety and even suicide, have been associated with changes in body weight (Mather et al, 2009). This will not only have an impact on most areas of an individual’s life but will also make dealing with obesity itself more of a challenge.

Conclusion

The human cost of failing to treat obesity is vast and impacts all facets of an obese person’s life. The increasing prevalence of obesity, together with a projected increase in diabetes and other associated comorbidities, will put an enormous strain on the already overburdened NHS in the coming years.

Owing to the nature of the obesity epidemic, and the extent of the population affected, Ard (2015) recently highlighted in the BMJ that primary care can play a crucial and important role in treating obesity. For many adults, primary care may be the only form of healthcare they receive, and it also provides the scale that is needed to disseminate treatments and interventions widely.

Primary care providers think they have few resources and a lack of sufficient training to provide an informed and effective obesity treatment plan for their patients (Wadden et al, 2013). Furthermore, Booth et al (2015) analysed the records of several thousand obese patients and found that 80% of them had never talked to their GP about their weight. It is, therefore, essential that primary care health professionals seek training in obesity care, online courses for which are now available, to make best use of every encounter.

Authors

Val Bullen
MSc, CBiol, FHEA, FRSM, Director of Education, The College of Contemporary Health

Victoria Feenie
BSc(Hons), MSc, ANutr, Communications Executive, The College of Contemporary Health

Online CPD Activity

Visit http://ccheducation.co.uk/quizzes/cpd to complete the CPD activity based on this article and gain a certificate of participation.


Ard J (2015) Obesity in the US: what is the best role for primary care? BMJ 350: g7846

Booth JN, Tomporowski PD, Boyle JM et al (2014) Obesity impairs academic attainment in adolescence: findings from ALSPAC, a UK cohort. Int J Obes (Lond) 38: 1335–42

Booth HP, Prevost AT, Gulliford MC (2015) Access to weight reduction interventions for overweight and obese patients in UK primary care: population-based cohort study. BMJ Open 5: e006642

Busby G, Seif MW (2012) Obesity in adolescence. In: Mahmood T, Arulkumaran S (eds). Obesity: A Ticking Time Bomb for Reproductive Health. Elsevier, Oxford: 53–65.

Brewis AA (2014) Stigma and the perpetuation of obesity. Soc Sci Med 118: 152–8

Centre for Longitudinal Studies (2014) Child Overweight and Obesity: Initial Findings from the Millennium Cohort Study Age 11 Survey. CLS, London. Available at: http://bit.ly/1NgfhSZ (accessed 25.03.15)

Collins JC, Bentz JE (2009) Behavioral and psychological factors in obesity. The Journal of Lancaster General Hospital 4: 124–7. Available at: http://bit.ly/1cuyEZx (accessed 25.03.15)

Dent M, Swanston D (2010) Briefing Note: Obesity and Life Expectancy. National Obesity Observatory, Oxford. Available at: http://bit.ly/1GlLpVw (accessed 25.03.15)

Drake AJ, Reynolds RM (2010) Impact of maternal obesity on offspring obesity and cardiometabolic disease risk. Reproduction 140: 387–98

Eli K, Howell K, Fisher PA, Nowicka P (2014) "A little on the heavy side": a qualitative analysis of parents' and grandparents' perceptions of preschoolers' body weights. BMJ Open 4: e006609

Finkelstein EA, Chen H, Prabhu M et al (2007) The relationship between obesity and injuries among U.S. adults. Am J Health Promot 21: 460–8

Gates DM, Succop P, Brehm BJ et al (2008) Obesity and presenteeism: the impact of body mass index on workplace productivity. J Occup Environ Med 50: 39–45

Gatineau M, Dent M (2011) Obesity and Mental Health. National Obesity Observatory, Oxford. Available at: http://bit.ly/1NbHFrh (accessed 25.03.15)

Han TS, Tijhuis MA, Lean ME, Seidell JC (1998) Quality of life in relation to overweight and body fat distribution. Am J Public Health 88: 1814–20

Harvey SB, Glozier N, Carlton O et al (2010) Obesity and sickness absence: results from the CHAP study. Occup Med (Lond) 60: 362–8

Health and Social Care Information Centre (2014) National Child Measurement Programme: England, 2013/14 School Year. HSCIC, London. Available at: http://bit.ly/1ETARLi (accessed 25.03.15)

Helping Overcome Obesity Problems (2014) Tackling Obesity: All Talk, No Action. HOOP, Dover. Available at: http://bit.ly/1BM81b0 (accessed 25.03.15)

Himes CL (2000) Obesity, disease, and functional limitation in later life. Demography 37: 73–82

Jia H, Lubetkin EI (2005) The impact of obesity on health-related quality-of-life in the general adult US population. J Public Health (Oxf) 27: 156–64

Jones Nielsen JD, Laverty AA, Millett C et al (2013) Rising obesity-related hospital admissions among children and young people in England: national time trends study. PLoS One 8: e65764

Kulie T, Slattengren A, Redmer J et al (2011) Obesity and women’s health: an evidence-based review. J Am Board Fam Med 24: 75–85

Lemon SC, Zapka J, Li W et al (2010) Step Ahead: a worksite obesity prevention trial among hospital employees. Am J Prev Med 38: 27–38

Luppino FS, de Wit LM, Bouvy PF et al (2010) Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry 67: 220–9

Marmorstein NR, Iacono WG, Legrand L (2014) Obesity and depression in adolescence and beyond: reciprocal risks. Int J Obes (Lond) 38: 906–11

Mather AA, Cox BJ, Enns MW, Sareen J (2009) Associations of obesity with psychiatric disorders and suicidal behaviors in a nationally representative sample. J Psychosom Res 66: 277–85

Matter KC, Sinclair SA, Hostetler SG, Xiang H (2007) A comparison of the characteristics of injuries between obese and non-obese inpatients. Obesity (Silver Spring) 15: 2384–90

Mehta NK, Chang VW (2009) Mortality attributable to obesity among middle-aged adults in the United States. Demography 46: 851–72

Naver KV, Grinsted J, Larsen SO et al (2014) Increased risk of preterm delivery and pre-eclampsia in women with polycystic ovary syndrome and hyperandrogenaemia. BJOG 121: 575–81