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Obesity has existed ever since civilisation has been recorded. The Venus of Hohle Fels, a crude statuette of a naked obese woman, is estimated to be 35000 years old - 10000 years older than her more famous cousin, the Venus of Willendorf. The recorded history of the treatment of obesity goes back thousands of years: in 500 bc, the ancient Indian surgeon Sushruta described "obesity, voracity, gloss of the body, increased soporific tendency and inclination for lounging in bed or on cushion" (Bhishagratna, 2006).

Tam Fry has been gazing into his political crystal ball in this issue of the British Journal of Obesity, predicting that David Cameron himself might become the next Obesity Czar in order to safeguard the “health of millions of children and the financial sustainability of the health service” (see page 46). Tam’s message is a mixture of optimism, pessimism and, most importantly, hope; the pantomime villains are unmasked, the possible heroes cheered on and a putative blueprint for successful obesity management for this and future generations drawn up. It is slightly depressing that the motivation for action is likely to be avoidance of the political embarrassment of a bankrupt NHS and safeguarding jobs for the boys in Westminster, rather than improving the nation’s health and reducing health inequalities, but any motivation is better than none. Not everyone with any power is so cynical; Jonathan Valabhji, NHS England’s Czar for obesity, type 1 diabetes and type 2 diabetes, is a talented clinician – and likeable character – who wants the best for his patients, but he, like the rest of us, will jump on any bandwagon that results in money and resources being released to fight obesity.

The sugar tax has arrived in the UK at last, albeit only in Jamie Oliver’s restaurants and a few others, but “the longest journey starts with the smallest step.” My mother used to say, “there’s only 20 calories in a teaspoon of sugar,” whilst she ladled at least two into my milky coffee, and my dentist used to sit at the local pub table munching sugar cubes as if they were dry-roasted peanuts. How things change!

This issue of the British Journal of Obesity describes some potentially exciting news from Public Health England (PHE) concerning the fight against obesity, alongside some encouraging clinical background.

A recent report from the EarlyBird Study appeared under the rather less prosaic title of “Childhood obesity: evidence for distinct early and late environmental determinants” (Mostazir et al, 2015). The findings suggested that two distinct factors were responsible for excess weight gain in different sectors of the childhood population at different ages. The successful prevention of childhood obesity requires understanding the cause, and this new research implies that fundamentally different strategies may be needed at different stages of childhood.

In 2013, more than 62% of adults in the UK and Ireland were classed as overweight or obese (Public Health England, 2015). Behaviour change has become accepted as a necessary component in the management of weight loss (Cavill and Ells, 2010). This was further confirmed by a British Psychological Society (2011) report, which suggested that psychological issues can be linked to the causes and consequences of obesity, and that psychological techniques and therapies should be incorporated into weight management healthy weight. Stewart et al (2010) suggested that up to 30% of people who undergo bariatric surgery begin to regain weight after 2 years, as a result of binge eating, emotional eating, triggers, strategies and/or their environment. The National Confidential Enquiry into Patient Outcome and Death revealed that only 29% of bariatric surgery patients in the UK received any psychological input before or after surgery to address these issues (Martin et al, 2012).

Obesity is one of the Cinderella services. We all know that it is a major problem and yet no-one wants to take responsibility for providing the service. Obesity has been a growing problem for the past decades. Latest figures suggest that 25% of the population are obese and that the direct costs of obesity and its comorbidities are in the order of £6 billion per year.

A recent visit to one of my local Burger King outlets left me with bewilderment. It was before the time in the morning when the items served are changed from the breakfast menu to main menu. I was asked to purchase a regular cappuccino coffee and, whilst waiting to be served, and out of interest, I wondered how many calories would be in this. On the menu billboard above the cashier, it said that a regular cappuccino was 71 kcal and a large was 105 kcal. However, the tray menu said 308 kcal and 387 kcal, respectively!

Weight management in primary care remains an area of controversy owing to inadequate mechanisms to define roles and responsibilities and to fund work done in this area, as well as an uncertain evidence base for the effectiveness of management by primary care clinicians. However, there are clear areas in which weight management is closely related to primary care, including risk assessment and signposting to self-help and tiered weight management services, plus an evolving role in long-term follow-up after bariatric surgery. This article summarises some of the methods whereby GPs can support weight management in primary care and explores limitations and barriers to carrying out those responsibilities, as well as emerging solutions. It also outlines the work of the Royal College of GPs Nutrition Group in developing new resources to support training in obesity management for primary care clinicians.

The NHS Commissioning Board has recommended the introduction of medical, multidisciplinary, multicomponent weight management services (Tier 3 services) for obese patients requiring specialised management, including assessment for bariatric surgery. Unfortunately, these have not yet been commissioned in many areas. Barriers identified include obesity being a low commissioning priority, therapeutic nihilism, medical workload constraints, a lack of trained staff, financial barriers to developing new services, and challenges of evaluation. A particular challenge is the lack of long-term funding and the complex tendering processes used in some areas. However, patients value these services, and the sparse academic literature shows encouraging results. Nonetheless, more robust evaluation of these services, including additional outcome measures and longer follow-up after discharge, is required to demonstrate cost-effectiveness to the NHS.

The British Obesity and Metabolic Surgery Society (BOMSS) recently published the first UK guidelines on perioperative and postoperative biochemical monitoring and micronutrition replacement for people undergoing bariatric surgery. In doing so, BOMSS aimed to provide guidance for safe practice and to reduce the variation in monitoring and prescribing between different units in the UK. In this article, we review these guidelines and provide a helpful summary for all healthcare professionals involved in the care of people who undergo bariatric surgery.

There is a growing cohort of people undergoing bariatric surgery, and these patients require lifelong follow-up. Recent NICE guidelines recommend a shared care model for the long-term management of these individuals; therefore, GPs need guidance on how to appropriately monitor and manage them. Following a review of the current literature and discussions with experts in the field, guidance has been developed that will aid clinicians in providing high-quality shared care alongside Tier 3 or 4 specialist teams. Areas discussed include monitoring long-term associated conditions, potential nutritional deficiencies, nutritional supplements, changes to medications post-surgery, post-surgery contraception advice and criteria for re-referral to specialist services.

The medical model of weight loss and maintenance often treats overweight and obesity as a logical, rational process that requires only knowledge, education and motivation for success. In this article, the often overlooked role of emotions in weight management is discussed. A new psychological self-help tool, which equips people with the emotional tools and skills required as a foundation to implement weight loss advice, is described, and the role of the clinical psychologist in weight loss initiatives is discussed.

The causes of childhood obesity are complex, and effective intervention requires a systemic approach. Obesity is established early in life, yet many healthcare and early-years professionals lack confidence to raise sensitive lifestyle issues in their work with young families. HENRY (Health, Exercise, Nutrition for the Really Young) has developed a range of unique and effective interventions focused on the start of life that include family support, practitioner training and building community resilience. HENRY’s research-based approach to tackling child obesity over the past 8 years suggests that it is possible to enable positive change. A distinctive element is its focus on parenting, emotional wellbeing and whole-family lifestyle as a foundation for enabling young children to develop healthy food preferences and eating and activity habits right from the start. Results are promising, with families making significant improvements to their lifestyle that are maintained at follow-up, including healthier eating across the whole family, increased activity levels and increased parenting efficacy.

Obesity in pregnancy is a major health issue which affects both mother and child, and about which there remains a lack of knowledge, education and support. However, pregnant women are generally highly motivated to do the best for their children, and clinicians have a number of opportunities to improve outcomes by providing education and counselling before conception, during pregnancy and after the birth. This article outlines the risks associated with obesity in pregnancy and provides advice on improving the care pathway for this important group of patients.

While reduction in energy intake is key to weight loss, it is challenging in practice to achieve a sufficient calorie deficit to achieve clinically significant weight loss. With indicators that a greater weight loss within the first year is a good predictor of long-term weight loss maintenance, the use of dietary methods to give a substantial early energy deficit could be beneficial. Low-energy (800–1200 kcal/day) formula diets (LEDs) and very-low-energy (<800 kcal/day) formula diets (VLEDs) have recently gained popularity in clinical practice as a tool to enable patients to achieve this substantial calorie deficit and, therefore, lose a significant amount of weight, with consequent improvements in obesity-related comorbidities. This review examines the current evidence for the use of LEDs and VLEDs for weight loss and improvements in obesity-related comorbidities, while helping to inform clinicians on their potential use in clinical practice.

Adults with intellectual disabilities (ID) not only experience a higher prevalence of obesity than the general population but also face barriers to accessing healthcare. Waist Winners Too (WWToo) is a weight management intervention for adults with ID, adapted from a current community weight management intervention, which was piloted in order to reduce inequalities in service access. In total, 29 adults with ID and BMI ranging from 28.6 to 54.3 kg/m² attended the intervention with carers. Recruitment was feasible and feedback positive. Attendance was good over 8 weeks but follow-up proved difficult. Statistical analysis showed statistically significant weight loss, but the intervention period was too short to achieve clinically significant weight loss of 5%. WWToo may be an effective intervention if held over a longer time period.

There is clear evidence from large clinical trials that type 2 diabetes can be prevented in high-risk individuals using intensive lifestyle change. The challenge for healthcare systems such as the NHS, however, is to translate these findings into routine clinical care and be as successful. We implemented a care pathway based on existing NICE guidelines for the management of people at high risk of type 2 diabetes at seven GP practices in Dorset. This 12-month intervention consisted of 16 group sessions, one individual appointment and participation in an already established community-based exercise programme. Twenty overweight or obese adults were enrolled in this pilot phase. In this article, we summarise our findings and provide evidence that diabetes prevention programmes can be translated and implemented in the routine primary care setting.

In March 2014, the consultation document Joined up Clinical Pathways for Obesity was published, exploring options for the future commissioning responsibilities of Tier 3 and 4 weight management services. What became apparent was the lack of reference to childhood weight management services (more so at Tier 3), which mirrors the scarcity of evidence-based research in this area. This article asks a number of key questions: who should provide Tier 3 services for children and young people (CYP), what does such a service look like and who should fund these services for CYP? Greater commitment is needed from the Department of Health to provide clarity for Tier 3 service providers. SHINE (Self-Help, Independence, Nutrition and Exercise), an established Tier 3 service for CYP with severe obesity, is an example of what a Tier 3 programme can look like. Finally, it is proposed that funding is better distributed across the Obesity Care Pathway to ensure that CYP with severe obesity can access appropriate treatment.

As our understanding of the causative factors and consequences of obesity increases, healthcare professionals and policy makers are faced with an ever-expanding amount of data that can appear overwhelming in the search for effective solutions to this global crisis. New ways to incorporate these developments and allow us to see the relationships between the findings are required. This article outlines the College of Contemporary Health’s Obesity DebateGraph, a new, free-to-use, online tool that can help to unravel the complexity of the obesity space, collaborate and share ideas, and better understand the ways to tackle the obesity pandemic.

While the majority of research into the effects of obesity on reproductive health focusses on women, the latest evidence shows that a large number of complications can also occur in obese men. This article summarises the effects of obesity on male reproductive health across a man’s entire lifespan, from the in utero environment, through puberty and adulthood, to the putative epigenetic effects on the offspring. Treatment options are also discussed, although this remains a somewhat overlooked area of research.

The prevalence of obesity in children aged 11–15 years was 37.8% in 2013. Since 2004 there has been a statistically significant increase of 2.6% in prevalence, compared with stabilisation in the under-11s. The aetiology of this is multifactorial. Adolescent obesity is linked with comorbidities such as type 2 diabetes, cardiac abnormalities and obstructive sleep apnoea, and the psychosocial impact is significant. Weight management in this age group presents particular challenges. In this article, the evidence base for various weight loss interventions in adolescents, including residential weight loss camps, individual and family-based behavioural therapy, technology such as texting and apps, and bariatric surgery, are reviewed. The real challenge, however, is the obesogenic environment; failure to tackle this will result in increasing prevalence.

By the time you get to this page, David Cameron may have unexpectedly announced that he, personally, is to lead the UK’s fight against obesity, and childhood obesity in particular. The promise that his Government, if elected, would address the problem emerged in the run-up to the May election, but without any hint that he might make obesity his “mission”. The scuttlebutt around Westminster at the end of June was that a surprise announcement would be made before Parliament’s recess – or earlier – but one never knows with Westminster.

This column aspires to be one that focuses on a piece of news that may surprise readers (see “Cameron for Obesity Czar” in the previous issue of this Journal, page 46), so I’m trying my hand now to coax out a little more detail on an idea likely to crop up in the Prime Minister’s Framework to tackle the epidemic.

Unfortunately, daily exercise is frequently not a habit in children, but there is a hint that it might become one after David Cameron’s “Framework to tackle childhood obesity” is launched in (possibly) January.

In this regular section, Matt Capehorn picks out recent key papers published in the area of obesity. To compile the digest, a PubMed search was performed for the 3 months ending April 2015 using a range of search terms relating to obesity. Articles have been chosen on the basis of their potential interest to healthcare professionals and are rated according to readability, applicability to practice and originality.

Why do we not use very-low-calorie diets (VLCDs) more? I appreciate that I may be biased, as I am Medical Director to a commercial provider; however, the evidence for their use is clear.VLCDs, also referred to as VLEDs (very-low-energy diets) and sometimes LELDs (low-energy liquid diets), are based on a diet of less than 800 kcal/day, provided by a range of shakes, soups, low-calorie meals or meal replacement bars, that are formulated to be nutritionally complete when adhered to.

For many years the advice has been clear: if you have a decent breakfast, over the course of the day you are more likely to consume fewer calories overall and, therefore, it is better for weight management; in other words, “skipping breakfast can make you fat.”