Obesity: Is the NHS Fat Prejudice? A New BBC2 Documentary Investigates

Obesity: Is the NHS Fat Prejudice? A New BBC2 Documentary Investigates
A BBC2 documentary on obesity and fat prejudice within the NHS, airing tonight (April 11th 2017) at 9pm, investigates whether obese patients are being refused life-changing treatment and surgery because of a fat-prejudice within the medical community (and indeed wider society) and a chronic lack of funding.

If you've ever hesitated to go to to your GP with a medical issue because you've suspected you'll be dismissed (or already have been) and told to lose weight first, then you'll want to watch this documentary.

Professor Rachel Batterham Phd, FRCP, FRCPE, is Head of Obesity Services at University College Hospitals and presents 'Obesity: How Prejudice Is The NHS?'. Professor Batterham sees obesity as a disease requiring treatment, rather than a 'lifestyle choice'. This standpoint is one that's debated throughout society and shapes everything from government health policies, to NHS funding and even your GPs own personal opinion, which will affect whether you're referred for treatment or told to solve your problems on your own.

The Cost of Obesity

From my point of view, there are two types of costs to consider when it comes to obesity. The personal cost of having a reduced quality of life, and the more obvious cost: medical treatment. The first cost is rarely considered. Society frequently minimises obesity as as a cosmetic issue that can be fixed with diet and exercise, without giving much thought to the chronic physical and psychological health consequences that result in a severely reduced quality of life for the individual, and even their families. 

The second cost, the bill for medical treatment, is usually footed by the NHS in the UK, rather than by the individual, and it's this, which causes a lot of debate within the media, government, academia and the medical community. 

To put a number on the financial cost, this was £5.1 billion in 2016, depending on your definition of an obesity-related cost (1). In the documentary, Professor Batterham explains how offering gastric bypass, a type of weight loss surgery, to eligible patients would pay for itself within 2-3 years of an operation being carried out, by eliminating the cost of future treatment and medication for obesity related illness, such as type 2 diabetes, lifestyle related cancers, hip and knee replacements, kidney disease, heart disease, stroke, and the list goes on. 

The problem is, most patients seeking support or this weight loss surgery are not being referred for treatment or access to support services, even though many of them meet the  eligibility criteria set out by the NICE guidelines - patients must have a BMI of 35 or over and a diagnosis of weight related condition, such as type 2 diabetes (2).

Why are we really against funding obesity treatment?

Our society has long had a political and economic history of not wanting to foot the bill for anything viewed as an 'individual's problem'. Rightly or wrongly so, this individualist attitude was one I came up against frequently as a former social worker. People outside of the profession often argued with me about funding for alcohol and drug rehabilitation programs, arguing that "no one forces and individual to drink or take drugs".  

I knew all too well as a social worker that serious, life threatening addictions didn't arise from waking up one day and deciding to become a crack addict or an alcoholic. In the same way that no one wakes up and chooses to be severely obese. None of these are 'lifestyle choices'. 

To give an extreme example (but unfortunately all too common), every one of my service users were self-medicating in an attempt to cope with the unspeakable traumas they had endured throughout their childhood and well into their adult lives. Sexual abuse, sex trafficking, child abuse from biological parents, foster carers and even adoptive families. There had been countless failures to protect and intervene from social services, health care and education services and the justice system: society's institutions. My service users battled with homelessness, mental illness, prison sentences, criminal activity, poor health and dire poverty. 

I think anyone having to go through these issues, if they were being honest, would be seeking comfort in some form, whether it's taking heroin to numb the emotional pain, consuming alcohol to block the thoughts, or food restriction as an attempt to gain some form of control in the midst of a chaotic life.  Those well versed in psychology will recognise all of these behaviours as 'maladaptive coping strategies'.

As I said, this is an extreme example, and I'm by no means saying that everyone who is obese has experienced abuse or trauma of some kind. Nonetheless, I feel it demonstrates that there can be, and usually is, an underlying psychological issue with any disordered or compulsive behaviour, and as with any addiction or eating disorder, this requires urgent treatment whether in the form of medical or psychological intervention or a combination of the two. 

When we don't treat the underlying issue and continue to dismiss such behaviours as the individual's own problem to deal with, this is when it becomes a societal issue. Ignoring these issues mean that they bleed into other areas of society: rising NHS costs, unemployment, rising costs of sick pay and disability benefits, rising community care bill, relatives having to leave jobs and become carers (and when it comes to drug and alcohol additions, crime too).  

It will always cost far more to fix a crisis than it does to prevent one in the first place.  

Is obesity and weight loss just a personal problem?

So where does this fit in with obesity? Where obesity has been caused by excessive eating, I would argue that the cause is often far more complex for the individual than simply a case of "just stuffing their faces because food tastes nice and not exercising because they're lazy".

Binge eating and excessive eating behaviours are, in my opinion, just like any other eating disorder. I view obesity has having roots in not only societal issues (i.e. increasingly sedentary lifestyles and jobs and the quality and affordability of food), but also deep-rooted psychological causes (emotional eating as a learned coping mechanism). As I've said before, I feel it also has a lot in common other addiction behaviour patterns and is a maladaptive coping strategy.

I'm sure there is very few people who would hesitate to recommend that an individual suffering with anorexia receives NHS treatment, whether medical or psychological, or both. So why is the approach obesity and binge eating any different?

I think there's a common misconception that treating obesity can be achieved simply with diet and exercise. There's very little consideration given to the person's current state of health (i.e. are they physically able to begin an exercise program?) or their mental health and the psychological causes of excessive overeating.

Gastric Bypass Surgery & NHS Tier 3 Treatment

Gastric bypass surgery is one of three types of bariatric surgery available on the NHS to eligible patients. With the bypass, the surgeon dissects a part of the stomach tissue, to make pouch the size of an egg. They then cut the bowl and re-route it up to pouch. This procedure changes how food is responded to by gut hormones and the brain and even affects taste as the hormones in saliva are altered.

It's important to note that weight loss surgery is by no means a quick or easy fix. Post surgery the patient will only be able to consume liquid for the first week, then for up to four weeks, the patient will only be able to manage 2tps of puréed food per meal. It'll also takes ages to eat this small meal, they'll have to chew really well and eat half teaspoon at the time to avoid discomfort. By 6 weeks, they will be able to gradually resume a healthy diet, with one huge caveat: eating too many refined sugars will result in "dumping syndrome", this is because food going into the new egg sized pouch, hits part of bowel, which is not used to large molecules of sugar. This causes the patient to feel faint, sweaty, sick, upset stomach & dizzy (3).

With gastric bypass surgery there's also the risk of bleeds, DVT, infection, and blood clots in the lungs (pulmonary embolism). These risk can affect 1 in 100 patients and the risk of death from this surgery is 1 in 1,000 (4).

While none of this is pleasant, for the patients, it feels like a second chance and the benefits of the surgery far outweigh the risks and their current suffering.

Before a referral for weight loss surgery (also known as Tier 4), patients will have to undergo treatment for two years under the Tier 3 program. This is a program involving a range of professionals working together to provide a diet and fitness program, as well as therapy sessions and behaviour workshops. It's often the case that after going through the program for two years, the patients are able to change their lifestyles, lose weight and manage their conditions without the need for treatment.

Unfortunately, with Clinical Commissioning Groups (CCGs) deciding how to spend limited funds locally, the funding put aside specifically for weight loss services can vary considerably between cities. As a result of this, access to Tier 3 is very limited, despite the effectiveness of the program, and many services have faced closure. Access to Tier 3, as well as the pathway to gastric bypass surgery, has become a post code lottery.

Is there a 'fat prejudice' in the NHS?

Many of the patients interviewed in the documentary felt that they had been dismissed by their GPs, often multiple times and over a span of years. Further down the line, this resulted in many of them being left in a 'Catch 22' situation, where their knees, hips or hearts were in trouble and meant that they couldn't exercise to help with the weight loss. At the same time, they were considered too overweight for surgery to replace joints or operate on heart problems. I have no doubt that there are medical reasons for not operating on obese patients, but I have to wonder how different their lives would have been, had they been referred to a specialist service to help them lose weight, years before.

What this documentary aims to get to the bottom of, is whether patients were dismissed because of a GPs unwillingness to see obesity as anything more than a personal issue with a straightforward fix, rather than a serious medical condition, or whether the services are being cut because of society's (and CCG's) reluctance to fund obesity treatments and services.

You can catch the documentary on BBC2, 9pm Tuesday 11th April.

References: 

1. Steer, Toni (2016) An update on adult obesity levels in the UK and the cost to the NHS: 

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