Saturday 21 January 2012

Obesity: The cause, the cost, the solution

"48 year old female, keeps fainting, patient is obese, weighs 35 stone"

A few months ago I wrote a blog called ‘Fat people, stairs and backs’. This particular post received a lot of praise but also angered a few. It was suggested I criticised without foundation or research and offered no reasoning to may argument. I did a follow up  post  which was a knee-jerk reaction to a rather abusive e-mail but decided I should in fact back up what I was saying with a much more researched piece. So I did! I wanted to look at the social reasons behind obesity and what impact obesity has when not prevented in childhood. I also wanted to highlight the benefits of using prevention rather than cure in tackling such a huge social problem. 

Obesity is a significant societal trend with effects being felt throughout the health care system, economy and society as a whole.  A person is deemed overweight if their body mass index (BMI) is between 25 and 30; a BMI over 30 is classed as obese and a markedly increased health risk. I attended a middle-aged female who had been experiencing DIB for several days as a result of chronic heart failure and episodes of fainting. The patient was of low socioeconomic status, weighed 35 stone and was in her upstairs bedroom.  We began treating her breathing while carrying out a risk assessment of her extrication.  Her condition was deteriorating but due to her size we were unable to safely carry her down the stairs. The decision was made to mobilise the fire brigade to assist us and the bariatric ambulance was called to convey.  The patient was taken out of the house through the window by a crane. This caused considerable delay in her receiving definitive care and despite aggressive management at hospital she died shortly after arrival. What led the patient to be in this position? Why was nothing done to avoid this situation? Why was she allowed to stay like this? How long had she been like this?

The NHS has been forced to focus on treatment of illness rather than prevention due to increasing demands and costs.  This leads one to question, however, where the responsibility for obesity prevention should lie.  Obesity costs the economy not only in health care but also in sick days, workplace injuries and disability pay.  Not only is the prevalence of obesity increasing in the Western community, those who are overweight are also heavier. This paints a bleak picture of a problem which has increased rapidly since the 1970’s; despite being on nearly every major government’s agenda.  The literature is focused towards prevention because ‘cure’ is a nearly impossible ideal and to achieve this we must look at children.

Nearly a quarter (23.1%) of children are overweight or obese by the time they start primary school, this increases to over a third (33.4%) by the time they finish. Health promotion is fraught with difficulties in school aged children as poor management of obesity can result in life-long unhealthy eating habits and avoidance of medical help. Our patient may have had a negative experience with a health care professional and avoidance behaviour is common in obese patients who do not want to be lectured or humiliated. Conversely to the conception that patients will use an illness to seek attention from their doctor, obese patients often avoid this interaction. There is risk of promoting the ‘sick role’ with obese children and all children could benefit from nutritional and physical activity advice. This should not be taught as ‘treatment’ for overweight children who may feel they have an illness as a result.

Obesity is not a disease, however it does appear to spread through social ties. There is literature to support that neighbourhood does increase childhood obesity especially when coupled with a lower socio-economic status. I firmly believe it is time for people to assume personal responsibility for the improvement of society. Although our patient’s obesity is juxtaposed to this ideal her individual community may have made her weight more acceptable. In the school environment however, a lower SES and being overweight are both major factors in teenagers suffering social marginalisation. This leads to emotional distress, low self esteem and lower expectations of their educational future . It is pertinent to note that class position is responsible for health, health does not determine class.

Careful education is imperative for these young people but education needs to be extended to the home. Our patient may have been obese for a number of reasons, however, it is likely she developed obesity from a young age. Poor family functioning, authoritarian parenting styles and single parent families have been cited as factors increasing the risk of childhood obesity . Other factors increasing the risk within the home are stressors; stressors in adults have been linked to obesity, this could be attributed to poor eating habits among stressed individuals and with a huge increase in incidence of stress these days it is of little surprise there is a similar increase in obesity.  This phenomena has been extended to children with specific factors being recognised for younger and older children. A positive association with obesity has been found in younger children who have a lack of cognitive stimulation and emotional support, whereas older children who live in a household with financial strain or members experiencing mental or physical problems (which could be a result of obesity) are at increased risk.

There is a strong correlation between obese parents and obese children and while there is an argument for a genetic predisposition, environmental factors are thought to be the most important. The increase in obesity has occurred among all socioeconomic groups therefore cannot be explained by genetics alone. Genetics can increase ones risk of developing the wide ranging complications of obesity, such as diabetes, high blood pressure and heart disease, some of which were observed in my patient. Obesity is associated with many chronic conditions  the cost of which have a huge impact on the economy. The parliamentary committee omit some of the most expensive areas of the cost of obesity from their calculations  this made it impossible to glean accurate figures for the true cost of obesity. It is estimated obesity costs the economy £4 billion a year and this is expected to rise to £6.3 billion a year by 2015. This kind of required financial support is not sustainable so a way to prevent the need for this financial burden is urgently needed.

Schools are the most appropriate setting for prevention, and therefor there is little we can physically do in the ambulance service other than refer.  The health promotion these kids need should only be undertaken by specialist educators as the message can be distorted.  Poor management can lead to starvation, laxative and slimming pill abuse amongst other drastic measures at a time when nutrition is vital for their developing bodies. If childhood obesity is allowed to progress to adulthood without specialist intervention the individual increases their risk of physical, emotional and social problems in later life.  I do not know the cause of our patient’s obesity or why it was allowed to continue to the situation I met her in.  Unfortunately, my patient did not get the help she desperately needed but hopefully if the right people set up the the right referral process maybe we as a nation can get to a point where prevention is a realistic option.


  1. Don't forget , obesity can also be caused genetically .

  2. Thats in the penultimate paragraph. There was some posting issues so reload the page and the full blog should now be visable.

  3. I resent this and how 'facts' are used as a basis to make a whole load of presumptions about someone because of how they look. I hold two masters degrees, come from a well off family, earn a high wage and own my own home. I walk 2 miles a day and consider myself moderately active. How you define how someone 'uses' the NHS I don't know, but i don't appear to use it any more or less than my peers some of whom are thin. I am also fat. I am fat because I have a big appetite and eat too much. I have a sedentary job which doesn't help. Since moving to the capital city I have gained 3 stone because of the lifestyle down here. I work hard, pay my taxes and have never taken a benefit in my life. I also eat more when I am stressed. That is my decision to make. Some people smoke or drink but are not stigmatized or judged in the same way as a fat person. Using 'facts' to make these judgments does not make it any better.

    1. A question? Have you left this comment just because you object to me criticising fat people? I say that because you clearly havn't read what I have written at all. Firstly, congratulations on your masters degrees and being well off and having loads of money from your high wage and having your own home in the city. Kudos. Totally irrelevant but well done.

      If you don't use the NHS much then this blog is not about you. That is because I have nothing to do with, don't have to carry you and don't have to crane you out of your house. It also means you don't have to rely on a bariatric ambulance. You know the reasons for your size, you are happy with them and like you say, that is your decision. This post and the similar ones are about those who don't work, can't work and are a drain on the NHS. Look at my post Pain, Cranes & Automobiles from the may archives. These people are who it is about.

      The way you me about your size and how wrong I am to say my own opinion can only comes from a presumption that I am not fat. Newsflash! I am clinically obese if you are believe BMI, but like you Im active, eat to excess and enjoy the nicer things as and when I can afford them. My choice and like you it doesnt impact on the NHS. My facts were fully researched, for each of reading references were removed as was the reference list and bibliography. If you want it via email I am happy to send the fully researched and fully referenced article. If you had read it properly you would see that the article is mainly about preventing obesity in children and how the social interactions and experiences people have lead to cause.

  4. In many ways, I can totally agree with what you're saying. However, my personal experience is that the NHS isn't anywhere near as helpful as it could be to help prevent obesity. I have seen my GP on numerous occasions (although that's not entirely true - I always have to see a different GP as the previous one has left) about my weight as it is going up and up and I would like to do something about this before it becomes a problem. Technically, I am now very obese as I have a BMI over 35, although I am fairly active (my dog won't let me be any other way!) and have a sensible healthy diet, as per an NHS dietician. But what a struggle I had just to get to see the dietician! Before then, I must have had about 4 or 5 appointments, each time being told that I was kidding myself about my diet and exercise levels (I wasn't) and that I should join weight watchers. Unsurprisingly, I'd already tried that, and found that to lose weight on their diet, I'd have to eat far less points a day than the diet allowed and I was constantly hungry. Even now, I feel I have been fobbed off by the NHS who can tell me all the things that I'm doing right and that I'm healthy, but not what I need to do to help myself.

    Whilst it sounds like I'm just waffling away about myself (sorry about that!), I felt prompted to add this comment after reading your point about where the responsibility for obesity prevention should lie. I'm sure that the NHS are very good at the 'eat less, exercise more' statement, and for basic concerns, I know that can help. But for people like me, where there is potentially more to it than that, it feels as though there is no support or help available. My size is an issue that gets me down on a regular basis - I'm in tears as I write this and I hate my body in a way I can't describe. My heart goes out to the girl you wrote about, and also the girl in the media recently who went through the same thing - I can only hope that more support becomes available before this becomes a regular occurrance in this country.

    Sorry for waffling on!

    1. Thank you for you comment. I can empathise with you, I really can and I assure you, I know exactly the problem you are facing. That is my point about the NHS, they are far to focused on treating what is already to late rather than help people who are asking for help before things get worse. At least you want to change. It's horrible to read how upset you are about it and I really wish I had the answer. Sadly I don't, just perceiver. If you want to discuss further with me, I have some pointers, email at

      Regarding the girl in the media recently, look at my post from the May archives 'Planes, Cranes and Automobiles' where I discuss that case further.

      Many thanks

      Ella x


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