Citerank: (67) 340964Tackling obesity in the UKWith concern growing that the Foresight analysis—that 50% of the UK population could be obese by 2050, at an annual cost to the nation of around £50 billion per year [2]—substantially underestimates the scale of the unfolding obesity crisis, the College of Contemporary Health is working with the wider policy community to develop a whole systems map of the obesity crisis and the potential responses.7F1CEB7, 348679Focus outcomes indicators on action by primary health professionalsThe Quality Outcomes Framework indicators on obesity should include, and focus on, indicators on the action taken by primary healthcare professionals on behalf of overweight or obese patients. [1]565CA4D9, 348700Health Professionals84E4A378, 348703Actions – Industry2794CAE1, 349151AMRCThe Academy of Medical Royal Colleges comprises the 20 medical Royal Colleges and Faculties across the UK and Ireland whose presidents meet regularly to agree direction in common healthcare matters. It provides a collective, clear and sure voice for the bene?t of patients and healthcare professionals across the four nations of the UK.58D3ABAB, 352368AMRC – RecommendationsThe AMRC presents 10 key recommendations – an ‘action plan’ – of steps that it believes must be taken to make real inroads into tackling the obesity crisis in the UK. The recommendations fall into three areas: actions to be taken by the healthcare professions; changing the ‘obesogenic’ environment; and making the healthy choice the easy choice.565CA4D9, 352369Actions to be taken by the healthcare professionsActions to be taken by the healthcare professions suggested by the AMRC.565CA4D9, 352370Changing the ‘obesogenic’ environment565CA4D9, 352371Making the healthy choice the easy choice565CA4D9, 352373Invest in weight management servicesThe departments of health in the four nations should extend and increase the provision of weight management services across the country, to mirror the provision of smoking cessation services.565CA4D9, 352374Improve nutritional standards for food in hospitalsIntroduce food-based standards—in line with those put in place for schools in England in 2006—in all UK hospitals in the next 18 months; with commissioners working with a delivery agent similar to the Children’s Food Trust to put these measures into place.565CA4D9, 352375Increase support for new parentsThe current expansion of the health visitor workforce in England should be accompanied by 'skilling up' the wider early years workforce to deliver basic food preparation skills to new mothers and fathers, and to guide appropriate food choices which will ensure nutritionally balanced meals, encourage breastfeeding and use existing guidance in the Personal Child Health Record as a tool to support this.565CA4D9, 352376Improve nutritional standards in schoolsThe existing mandatory food- and nutrient-based standards in England should be applied to all schools including free schools and academies. This should be accompanied by a new statutory requirement on all schools to provide food skills, including cooking, and growing – alongside a sound theoretical understanding of the long-term effects of food on health and the environment.565CA4D9, 352377Reduce fast food outlets near schoolsPublic Health England should, in its first 18 months of operation, undertake an audit of local authority licensing and catering arrangements with the intention of developing formal recommendations on reducing the proximity of fast food outlets to schools, colleges, leisure centres and other places where children gather.565CA4D9, 352378Restrict junk food advertisingBan television advertisements of foods high in saturated fats, sugar and salt before 9pm, and seek agreement with commercial broadcasters not to advertise these foods on internet ‘on-demand’ services. [2]565CA4D9, 352380Improve food labellingMajor food manufacturers and supermarkets should agree in the next year a unified system of traffic light food labelling (to be based on percentage of calories for men, women, children and adolescents) and visible calorie indicators for restaurants, especially fast food outlets.565CA4D9, 352381Mandatory health impact assessments for local planning decisionsLocal authority planning decisions should be subject to a mandatory health impact assessment, which would evaluate their potential impact upon the populations’ health.565CA4D9, 352560Existing training is inadequate and ineffectiveTraditional methods of training for healthcare professionals are inadequate and ineffective with respect to obesity.1198CE71, 352713Who should improve obesity training for healthcare professionals?Who should improve systems of obesity education and training across all health professional groups to ensure that all professional primary and secondary healthcare groups are appropriately competent to respond to the demands of the obesity crisis.58D3ABAB, 370328Some clinicians are insensitive in dealing with obese patientsSome clinicians continue to be insensitive, ineffective, and lack confidence when dealing with patients who have problems with their weight.1198CE71, 370330Weight management services are in short supplyThe Academy of Medical Royal Colleges notes that doctors don't have sufficient services available to refer people – that there are a limited number of well-designed fully evidence-based, effective and transferable weight management programmes, available for use in routine NHS primary care.1198CE71, 370331Most obese UK children lack access to weight management programmesThe majority of obese children in the UK don't have access to an evidence-based, proven, multicomponent child weight management programme as recommended by NICE (2006).1198CE71, 370332Early intervention programmesThe investment in weight management services should include greater provision for early intervention programmes.109FDEF6, 370334Weight management service provision is poor in comparison to smokingFrom a clinical perspective, weight management provision needs to mirror the coverage that smoking cessation services have achieved; yet, the investment in smoking cessation programmes remains significantly higher than the investment in weight management programmes. As a comparator, the NHS spent £88.2 million on smoking cessation services in 2011/12.1198CE71, 370335Many healthcare professionals are overweight and obeseDoctors continue to be a trusted and respected source of advice and guidance for patients over their lifestyle choices; however, many healthcare professional struggle with their own weight which can make them less effective both as messengers and exemplars. 1198CE71, 370336Require and examine obesity knowledge as part of curriculaKnowledge, understanding and training in nutrition, physical activity, exercise and the public health aspects of obesity should be an essential part of undergraduate and postgraduate curricula in every discipline because complications of obesity cross all specialty and professional boundaries. This knowledge should be examined. 959C6EF, 370338Weight management services can save more money than they costSome well-designed fully evidence-based, effective and transferable weight management programmes are even economically ‘dominant’ (i.e. they save the NHS more money than it costs to provide the service).1198CE71, 370339Many smaller providers lack formal evidence to support interventionsWhile some of the larger commercial providers have had their efficacy assessed by means of randomised control trials and other evaluative methods, many smaller providers have no such formal evidence to support their interventions.1198CE71, 370342Training should reflect the different needs of different team membersDifferent members of the team will need different training. For example, the role of the GP in an initial consultation differs greatly from that of the bariatric surgeon and his or her team assessing a patient’s suitability for surgery. Different teams need different skills for different patients in different scenarios but healthcare professionals’ education.959C6EF, 370346Training should include sensitive recognition and appropriate referralAll health professionals should have some basic training in sensitive recognition and appropriate referral for overweight and obese patients.959C6EF, 370347NICE guidance has been ignored on bariatric servicesAn investigation by GP newspaper published in December 2014 found that over half of the UK's primary care organisations (PCOs) do not follow NICE or SIGN guidance on bariatric surgery [2].1198CE71, 371449Early years’ intervention is vital to reducing health inequalities1198CE71, 371774Protect and increase green spacesPublic Health England should provide guidance to Directors of Public Health in working with Local Authorities to encourage them to protect or increase green spaces.565CA4D9, 371802Improved engagement and concentrationImproving the food and dining environment for children increases the likelihood that children will be engaged and concentrate in afternoon lessons.1198CE71, 371803Apply mandatory food- and nutrient-based standards to all schoolsThe existing mandatory food- and nutrient-based standards in England should be applied to all schools including free schools and academies.565CA4D9, 371804Require all schools to provide food skills and understandingIntroduce a statutory requirement on all schools to provide food skills, including cooking, and growing, alongside a sound theoretical understanding of the long-term effects of food on health and the environment.565CA4D9, 396117Improve obesity training for healthcare professionalsImprove systems of obesity education and training across all health professional groups to ensure that all professional primary and secondary healthcare groups are appropriately competent to respond to the demands of the obesity crisis.565CA4D9, 399556Improve obesity training for healthcare professionalsImprove systems of obesity education and training across all health professional groups to ensure that all professional primary and secondary healthcare groups are appropriately competent to respond to the demands of the obesity crisis.565CA4D9, 399572Improve food labellingMajor food manufacturers and supermarkets should agree in the next year a unified system of traffic light food labelling (to be based on percentage of calories for men, women, children and adolescents) and visible calorie indicators for restaurants, especially fast food outlets.565CA4D9, 399577Improve nutritional standards for food in hospitalsIntroduce food-based standards—in line with those put in place for schools in England in 2006—in all UK hospitals in the next 18 months; with commissioners working with a delivery agent similar to the Children’s Food Trust to put these measures into place.565CA4D9, 399578Improve nutritional standards in schoolsThe existing mandatory food- and nutrient-based standards in England should be applied to all schools including free schools and academies. This should be accompanied by a new statutory requirement on all schools to provide food skills, including cooking, and growing – alongside a sound theoretical understanding of the long-term effects of food on health and the environment.565CA4D9, 399592Invest in weight management servicesThe departments of health in the four nations should extend and increase the provision of weight management services across the country, to mirror the provision of smoking cessation services.565CA4D9, 399598Mandatory health impact assessments for local planning decisionsLocal authority planning decisions should be subject to a mandatory health impact assessment, which would evaluate their potential impact upon the populations’ health.565CA4D9, 399602Protect and increase green spacesPublic Health England should provide guidance to Directors of Public Health in working with Local Authorities to encourage them to protect or increase green spaces.565CA4D9, 399605Existing training is inadequate and ineffectiveTraditional methods of training for healthcare professionals are inadequate and ineffective with respect to obesity.1198CE71, 399606Who should improve obesity training for healthcare professionals?Improve systems of obesity education and training across all health professional groups to ensure that all professional primary and secondary healthcare groups are appropriately competent to respond to the demands of the obesity crisis.58D3ABAB, 399607Many healthcare professionals are overweight and obeseDoctors continue to be a trusted and respected source of advice and guidance for patients over their lifestyle choices; however, many healthcare professional struggle with their own weight which can make them less effective both as messengers and exemplars. 1198CE71, 399653Increase support for new parentsThe current expansion of the health visitor workforce in England should be accompanied by 'skilling up' the wider early years workforce to deliver basic food preparation skills to new mothers and fathers, and to guide appropriate food choices which will ensure nutritionally balanced meals, encourage breastfeeding and use existing guidance in the Personal Child Health Record as a tool to support this.565CA4D9, 399674Improved engagement and concentrationImproving the food and dining environment for children increases the likelihood that children will be engaged and concentrate in afternoon lessons.1198CE71, 399675Apply mandatory food- and nutrient-based standards to all schoolsThe existing mandatory food- and nutrient-based standards in England should be applied to all schools including free schools and academies.565CA4D9, 399676Require all schools to provide food skills and understandingIntroduce a statutory requirement on all schools to provide food skills, including cooking, and growing, alongside a sound theoretical understanding of the long-term effects of food on health and the environment.565CA4D9, 399677Restrict junk food advertisingBan television advertisements of foods high in saturated fats, sugar and salt before 9pm, and seek agreement with commercial broadcasters not to advertise these foods on internet ‘on-demand’ services. [2]565CA4D9, 399695Focus outcomes indicators on action by primary health professionalsThe Quality Outcomes Framework indicators on obesity should include, and focus on, indicators on the action taken by primary healthcare professionals on behalf of overweight or obese patients. [1]565CA4D9, 399716Weight management services are in short supplyThe Academy of Medical Royal Colleges notes that doctors don't have sufficient services available to refer people – that there are a limited number of well-designed fully evidence-based, effective and transferable weight management programmes, available for use in routine NHS primary care.1198CE71, 399717Most obese UK children lack access to weight management programmesThe majority of obese children in the UK don't have access to an evidence-based, proven, multicomponent child weight management programme as recommended by NICE (2006).1198CE71, 399718Early intervention programmesThe investment in weight management services should include greater provision for early intervention programmes.109FDEF6, 399719Weight management service provision is poor in comparison to smokingFrom a clinical perspective, weight management provision needs to mirror the coverage that smoking cessation services have achieved; yet, the investment in smoking cessation programmes remains significantly higher than the investment in weight management programmes. As a comparator, the NHS spent £88.2 million on smoking cessation services in 2011/12.1198CE71, 399720Weight management services can save more money than they costSome well-designed fully evidence-based, effective and transferable weight management programmes are even economically ‘dominant’ (i.e. they save the NHS more money than it costs to provide the service).1198CE71, 399721Many smaller providers lack formal evidence to support interventionsWhile some of the larger commercial providers have had their efficacy assessed by means of randomised control trials and other evaluative methods, many smaller providers have no such formal evidence to support their interventions.1198CE71, 399735Some clinicians are insensitive in dealing with obese patientsSome clinicians continue to be insensitive, ineffective, and lack confidence when dealing with patients who have problems with their weight.1198CE71, 399738Require and examine obesity knowledge as part of curriculaKnowledge, understanding and training in nutrition, physical activity, exercise and the public health aspects of obesity should be an essential part of undergraduate and postgraduate curricula in every discipline because complications of obesity cross all specialty and professional boundaries. This knowledge should be examined. 959C6EF, 399739Training should reflect the different needs of different team membersDifferent members of the team will need different training. For example, the role of the GP in an initial consultation differs greatly from that of the bariatric surgeon and his or her team assessing a patient’s suitability for surgery. Different teams need different skills for different patients in different scenarios but healthcare professionals’ education.959C6EF, 399740Training should include sensitive recognition and appropriate referralAll health professionals should have some basic training in sensitive recognition and appropriate referral for overweight and obese patients.959C6EF, 399767Early years’ intervention is vital to reducing health inequalities1198CE71, 399777Reduce fast food outlets near schoolsPublic Health England should, in its first 18 months of operation, undertake an audit of local authority licensing and catering arrangements with the intention of developing formal recommendations on reducing the proximity of fast food outlets to schools, colleges, leisure centres and other places where children gather.565CA4D9, 399796NICE guidance has been ignored on bariatric servicesAn investigation by GP newspaper published in December 2014 found that over half of the UK's primary care organisations (PCOs) do not follow NICE or SIGN guidance on bariatric surgery [2].1198CE71, 399872Pilot a 20%+ tax on all sugary, soft drinks for 1 yearFor an initial one year, a duty should be piloted on all sugary soft drinks, increasing the price by at least 20%. This would be an experimental measure, looking at price elasticity, substitution effects, and to what extent it impacts upon consumption patterns and producer/retailer responses.109FDEF6

Our eighth recommendation is that:

For an initial one year, a duty should be piloted on all sugary soft drinks, increasing the price by at least 20%. This would be an experimental measure, looking at price elasticity, substitution effects, and to what extent it impacts upon consumption patterns and producer/retailer responses.

...

Hungary already has fiscal measures in place that tax foods high in salt, fat and sugar. The tax applies to foodstuffs with high sugar, salt, and/or caffeine content, although at levels that would best be described as peppercorn, for example, 10 Hungarian forints (approximately two pence) per litre of sugar-sweetened beverages. Meanwhile France has very recently introduced a tax on soft drinks of approximately five pence per litre. Denmark, which has long taxed sugary sweets, drinks, and banned trans-fats, has also tested a slightly broader programme. In October 2011 a tax of 16 Danish kroner (about £1.74) per each kilogram of saturated fat was introduced. New Scientist estimated that equivalent figures in US dollars would be an extra 12 cents (five pence) on a bag of crisps, and 40 cents (25 pence) on a burger. This approach may later be re-introduced in a revised form.

There is now a considerable weight of modelling evidence around fiscal mechanisms and its effect on consumption of unhealthy food. Rayner et al’s 2012 paper for the British Medical Journal offers a comprehensive summary of this evidence. According to much of this evidence, the rates of taxation in Hungary and France may be too low to see much tangible effect on consumption but nonetheless it is a step in the right direction. The modelling evidence suggests that taxation of products high in fat, sugar and salt would not only result in reduction in consumption but also be an important cost-saving intervention. An Australian study calculated a saving of 559,000 disability-adjusted life-years on a 10 per cent tax, with an initial AU$18m investment.

Another policy response suggested by Sir Nicholas Wald amongst others has been the introduction of an excise ‘SASS’ tax on each gram of saturated-fat, alcohol, salt and sugar, rather than a VAT-style tax on just one or individual ingredients. Sir Nicholas suggests this approach would impact primarily on the manufacturer, who would be incentivised to adjust their price accordingly to promote healthier alternatives and smaller portion sizes. He believes that this approach ‘influences the market, but preserves consumer choice’, and models the potential impact to suggest that a higher-fat burger meal would be harder hit by the taxation, adding on 39 pence versus nine pence for a lower fat chicken meal.

There have also been suggestions that taxation should be accompanied by subsidisation of healthier choices. An experimental purchasing study by Epstein et al suggests that the money that people save on lower-calorie foods is then spent on other high-calorie low-nutrient foodstuffs, so individuals’ overall calorie intake wasn’t reduced. By contrast, they found that taxation alone reduced individuals overall energy intake while reducing the proportion of fat and increasing the proportion of protein purchased.

While all of these developments should continue to be closely monitored, after careful consideration we believe it is too early for the UK to introduce these broad fiscal mechanisms. Concerns were raised about the price elasticity of different foodstuffs, and also the substitution effect. Furthermore, the political acceptability of fiscal measures around foodstuffs has probably been reduced following the furore around the proposed so-called ‘pasty tax’ in March 2012.

Nonetheless, we believe that we should look at the ‘soda tax’, now successfully implemented across many states in the USA and the measure introduced in New York to restrict the size of sugary soft drinks sold. The New York Department of Health and Mental Hygiene helpfully defines a ‘sugary drink’ as one that ‘has greater than 25 calories per 8 fluid ounces [or 227ml] of beverage’.

We therefore believe that a tax on sugary soft drinks, as a natural experiment, would be a bold and progressive policy move on the part of the UK government. Looking at Mytton et al’s review of the evidence which suggests that increased taxation rates of 20% are needed to have sufficient impact on consumption. Therefore we consider that a minimum price increase of 20% on sugar-sweetened drinks, trialled for at least one year, would begin to give economists an indication of the possibilities of such fiscal mechanisms, and in the longer term, provide an opportunity to assess the health benefits. Sustain estimates that a duty of just 20p per litre could generate revenue of approximately one billion pounds per year which, if hypothecated, could be used to provide weight management programs across the country.