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1. © The Economist Intelligence Unit Limited 2016
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CONFRONTING OBESITY IN THE UK
The need for greater coherence
As is the case in other European countries, UK public opinion generally favours the belief that
obesity is largely a lifestyle issue. A recent survey by the European Association for the Study
of Obesity (EASO) found that 92% of UK respondents believe that obesity is caused by lifestyle
choices, compared with a European average of 79%.1
Moreover, according to the survey only 18%
of UK respondents recognise obesity as a disease, compared with nearly half of the general survey
sample (46%).
Yet a closer look suggests that public attitudes may be skewed by a significant element of denial:
while the EASO survey found that more than half of UK respondents (52%) considered their weight to
be normal and healthy, 21% of those who described themselves in this way were, in fact, technically
overweight. And more than one-third of those who considered themselves to be overweight (36%)
were actually obese.
The emphasis on behavioural management as a priority in government obesity policy was evident in an
October 2015 report from Public Health England, an operationally autonomous executive agency of the
Department of Health, which proposed a series of regulatory initiatives to reduce sugar consumption,
including the possible introduction of a sugar tax.2
More recently the chief executive of England’s
National Health Service (NHS), Simon Stevens, announced plans to introduce a sugar tax in hospitals
and local health centres by 2020.3
Balancing prevention and disease management
As highlighted by The Economist Intelligence Unit’s recent report on Confronting Obesity in Europe,4
lifestyle-focused programmes have an important role to play in preventing obesity in those with a
healthy weight. However, a policy focus on prevention fails those who are already severely obese. Dr
Matthew Capehorn, clinical manager of the Rotherham Institute for Obesity (RIO) in South Yorkshire,
notes that while some £5bn (US$7.1bn) is spent on prevention programmes in the UK, just £300m is
spent on treatment.
“Part of the problem lies in obesity not being viewed as a medical problem by healthcare
professionals,” says Professor Rachel Batterham, head of the University College London Hospital
Bariatric Centre for Weight Management and Metabolic Surgery. “A doctor would never let a patient
walk out of their clinic with very high blood pressure, as they would recognise this as a risk factor
A country case study by The Economist Intelligence Unit
1
EASO, Obesity: An
Underestimated Threat:
Public Perceptions of Obesity
in Europe, May 2015.
2
Public Health England,
Sugar Reduction: The
evidence for action, October
2015.
3
“NHS chief to introduce
sugar tax in hospitals to
tackle UK obesity crisis”,
The Guardian, January 17th
2015.
4
Economist Intelligence
Unit, Confronting obesity
in Europe: Taking action
to change the default
setting, November 2015.
Available at: http://
www.eiuperspectives.
economist.com/healthcare/
confronting-obesity-
europe-taking-action-
change-default-setting

2. 2 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN THE UK The need for greater coherence
for cardiovascular disease and offer advice and treatment. Obesity is a risk factor not only for
cardiovascular disease but also for type 2 diabetes and certain types of cancer, and patients need to be
offered the appropriate treatment.”
For those who find it most difficult to manage their weight, a more comprehensive approach to obesity
is gaining traction. Obese patients visiting the RIO and a handful of other clinics are among the few in
the UK able to get a taste of what a comprehensive weight-loss management service looks like.
The RIO employs a multidisciplinary team of healthcare providers who can help with all aspects of
managing weight problems, from specially trained nurses and healthcare assistants to dieticians and
“cook-and-eat” skills education. Psychologists are on-site to provide talking therapies, while exercise
therapists offer personalised training programmes and facilities for group therapies and nutritional
advice.
Yet the RIO model is unusual not only in the rest of Europe—it is a rarity in England as well, despite
the fact that under the NHS such services are theoretically meant to be provided across the country
(Scotland, Wales and Northern Ireland, with obesity rates of 27%, 22.2% and 24% respectively,
have their own healthcare services). And in this regard, it is symptomatic of the extent to which
preventative approaches to curbing obesity still tend to dominate the national debate. In addition, it
reflects the uneven provision of weight-loss treatment across England’s NHS, despite an increase in the
obesity rate from 22.4% to 24.8% between 2003 and 2013.5
A 2014 report by the McKinsey Global Institute concluded that while education and personal
responsibility remain critical elements of any programme to reduce obesity, they are insufficient on
their own.6
The report also found that intensive weight-management programmes and surgery are
rated more highly as far as strength of evidence is concerned than public-health campaigns. Indeed,
the one-quarter of the UK population that is obese cost the NHS £6bn-8bn in 2015, and this is
expected to rise to £10bn-12bn in 2030.7
A fragmented approach to treatment
The NHS divides treatment for weight problems into four separate tiers (see table below). While a
hierarchy for intensive weight-reduction treatment is spelt out by NHS guidelines, Dr Capehorn argues
that continued structural reforms of the healthcare system have led to confusion over accountability,
threatening to undermine the provision of a coherent service further, and contribute to the perception
that the government is not fully committed to adequately investing in treatment.
“A survey to look at Tier 3 provision showed that 40% of CCGs [clinical commissioning groups, which
work together in general practices to plan, design and buy local health services in England] have no
access to Tier 3; 60% have access, but the level of access varies significantly,” Dr Capehorn says. In
London, for example, a recent survey revealed that just four CCGs out of a total of 21 had commissioned
Tier 3 services, according to Professor Batterham. She adds that the shortage of Tier 3 services acts as
a “huge bottleneck”, as people with severe obesity are forced to wait longer to be assessed, have their
associated medical problems treated and receive weight-loss advice.
5
Baker, C, Obesity Statistics,
House of Commons Library
Briefing Paper, No. 3336,
June 26th 2015, p. 5.
6
McKinsey Global Institute,
Overcoming obesity: An
initial economic analysis,
November 2014, pp. 10
and 17.
7
“Obesity bigger cost
for Britain than war and
terror”, The Guardian,
November 20th 2014.

3. 3© The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN THE UK The need for greater coherence
Patients are meant to advance to higher tiers only once they have exhausted the services in previous
ones. However, there are exceptions to this rule. Patients who meet the Tier 3 referral criteria—those
with a body mass index (BMI) of more than 40, a BMI of more than 30 plus associated illnesses or raised
waist circumference with associated illnesses—can bypass Tier 2, although Tier 3 is theoretically for
those in Tier 2 who have failed to hit weight-loss targets. Since 2013, however, patients cannot be
referred to Tier 4 without having gone through Tier 3. The complexity of the structure creates particular
challenges in localities where full services are inadequate or unavailable.
“We have clear guidance regarding the multidisciplinary composition of Tier 3 teams, but there is a
lack of clarity regarding the best approach to achieve improved health outcomes with non-surgical
weight-management programmes,” Professor Batterham says. “A lot of centres would like to set up Tier
3 services, but in order to do this, CCGs need to commission these.”
From April 2016 Tier 4, which generally covers surgical options, is due to be transferred from the
Department of Health to CCGs. A key criterion for this transfer to occur is that safe and efficient care
should be at the forefront of any changes, with an assurance that the transfer of responsibility will not
have a negative impact on patients.
“We did a survey, and less than 20% of CCGs knew about the fact that they would be getting
responsibility for bariatric surgery,” explains Dr Capehorn, who is a member of the group overseeing
the change. He predicts that many CCGs are likely to ask to postpone the transition, given that many
are still adjusting to managing Tier 3 provision.
“CCGs don’t have the experience or desire to run bariatric surgery; there is a real danger that the
uncertainty will mean lots of hospitals will switch experts, such as dieticians and surgeons, to other
services,” warns Professor Batterham.
Table: Treatment for weight problems in the UK: the four tiers
Tier Scope Responsible agency
1 Local public-health interventions and primary-care activity inside
general practice surgeries, such as weighing and measurement
by nurses, the broaching of weight issues and assessment of
motivation
Local health authorities
2 Community weight-management groups run by local dieticians or
commercial groups
Local health authorities
3 Weight-loss medication prescribed by general practitioners,
specialist dietician referrals and psychological intervention
Clinical commissioning groups
4 Surgical options, including bariatric surgery NHS England (at least until April
2016); clinical commissioning
groups (possibly from April 2016)

4. 4 © The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN THE UK The need for greater coherence
Inconsistent availability of surgery
In 2014 the National Institute for Health and Care Excellence (NICE), which advises the government
on healthcare investment, issued new guidance allowing physicians to consider bariatric surgery as a
treatment for those with a BMI of 30 to 35 and recent onset of type 2 diabetes. Previously, only those
with a BMI of 35 to 40 and an additional health condition that could be improved by surgery were
considered.8
Experts predicted at the time that the new guidelines could double or triple the number of people
undergoing surgery in the UK annually. Just 18,000 had bariatric surgery between 2010 and 2013
in the UK, 4,000 of whom also had diabetes.9
In 2015 the number of bariatric procedures in the
UK decreased to around 5,800 from 6,200 in 2014, fewer than expected given the more generous
guidelines, according to Professor Batterham.
A study comparing seven European countries found that bariatric surgery was underutilised in England
in 2012: the highest utilisation of bariatric surgery (defined as the number of surgeries per 1m
population) was observed in Belgium (928), Sweden (761) and France (571), while England (117) and
Germany (72) had the lowest utilisation rates.10
Costs remain a major sticking point—both for those arguing in favour of greater use of bariatric
surgery and those arguing against greater use. The NHS has acknowledged that bariatric surgery
is significantly more expensive than conservative disease management in the short term, but may
actually be more cost-effective in the long run.11
Concerns about short-term costs remain prevalent:
the NHS’s Mr Stevens recently argued that expert proposals to offer surgery to an additional 1.4m
morbidly obese people would use up all of the £8.4bn in additional funding that the government has
pledged to the NHS.12
According to Professor Batterham, NICE’s new obesity guidelines are comprehensive and cover all
aspects of obesity prevention and treatment. “The updated guidelines with respect to bariatric
surgery, are evidence-based and clear. The problem is that the guidelines are not being implemented.
This situation will hopefully be improved by the NICE quality standards for obesity that are due to be
published later this year.”
A draft version of the new quality standards, which NICE put out for consultation in December 2015,
spells out a list of proposed actions: that all obese patients who come into hospital need to be told
their BMI; that health providers discuss the potential health consequences with patients; that severely
obese patients receive a referral to more comprehensive weight-management services if earlier
interventions have been unsuccessful; and that children with a BMI at or above the 98th centile be
assessed for related conditions, such as type 2 diabetes. The standards also propose a structure for
assessing and referring patients for bariatric surgery and for follow-up.13
8
“UK NICE Expedites
Access to Bariatric Surgery
in Diabetes”, Medscape,
November 28th 2014.
Available at: http://
www.medscape.com/
viewarticle/835605
9
Ibid.
10
Borisenko, O, Colpan, Z
et al, “Clinical Indications,
Utilization, and Funding
of Bariatric Surgery in
Europe”, Obesity Surgery,
August 2015, Vol. 25, No. 8,
pp 1408-16.
11
NHS Commissioning
Board, “Clinical
Commissioning Policy:
Complex and Specialised
Obesity Surgery”, April
2013, p. 14.
12
“NHS chief to introduce
sugar tax in hospitals to
tackle UK obesity crisis”,
The Guardian, January 17th
2015.
13
NICE, Obesity:
clinical assessment and
management, NICE
quality standard, Draft for
Consultation, December
2015, pp. 7-8. Available at:
http://www.nice.org.uk/
guidance/GID-QSD128/
documents/draft-quality-
standard

5. 5© The Economist Intelligence Unit Limited 2016
CONFRONTING OBESITY IN THE UK The need for greater coherence
Although the UK has a carefully designed structure in place to provide an ascending level of care to
seriously obese patients, structural reforms of the NHS, budget constraints and a policy focus that still
emphasises prevention over treatment have all helped to undercut the delivery of a coherent set of
services. A commitment to investment in a multistranded programme and the cultural change needed
to support it will be necessary to enable obesity services in the UK to live up to their potential.