Prof Donal O'Shea, a well-known medical specialist on obesity, doesn't think Ireland is in the throes of an obesity epidemic. In fact, he believes it's much worse than that.
"It's a pandemic, which is a level above epidemic. Eighty per cent of type two diabetes is related to overweight and obesity, and up to 40% of the common cancers are driven by obesity. A link between dementia and obesity is now evident. Obesity is driving many diseases and in turn it is making every disease that it causes worse."
Currently, around one in four 3, 7 and 12 year-olds are either overweight or obese, he points out.
Obesity warning signals
Prof O'Shea says recent research funded by the Children's Medical Research Centre in Crumlin should send further warning signals about the seriousness of the childhood obesity problem.
"The research shows that in obese children as young as six the genes linked to the development of diabetes and heart disease are switched on, and the genes for cancer defence are switched off. So the near-inevitability of overweight children developing type 2 diabetes and of being at increased risk of cancer are now there for people to see."
"Because diseases such as diabetes and cancer are no longer to the same extent the killers they used to be, with even cancer starting to become more of a chronic disease, increasing obesity and its effects are simply adding to the years of disease people are living with from a younger and younger age."
"This is in many ways a pharmaceutical industry dream, but in terms of planning and funding health services, it's a logistical nightmare."
Health service demands
Prof O'Shea says the health service is already struggling to keep up with the burden of chronic disease.
He points out that there are currently only two publicly-funded hospital treatment units dealing with obesity - the unit where he is based at St Columcille's Hospital, Loughlinstown/St Vincent's in Dublin and the unit in Galway under Dr Francis Finucane.
"That's two units to treat the 280,000 people in Ireland with a body mass index of over 40."
Prof O'Shea, who is consultant in endocrinology and diabetes at St Vincent's and Loughlinstown, said hospital services are struggling to keep up with demand.
"In Loughlinstown, we have 4,200 diabetes patients, we have 3,800 outpatient appointment slots per year and we are not even able to see then once a year. That is mirrored all around the country."
"We are in the middle of a Tsunami in terms of overwhelming demands on the health service. We hear a lot about reductions in trolley wait times, and cutting back on waiting lists, but the way things stand, there is no way things can really improve due to the demands on the system from chronic disease and an ageing population."
Waiting list massaging?
"Any senior figure in the HSE or Department of Health who says we can do something to improve waiting lists in the next six months or that we can get rid of waiting lists in the next six months is just not looking at the reality"
Prof O'Shea claims the recent loudly-trumpeted reduction in long waiters on out patient lists has, in his experience, to some extent been a book-keeping exercise.
"What they have done, as far as I can see, is 'suspend' part of the waiting list. People who were waiting over a year for a first appointment at the Loughlinstown obesity clinic were recently written to and asked if they still wanted to be seen, and were given three days to respond on whether or not they wanted to be seen."
"If they didn't get back to the HSE within three days they were removed from the waiting list. If they were lucky enough to get their reply back in time they were designated as due to be seen sometime this year, but these patients no longer appear on the official waiting list - around 350 of our obesity patients have been suspended in this way. They are a 'suspended cohort of patients awaiting review'."
Dr O'Shea describes this exercise as 'Yes Minister gone mad'. "These 350 patients are in limbo but they are officially off the waiting list. We will really struggle to see them all this year as our capacity is for only 200 new patients a year."
"This waiting list initiative is a numbers game that has occupied too much time for too many people to make a situation that is bad for a particular reason look good for no reason."
'Doing more with less'
"There is this mantra at the moment about health services needing to be more efficient, about doing more with less. That simply doesn't apply in healthcare. Anyone who thinks there will be savings in health in the next 10-15 years is wrong-healthcare will get more and more expensive, both in looking after the individual disease because the drugs have become more sophisticated and costly, and in terms of the volume of longer-living patients with chronic disease."
"The next Minister for Health needs to come in and say it's not going to be possible to do this more cheaply, yes we need to do it differently, but anyone who is expecting savings will have to accept poorer outcomes and more complications of chronic diseases."
Government action on obesity
While Prof O'Shea is critical of James Reilly's policy on waiting lists and hospital services, he believes the Health Minister has a more impressive record on the question of reducing obesity levels and improving lifestyles.
"In fairness to the Minister, his commitment to prevention and public health has been significant. He put childhood obesity on the agenda during Ireland's EU presidency last year, and the EU has committed to an action plan that is now going to the Greek Presidency for endorsement, which very rapid by EU standards. I will be going to Athens with the Department of Health later this month and we will stress the need to action this plan."
Prof O'Shea is a member of the Special Action Group on Obesity set up by Minister Reilly to tackle the problem.
He says this group is trying to progress a number of headline items and one of the first initiatives promoted by James Reilly was calorie-posting on restaurant menus.
Progress on this, Donal O'Shea says, has been 'achingly slow', but there have been some developments, he admits.
The Food Safety Authority of Ireland (FSAI) is about to launch a calculator that will allow restaurants to assess calorie content in the meals they provide and inform the customer accordingly.
"This is expected to be launched by the Minister before Easter. The calculator will allow restaurants to type in the ingredient, the amount of it, the way it has been cooked, and that will give then a good estimate of the calorie count within about 25%."
"A lot of people will eat a meal that might have 1,000 calories - almost their total daily requirement, so it is important for people to have this information. Calorie-posting influences the choice of around one in five Americans and results in them purchasing food with fewer calories. I think if it influences that level of Americans it has the potential to influence up to 35% of Irish people, as we tend to be a little more engaged and curious about these things."
In another initiative, the HSE has insisted that outlets selling snacks and meals in hospitals must display calories on their menus.
"This is important, because in hospitals people would tend to be a bit more health aware, and people will be able to find out that say, the muffin they are buying might have 500 calories."
"In another initiative, there will be a policy change within the HSE, where vending machines in health premises will have to stock more healthy items than unhealthy ones. I believe this will be introduced this year."
"In hospitals, everyone is a bit more health aware so they will look at, for example, a muffin in a hospital café and they will see that it has 500 calories or they will look at the shortbread and it has 600 calories etc. Hospital cafes and restaurants will have to post calories on their menus."
There will be a policy change within the HSE on vending machines where all machines will have to stock healthy items more than unhealthy items. People will be presented with a healthy choice in the vending machine, and that I believe is coming in this year at some point."
Prof O'Shea says calorie counting is a simple but important measure, 'and that's why it has been so opposed by industry in the United States and here'.
"The Restaurants Association of Ireland opposed it, the food and drink industry were unenthusiastic about it, but this has been overcome to a certain extent. McDonald's have already implemented calorie counting, as have Insomnia and Starbucks, although Burger King hasn't implemented it, except where they are obliged to by the owner of a centre where Burger King might have an outlet, for example, a motorway service station."
On the proposals for a tax on sugar-sweetened drinks, Dr O'Shea chaired the group that recently produced a report on the potential impact of this measure.
"The best estimates are that introducing this tax would impact positively in a short time frame on obesity rates in Ireland. The Health Minister is very positive about this and has brought the measure to cabinet three times. Unfortunately, he failed to get approval each time."
"I would hope that it will be brought to Cabinet again. I suppose the reason to date that it hasn't been implemented is nervousness over possible job losses etc edging out certainty over reducing deaths and illness. At any point of an economic cycle there will be nervousness about jobs, but ultimately, we are either serious about tackling the obesity and chronic disease epidemic or we are not."
"Taking action on sugary drinks is just one small part of the jigsaw. For childhood obesity to be tackled you also need more parental commitment to opposing the environment, because you have to do this to keep your child fit and healthy."
"You also need schools to support parents and deliver a good physical activity curriculum. You need communities demanding that restaurants in their area serve kids'-size portions, have water and milk available as drinks. You need policy-makers to try and back that up with the right environment that will support these measures."
On bariatric surgery for cases of severe obesity, Donal O'Shea says the current Dublin service, which has recently moved from Loughlinstown to St Vincent's, has significant waiting lists.
However, since the move to St Vincent's last year, additional capacity for this surgery has led to an increase in the number of operations.
"We are now getting two cases a week done, whereas before it was around 30 in a year."
"The evidence for the benefits of weight-reduction surgery is growing, but we need to increase greatly its availability here. In Scandinavian countries they do do 1,000 operations per million of the population, whereas last year in Ireland the two publicly-funded units in Dublin and Galway did around 70 between them."
Care in the community
Prof O'Shea says that while obesity services in hospitals are under pressure, ideally, obesity is not a condition that should be managed in hospital.
"You need primary care to have dietitians, physiotherapists, access to psychology etc, and it doesn't have these at present."
He says that while there is still a long way to go in the battle against obesity, diabetes services are beginning to improve.
"We now have a national diabetes foot care programme, although it is not yet fully resourced. We have a diabetes eye screening programme, there is more shared care between GPs and hospitals in our area. So diabetes is beginning to get its house in order for the delivery of most of the care in the community."
However, Prof O'Shea warns against stripping hospitals of resources so that these can be put into primary care, as this will affect hospital services.
He says while GPs and primary care are being given the tools to for managing diabetes patients in the community, they also need resourcing to take on the increasing burden of looking after patients living longer with other chronic conditions.
Dr O'Shea says people are now living longer in part because of improvements in drug treatments.
However, he says lifestyle change can also have a huge impact on people's health, although not necessarily a significant impact on weight-loss in the absence of simultaneous dietary changes.
"If regular physical activity was a drug there would be no drug as good as it for reducing your risk of getting serious diseases such as diabetes, heart disease and cancer. And it's free."
Most over 50s overweight/obese
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