Editorial
The UK Prime Minister, David Cameron, has announced that people who claim sickness benefit (incapacity benefit, severe disablement allowance, or employment and support allowance) because of obesity could have this money withdrawn if they refuse treatment for their disorder. As part of their campaign for the next UK general election on May 7, 2015, the Conservative Party has pledged to reduce the benefits bill by £12 billion during the next parliamentary term if elected. Cutting benefits for people who are out of work for a preventable disorder if they refuse treatment might seem like a reasonable contribution to this target, and David Cameron has ordered a rapid review by Professor Dame Carol Black (an adviser to the UK Department of Health) into the feasibility of implementation of such an initiative. Although many people who claim sickness benefits for obesity might welcome the opportunity to take part in an intervention that helps them to lose weight, any mandated program should have a strong evidence base for success. Unfortunately, diet and lifestyle interventions have restricted, often transient, benefits due to biological adaptations, that act to sustain high bodyweight. It is therefore important to ask whether requiring people to participate in weight-loss programmes, despite a high likelihood of failure, is acceptable from the point of view of an individual, provider, or society. Although there is some success with pharmacological treatments for obesity, the only treatment for obesity that has been proven to be successful for substantial long-term weight loss and improved quality of life in a high proportion of people is bariatric surgery. Requiring people to undergo a major surgical procedure as a condition of receiving benefits seems far from ethical. Another necessary consideration is what strategies will be implemented for individuals who try but fail to lose weight on the required programmes. To continue claiming benefits, would it be sufficient for a person to show that they have tried but failed? And how will “trying” be determined? If people do not lose weight with one scheme, will they be enrolled into another more aggressive programme? Is there potential for escalation of treatment to bariatric surgery in people who have not lost weight with other interventions? Iain Duncan Smith, the UK Secretary of State for Work and Pensions, has been keen to point out that people should not be penalised if www.thelancet.com/diabetes-endocrinology Vol 3 April 2015
they try to improve their condition but are not successful. However, this notion introduces the possibility of people enrolling in programmes that they have no intention of engaging with. As for saving costs, this approach falls down on several points. First, a freedom of information request showed that the number of people claiming sickness benefits with obesity as the primary reason for the claim is actually very small (only 1780 people as of May, 2014) when considered in the context of the roughly 2·5 million people claiming these benefits in total. Second, although government funding already supports some diet and lifestyle programmes for people with obesity, more funding would be needed to recruit and train staff to deliver these services and to monitor attendance and participation. Third, if the treatments are ultimately unsuccessful in most people, then money will have been spent on the interventions without reduction in the benefits bill. Fourth, if pharmacotherapy or bariatric surgery are offered (or mandated) for individuals who wish to continue to claim benefits, this could pose a substantial cost for the UK’s National Health Service. Fifth, if people are no longer deemed eligible to receive benefits because of their obesity, but are not employed, they will simply be moved from one type of benefit (sickness) to another (eg, Jobseeker’s Allowance). Thus, making weight-loss programmes a condition for receipt of sickness benefits in obese people seems financially and ethically questionable. The funding needed to implement and enforce such a scheme would be much better spent on provision of services to the greater UK population. Increasing funding to provide access to weight-loss schemes for all those who are motivated would be a great start. In addition, the funds could usefully be spent on benefits such as universal free access to leisure facilities, investment in healthy outdoor spaces, and public health education about healthy diet and lifestyle. These initatives offer enormous potential for obesity prevention. Instead of investment in a scheme that, at best, provides a short-term election soundbite, the government would be better placed to invest in schemes with the potential to improve the long-term health of the whole UK population. ■ The Lancet Diabetes & Endocrinology
Life In View/Science Photo Library
Tackling obesity—is coercion an option?
For more on the adaptations to obesity that can be barriers to weight loss see Comment page 232 For the freedom of information request see https://www.gov. uk/government/uploads/system/ uploads/attachment_data/ file/403970/FOI_2015-105_ Publishing.pdf
227
The UK Prime Minister, David Cameron, has announced that people who claim sickness benefit (incapacity benefit, severe disablement allowance, or employment and support allowance) because of obesity could have this money withdrawn if they refuse treatment for their disorder. As part of their campaign for the next UK general election on May 7, 2015, the Conservative Party has pledged to reduce the benefits bill by £12 billion during the next parliamentary term if elected. Cutting benefits for people who are out of work for a preventable disorder if they refuse treatment might seem like a reasonable contribution to this target, and David Cameron has ordered a rapid review by Professor Dame Carol Black (an adviser to the UK Department of Health) into the feasibility of implementation of such an initiative. Although many people who claim sickness benefits for obesity might welcome the opportunity to take part in an intervention that helps them to lose weight, any mandated program should have a strong evidence base for success. Unfortunately, diet and lifestyle interventions have restricted, often transient, benefits due to biological adaptations, that act to sustain high bodyweight. It is therefore important to ask whether requiring people to participate in weight-loss programmes, despite a high likelihood of failure, is acceptable from the point of view of an individual, provider, or society. Although there is some success with pharmacological treatments for obesity, the only treatment for obesity that has been proven to be successful for substantial long-term weight loss and improved quality of life in a high proportion of people is bariatric surgery. Requiring people to undergo a major surgical procedure as a condition of receiving benefits seems far from ethical. Another necessary consideration is what strategies will be implemented for individuals who try but fail to lose weight on the required programmes. To continue claiming benefits, would it be sufficient for a person to show that they have tried but failed? And how will “trying” be determined? If people do not lose weight with one scheme, will they be enrolled into another more aggressive programme? Is there potential for escalation of treatment to bariatric surgery in people who have not lost weight with other interventions? Iain Duncan Smith, the UK Secretary of State for Work and Pensions, has been keen to point out that people should not be penalised if www.thelancet.com/diabetes-endocrinology Vol 3 April 2015
they try to improve their condition but are not successful. However, this notion introduces the possibility of people enrolling in programmes that they have no intention of engaging with. As for saving costs, this approach falls down on several points. First, a freedom of information request showed that the number of people claiming sickness benefits with obesity as the primary reason for the claim is actually very small (only 1780 people as of May, 2014) when considered in the context of the roughly 2·5 million people claiming these benefits in total. Second, although government funding already supports some diet and lifestyle programmes for people with obesity, more funding would be needed to recruit and train staff to deliver these services and to monitor attendance and participation. Third, if the treatments are ultimately unsuccessful in most people, then money will have been spent on the interventions without reduction in the benefits bill. Fourth, if pharmacotherapy or bariatric surgery are offered (or mandated) for individuals who wish to continue to claim benefits, this could pose a substantial cost for the UK’s National Health Service. Fifth, if people are no longer deemed eligible to receive benefits because of their obesity, but are not employed, they will simply be moved from one type of benefit (sickness) to another (eg, Jobseeker’s Allowance). Thus, making weight-loss programmes a condition for receipt of sickness benefits in obese people seems financially and ethically questionable. The funding needed to implement and enforce such a scheme would be much better spent on provision of services to the greater UK population. Increasing funding to provide access to weight-loss schemes for all those who are motivated would be a great start. In addition, the funds could usefully be spent on benefits such as universal free access to leisure facilities, investment in healthy outdoor spaces, and public health education about healthy diet and lifestyle. These initatives offer enormous potential for obesity prevention. Instead of investment in a scheme that, at best, provides a short-term election soundbite, the government would be better placed to invest in schemes with the potential to improve the long-term health of the whole UK population. ■ The Lancet Diabetes & Endocrinology
Life In View/Science Photo Library
Tackling obesity—is coercion an option?
For more on the adaptations to obesity that can be barriers to weight loss see Comment page 232 For the freedom of information request see https://www.gov. uk/government/uploads/system/ uploads/attachment_data/ file/403970/FOI_2015-105_ Publishing.pdf
227
