The increase in obesity has been identified as a major public health threat. It has been predicated by the Government Office for Science Foresight that without taking action nearly 60% of the UK population will be obese by 2050, which would have serious financial consequences for the NHS and the economy.1
The causes are complex and related to behavioural, social and environmental factors therefore to tackle obesity a range of agencies and communities need to work together to:
Change the obesogenic nature of the local environment.
Develop opportunities to make healthy choices easier.
Help those already obese or at high risk of becoming obese.
This strategy provides a framework for local action and seeks to:
Provide an understanding of the extent of the problem in the local population and sets goals.
Provide leadership by bringing together a multi agency group.
Choose interventions that evidence has shown to be effective.
Enable monitoring and evaluation.
Build up local capacity via training.
There is a focus on childhood overweight and obesity in line with government recommendations. This two year evidence based strategy will require funding, the costs and resources required are provided in the action plan.
2.0 The organisation
2.1 The geographical area and population
To make up the target population for this strategy, 90% of Preston’s population and 15% of South Ribble were chosen, this is a population of approximately 150,000.
Preston’s health profile3 shows there are inequalities with nearly 40% of the residents living in the most deprived quintile. The percentage of children classified as obese is similar to the England average. South Ribble’s health profile4 shows less than 5% of residents living in the most deprived quintile, child poverty and deprivation rates are low, the percentage of children classified as obese is better than the England average. Preston has a Black Minority Ethnic (BME) population of 15.5% which is greater than the England average, the largest majority being Asian (Indian the majority) or Asian British.3 South Ribble has a BME population of less than 5%.4
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To ensure the population had a range of social classes, age groups and ethnic groups, two of the most deprived wards of Preston (Ribbleton [GL] and Fishwick [GB]) – total population 12,720 were replaced with 3 less deprived wards of South Ribble (Broad Oak [GC], Kingsfold [GL] and Middleforth [GU]) – total population 12,430, see Figure 1. This ensured the target population for the purpose of this strategy was approx 150000 with mixed class, age and ethnicity. The geographical area for the purposes of this strategy is called Preston Ribble Council.
Figure 1: Wards of Preston (A) and South Ribble (B) 5
(A)
(B)
KEY:
Source: http://www.lancashire.gov.uk
2.2 Health Improvement
As part of Preston Ribble Council, the Health Improvement Team delivers a range of services and health campaigns designed to improve the health and wellbeing of the population of Preston Ribble.
The health improvement team includes public health consultants and practitioners who work with the NHS, other organisations, the voluntary sector and local business to provide education and training services to empower residents of Preston Ribble to make healthy lifestyle choices.
Health improvement and tackling inequalities is an integral part of Preston Ribble Council’s Culture. All policies that support health improvement are evidence based. Partnership working is a necessity to deliver the health improvement agenda.
3.0 Obesity strategy development
Obesity is a multi-faceted problem and therefore requires a multi-agency solution. A multi-agency Obesity Strategy Group was set up with key partners from the Local Authority, NHS and the voluntary sector to develop this strategy. The group was lead by the Health Improvement team’s consultant in public health. It sets out how partners and communities will work together to reduce obesity by taking into account the specific needs of the local population. This strategy will link in with other strategic plans to ensure tackling obesity is high on the political agenda of Preston Ribble Council.
4.0 Background
4.1 Defining overweight and obesity
Overweight and obesity are terms used to describe excess body fatness which can lead to adverse effects on health and wellbeing.2 Overweight and obesity occurs when energy intake from food and drink is greater than energy expenditure i.e. what is used by the body. The causes however are more complex and related to behavioural, social and environmental factors.2
The calculation of BMI body mass index (BMI=weight/(height)2) > 30 kg/m2.is a widely accepted definition obesity. The World Health Organisation produced a classification of overweight adults based on BMI, see Table 1.
Table 1 Classification of overweight adults.6
Classification BMI (Kg/m2) Risk of co-morbidities
Underweight < 18.5 Low (but the risk of other
Clinical problems increased)
Normal weight 18.5 – 24.9 Average
Overweight > 25
Pre-obese 25 – 29.9 Increased
Obese class I 30.0 – 34.9 Moderate
Obese class II 35.0 – 39.9 Severe
Obese class II > 40.0 Very severe
Source: Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. Geneva. World Health Organisation, 2000 (WHO Technical Report Series, No 894)
Guidance published by the National Institute for Health and Clinical Excellence now recommends the use of waist circumference in conjunction with BMI as the method of measuring overweight and obesity and determining health risks.7
Because a child’s BMI varies with age and sex, the BMI score for children is related to the UK 1990 BMI growth reference charts.8
4.2 Obesity and Health
Life expectancy is reduced in obesity cases by an average of three years, and in severe obesity cases (BMI >40) life expectancy is reduced by eight to ten years.9 It has been estimated that the cost to the UK economy from overweight and obesity was £15.8 billion per year in 2007, £4.2 billion of which were costs to the NHS.9
Childhood obesity
Short term risks mostly include emotional and psychological affects associated with being overweight through being teased by peers, resulting in low self esteem and depression. There are longer term consequences as obese children are more likely to become obese adults, there are however some obesity related conditions such as type 2 diabetes which have increased in overweight children.9
Adult obesity
Evidence has shown that adult obesity is associated with a range of health problems including those related to; the musculoskeletal system because of the extra strain on joints; circulatory system e.g. coronary heart disease and stroke; metabolic and endocrine system e.g. type 2 diabetes; cancers such as breast and colon; reproductive problems; gastrointestinal and liver disease and psychological and social problems.9
5.0 The scale of the problem in the UK
Within the last 25 years, the prevalence of obesity in the UK has more than doubled.1 The latest Health Survey for England (HSE) in 2009 showed that the proportion of obese men increased from 13% in 1993 to 22% in 2009 and from 16% of women in 1993 to 24% in 2009 i.e. more women are obese than men, there were however more overweight men (44%) than women (33%).10 The 2007 Foresight Report predicted that if no action were taken, by 2025 47% of men and 36% of women will be obese and Britain could be a mainly obese society by 2050, adding £5.5 billion annual cost to the NHS.1
The rise in obesity among 2-10 year olds from 1 in 10 in 1995 to 1 in 7 in 2008 appears to be flattening out.10 There are however, still 1 in 5 children that are overweight or obese by the age of 3 years.11
Rates of obesity are higher among some Black and Minority Ethnic (BME) communities and also in lower socioeconomic groups.12 The latest Health Survey for England in 2009 also showed the link between obesity and deprivation, women in the lower income quintiles had a higher BMI and greater prevalence of obesity than those women in higher income quintiles, there was no apparent pattern in men,10 see Figure 2.
Figure 2 Age-standardised prevalence of overweight and obesity by equivalised household income and sex.10
6.0 The scale of the problem in Preston Ribble Council.
Using the NICE costing tool13 the selected population obesity and overweight prevalence and numbers were calculated, see Appendix 1. The extent of the problem is summarised in Figure 3. There are an estimated 4511 children and young people who are classified as obese (BMI over 30), and a further 4580 who are classified as overweight (BMI between 25 and 30). There are an estimated 31993 adults who are classified as obese and a further 51821 who are classified as overweight. 22.9% of adult females and 26.8% adult males are obese.
Figure 3 the extent of the problem in Preston Ribble
Obese
Overweight
Normal weight
Adults
BMI > 40 n=2105*
BMI 30-39 n=29888*
BMI 25-30 n=51821*
Children & Young people
BMI >40 n=69*
BMI 30-39 n=4442*
BMI 25-30 n=4580*
*NICE costing tool
The National Child Measurement Programme (NCMP) introduced in 2005 aims to monitor the prevalence of overweight and obesity in children in Reception Year and Year 6. The table below presents the results for the local authorities of Preston and South Ribble compared to the North West and national averages.
Table 2 Local prevalence of overweight and obesity among children for the Local Authorities of Preston and S.Ribble and for England 2009/10 and 2008/09 14
Reception
Year 6
Overweight
Obese
Overweight
Obese
2008/09
Preston
10.9
8.5
13.1
17.3
S.Ribble
11.5
6.8
15.6
16.3
NW
13.5
9.6
14.1
18.9
England
13.2
9.6
14.3
18.3
2009/10
Preston
12.5
9.1
12.9
17.0
S.Ribble
15.3
8.5
14.0
18.0
NW
13.7
9.9
14.8
19.3
England
13.3
9.8
14.6
18.7
Source: http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/obesity
The table above shows an increase from 2008/09 to 2009/10 in Reception Year in the numbers of overweight and obese children in both Preston and S.Ribble. In Year 6 there was just an increase in obese children in S.Ribble. The targeted population for this strategy is ‘Preston Ribble’, as the population is 90% Preston and 15% South Ribble these increases are clearly a concern.
A report by Intelligence for Healthy Lancashire (Joint Strategic Needs Assessment) on childhood obesity in Lancashire showed that measurements of year 6 pupils from the 08/09 NCMP dataset highlighted that across Lancashire there could be found extremes of weight (underweight and obese) in the most deprived areas and there was a link between higher levels of overweight and lower levels of deprivation.15
6.1 The local cost of obesity
Using the NICE costing tool for the target population of Preston Ribble, the estimated savings from implementing NICE guidance is approximately £43,000 savings on prescriptions and £127,000 in GP contacts, see appendix 1. That is the current local cost to the NHS of not implementing NICE guidance for tackling obesity is approximately £170,000. There would be however additional costs with disease associated with overweight and obesity plus costs on the economy from days off work due to obesity and associated diseases and conditions.
7.0 National Drivers and Guidance
Reducing obesity is a national priority for government as highlighted in the recently published white paper ‘Healthy Lives, Healthy People: Our Strategy for public health in England’.16 In January 2008, the government published the national obesity strategy ‘Healthy Weight Healthy Lives’.17 It highlighted the need for a long term approach and set out a new Public Service Agreement target for England:
‘Our ambition is to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to achieve and maintain a healthy weight. Our initial focus will be on children: by 2020, we aim to reduce the proportion of overweight and obese children to 2000 levels’.17
In 2006 Nice Guidance on Obesity was issued, this set out guidance on ‘prevention, identification, assessment and management of overweight and obesity in adults and children in England and Wales’.7 In addition to the NHS the guidance was also aimed at non-NHS settings for example, local authorities, schools early years and workplaces and sets out recommendations aimed at these various settings. It was also highlighted that obesity cannot ‘simply be addressed through behavioural change at individual level; population based interventions are needed to change the “obesogenic environment” of modern industrialised nations’.7
The Foresight Report, ‘Tackling Obesity: Future Choices’ (2007) highlighted that obesity is determined by ‘a complex multifaceted system of determinants’ and that in the 20th century ‘the pace if technological revolution outstrips human evolution’ which has left an ‘obesogenic environment’.1 To tackle the complexities of obesity the report advocated using a multi agency or whole system approach. The report concluded that ‘Preventing obesity requires changes in the environment and organisational behaviour, as well as changes in group, family and individual behaviour’.1
8.0 Effective interventions
Research highlighted in the Foresight report1 found that the top five policy responses which they assessed as having the greatest average impact on obesity levels were:
€ ‘increasing walkability/cyclability of the built environment
targeting health interventions for those at increased risk
controlling the availability of/exposure to obesogenic foods and drinks
increasing the responsibility of organisations for the health of their
employees
€ early life interventions at birth or in infancy.’ 1
9.0 The Local Approach
‘Healthy weight, healthy lives: a cross government strategy for England’17 and the accompanying ‘Healthy weight, healthy lives: a toolkit for developing local strategies’2 have been utilized to develop this strategy for Preston Ribble. It supports the government’s recommended approach of focusing on five key themes:
Children: Healthy growth and healthy weight. The stages of pre-conception, breast feeding, infant nutrition through to early years can shape outcomes and choices made in adulthood.18
Promoting healthier food choices. Supporting the government’s recommendation for promotion of a healthy, balanced diet.
Building physical activity into our lives. Supporting the government’s recommendation of promoting active living throughout the life course.
Creating incentives for better health. Promoting action for maintaining a healthy weight in the workplace through promotion of healthy eating choices and more opportunities for physical activity within the workplace.
Personalised support for overweight and obese individuals. Providing clinical care pathways to assess and manage overweight and obesity through effective weight management services.
A life course approach has been used to assess the various stages of peoples’ lives where evidence has shown targeting interventions can be successful in preventing or treating overweight and obesity. This strategy uses ‘universal’ population preventative approaches in addition to ‘targeted’ interventions for those already obese or at high risk of developing. As evidence suggests peoples lives are shaped from very early years11,18 this strategy focuses on children’s health.
To help people overcome barriers to maintaining a healthier lifestyle and changing their behaviour, this strategy takes a combined approach as recommended in the Foresight Report1 that is using types of interventions that focus on the determinants of behaviour such as the environment and education, the second type of intervention focuses on the behaviour itself in those at risk.1 The strategy uses all 5 different approaches to health promotion, i.e. medical, behaviour change, education, empowerment and social change to tackle both the determinants and the behaviour itself.
10.0 The Obesity Strategy Aim and Objectives
The overall aim of the strategy is to reduce obesity levels in the local population of Preston Ribble. The strategy has three strategic themes with objectives:
Change the obesogenic nature of the local environment.
Develop opportunities to make healthy choices easier.
Help those already obese or at high risk of becoming obese.
10.1 Change the obesogenic nature of the local environment
Objectives:
Influence public policy
Influence businesses to become healthy workplaces
Work with communities to make active lifestyles easier
As planning and transportation policy development can have huge effects on opportunities for activity within the local built environment, it is important that health issues such as obesity are considered in policy decisions, Health Impact Assessment (HIA) should form part of policy development. As part of this strategy’s action plan HIA training will be rolled out to planning and transportation teams within the council.
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Foresight report1 found that one of the five policy responses which they assessed as having the greatest average impact on obesity was increasing the walkability/cyclability of the built environment. The report highlighted that ‘residents of highly walkable neighbourhoods are more active and have slightly lower body weights than their counterparts in less walkable neighbourhoods’, it was also highlighted how perceptions of social nuisances may increase the risks of obesity.1 Therefore key actions of this plan include interaction between Environmental Health, Housing, Police and communities to tackle social nuisances, set up community action teams and working with communities to empower and reassure residents.
Community food growing initiatives have been recognised as providing benefits to help tackle obesity, they can offer physical activity, increase food knowledge and give a better appreciation of food that helps them make healthier food choices, in addition they help create cohesive communities and social inclusion thereby reducing health inequality.19 Because of the potential health gain this strategy aims to set up several community horticultural projects targeting the most deprived areas likely to have high risk individuals.
The influence of the workplace on health of employees is well recognised and the Foresight report1 found increasing the responsibility of organisations for the health of their employees was one of the five policy responses which had the greatest impact on obesity. As part of this strategy the importance of this has been recognised and therefore a newly created ‘health & wellbeing workplace officer’ will be recruited to promote and facilitate the development of healthy active workplaces promoting the national ‘Workwell campaign’20 a health and wellbeing workplace award scheme will be launched.
10.2 Develop opportunities to make healthy choices easier.
Objectives:
Enable young children to eat a healthy diet
Enable adults and families to eat a healthy varied diet
The stages of pre-conception, breast feeding, infant nutrition through to early years can shape outcomes and choices made in adulthood.18 In ‘Tackling obesity through the healthy child programme, a framework for action’ evidence is presented which strengthens the argument for focusing interventions in the very early years, it is highlighted that epidemiological studies have shown once obesity is established in a child it can continue into adulthood.11 The Foresight report1 found that one of the five policy responses which they assessed as having the greatest average impact on obesity was early life interventions at birth or in infancy. Therefore this strategy focuses on early years as they have been identified as critical opportunities for interventions in the life course, see figure 4.
Figure 4 Critical opportunities for intervention in the life course of an individual 1
Source: Government Office for Science (2007) Tackling Obesity: Future Choices, Foresight Report. http://www.bis.gov.uk/assets/bispartners/foresight/docs/obesity/17.pdf
Breastfeeding can provide protection against obesity and related health problems in later life22 and that by breastfeeding mothers are more likely to return to their pre-pregnancy weight.23 It has been recommended by the WHO and the Department of Health that breastfeeding should be encouraged for the first 6 months of life.24 This strategy includes actions to increase uptake of breastfeeding.
Both parents and childcare providers have a role in ensuring children have healthy balanced diets. This strategy includes actions to help ensure healthy eating at childcare premises. A healthy eating award scheme for childcare will be launched to encourage and provide recognition to childcare providers.
NICE guidance recommends a whole school approach to tackling overweight and obesity.7 Healthy weight healthy lives highlights the importance of schools in ensuring opportunities are provided for children to develop healthy eating habits. This strategy therefore supports ‘Healthy Schools’25 and also increasing the take-up of school meals.
National qualitative research commissioned by the Department of Health for the change 4 life campaign included segmentation of the population into 6 clusters, it was identified that 3 cluster types that were more at risk of obesity, Clusters 1 and 2 also had low income, these clusters each require specific key messages.26 See Figure 5. People on low incomes (Cluster 1 and 2 ) will be targeted as the Food Standards Agency low income and diet survey highlighted they had poorer diets due to several factors including a lack of cooking skills and knowledge.27
Figure 5 Department of Health Segmentation analysis 26
Taking an educational approach to promote healthy food choices in the home this strategy will implement a package of workshops designed for these high risk clusters to provide knowledge, practical skills and confidence to prepare healthy affordable food.
As BME communities have also been identified as high risk of obesity, they will also be targeted for healthy eating workshops. As suggested in ‘Healthy Weight Healthy Lives a toolkit for developing local strategies’ 2 to effectively engage BME communities, interventions will be culturally appropriate and group workshops will include sharing ideas how to make traditional meals healthy.
The availability of affordable fresh food in deprived areas will also be address by this strategy, by introducing initiatives such as fruit and vegetable box schemes and food co-operatives which will promote local sustainable suppliers.
10.3 Help those already obese or at high risk of becoming obese
Objectives:
Identify early those at high risk of overweight or obesity and direct towards appropriate intervention
Ensure provision of and equal access to weight management services for those who want to loose weight.
As the numbers of obese individuals is forecast to rise1 it is paramount that services are in place to meet their needs and help individuals reduce and maintain a healthy weight. For those individuals already burdened with obesity or are at high risk of becoming, comprehensive care pathways for both adults and children will be developed using NICE guidance7,28 to ensure they are evidenced based.
It was recommended in ‘Healthy Weight Healthy Lives a toolkit for developing local strategies’ that more weight management services should be commissioned.2 Counterweight is an evidence based weight management programme that has been shown to be highly cost effective.29 This strategy will therefore utilize this cost effective service to ensure weight management services are available for those who want to loose weight. Weight management schemes designed specifically for children will also be assed and introduced on securing funding e.g. MEND (Mind, Exercise, Nutrition, Do it).30
The full Obesity Strategy Action Plan is shown in Table 4.
11.0 Monitoring and evaluation
The implementation and monitoring of this strategy will be overseen by the Obesity Strategy Group for Preston Ribble. To measure success of the overall aim of reducing obesity levels in the population, overarching strategy indicators are shown in Table 3.
Table 3 Overarching strategy indicators.
Indicator
Source
Timing
1
% children in Reception who are obese
NCMP
Annually Feb
2
% children in Reception who are overweight or obese
NCMP
Annually Feb
3
% children in Yr 6 who are obese
NCMP
Annually Feb
4
% children in Yr 6 who are overweight or obese
NCMP
Annually Feb
5
Prevalence of BMI > or equal to 30 in adults over age of 16 in previous 15 months in GP registers
QoF
Annually
The Obesity Strategy Action Plan shown in Table 4 includes an evaluation framework. For each action, the outcome and performance measure is indicated. The highlighted lead will be responsible for ensuring the specified outcomes and performance indicators are measured and reported back to the Strategic Obesity Group at the specified time.
Table 4 Obesity Strategy Action Plan
Strategic Theme 1: Change the obesogenic nature of the local environment
Objectives and key actions
Approach to health promotion indicated:
(medical / behaviour change / educational / empowerment / social change)
Timescale
Resources
Lead responsibility and partners
Performance Measure / Outcome
(Social Change)
Objective: Influence public policy
Ensure HIA part of policy development
Roll out HIA training to planning and transportation teams within the council.
Within 6 months
IMPACT 5 day HIA training course for team leaders (£700 pp)
In house HIA awareness 1 day course delivered by trained HIA champions.
Council
Training providers
All team leaders completed 5 day HIA course
1 day in house HIA awareness training attended by 90% of officers
Increase availability of active transport –
Planning and transportation to map existing cycling and walking routes around the district and undertake a gap analysis of opportunities for more routes.
Within 6 months
Planning Officer time
Planning
Parks and Leisure
Transport
Existing cycling & walking routes mapped.
Results of gap analysis reported.
Restrict access to unhealthy food.
Work with planning to restrict permission of fast food outlets within 500 metres of schools
Ongoing
Planning Officer time
Planning
PCT Health Promotion
No applications granted after 1 year.
Improve walkability of neighbourhoods.
Improve timely interaction between Environmental Health, Housing, Police to tackle social nuisances.
Monitor community satisfaction via questionnaires / community meetings every year.
Ongoing
Procedural development time by all partners.
Environmental Health
Housing Department
Housing Associations
Police
Community Groups
Community group and resident feedback of significant improvement.
Establish new food growing sites to improve the health and well being of residents.
Identify land available for food growing projects.
Within 6 months
Planning Officer time
Planning
Sustain
Land Owners
4 new growing sites to be established.
Objective: Influence businesses to become healthy workplaces
Organise an area forum and develop website for representatives of local businesses to raise awareness in employers of production benefits in promoting healthy lifestyles. Promote business in the community workwell campaign, case studies of good practice.
Within 6 months
Health and wellbeing workplace officer (in Environmental Health) £30K
Environmental Health,
PCT Health Promotion,
Occupational Health,
IT
Existing Area Business and Commerce Forums
Forum website developed.
Influence roll-out of workplace policies to
tackle obesity via newly appointed health and wellbeing workplace officer – employed to promote and facilitate the development of healthy active workplaces.
1 – 2 years
Health and wellbeing workplace officer
Environmental Health,
PCT Health Promotion,
Occupational Health,
Existing Area Business and Commerce Forums
Feedback from forum of increase in healthy policies. (website survey monkey at 1 and 2 years)
Critically assess workplace practices in NHS and the Local Authority and introduce policies that encourage physical activity and healthy eating. Promote implementation of NICE Guidance 43.
1 – 2 years
Health and wellbeing workplace officer
Environmental Health
PCT Health Promotion, Human Resources teams, Occupational Health,
Catering services
All NHS and LA workplaces assessed after 2 years.
Launch a workplace health and wellbeing award scheme to encourage employers to recognise the influence that they can have on their employee’s health.
6 – 12 months
Health and wellbeing workplace officer time, LA communications team
Environmental Health,
Council Comms,
PCT Health Promotion,
Occupational Health,
Existing Area Business and Commerce Forums
Award scheme launched after 12 months.
(Empowerment)
Objective: Work with communities to make active lifestyles easier
Work with communities to identify perceived needs for cycling and walking routes.
6 – 12 months
Planning Officer time
Planning
Parks & Leisure
Community Groups
Health walk Leaders
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