Westminster Obesity Prevention and Treatment Strategy 2006 – 2009
November 2006
Introduction
The World Health Organisation has declared the rising levels of obesity to be an international epidemic, with urgent action required by member countries, to address the chronic disease burden the epidemic creates. In Securing Good Health for the Whole Population[1], Derek Wanless warned that unless the population becomes fully engaged in their own health, the NHS will be unaffordable by 2020. He specifically cited the rise in levels of obesity, with the accompanying increase in co-morbidities such as diabetes, as contributing to a possible collapse in the health service. Choosing Health[2] cites obesity and tackling weight management as a major strand of work for both the heath service and local government, as well as the general public.
The Obesity Strategy supports one of the key objectives proposed in the Westminster's City Plan, 2006-2016, Working Together to Shape Our City’s Future[3], and supports the cross-cutting health issues than are present throughout the plan. The City Plan recognises that levels of physical activity are reducing and obesity is increasing, which is considered a key concern for the 10 years of the Plan. The obesity strategy will support the City Plan to deliver its agenda of delivering preventative health services and work to reduce the stark health inequalities that are experienced across the borough.
Addressing obesity and the factors which lead to obesity will help to reduce health inequalities, thereby contributing to achieving the goals of the Westminster Local Area Agreement[4], the Health Inequalities Action Plan (forthcoming), the Programme for Healthier Westminster[5] and the Local Area Regenerations Plans. Addressing childhood obesity is a key component of the Be Healthy strand of Every Child Matters: Change for Children[6] and will be reviewed in the forthcoming Westminster Joint Area Review and Annual Performance Assessment.
A key indicator of success for the Westminster PCT’s 2006/7 Corporate Objective 1.1 (Implementing Delivering Choosing Health) is the development and implementation of an Obesity Strategy. Preventing obesity, a known risk factor for diabetes and coronary heart disease (CHD), are important areas of work for several National Service Frameworks, including the Children, Young People and Maternity Services NSF, the Diabetes NSF and the CHD NSF.
Westminster PCT and Westminster City Council were already working to address healthy eating and physical activity in the joint Health Promotion Strategy for Westminster: 2005 to 2008[7] when Delivering Choosing Health[8] was published. By establishing an Obesity Strategy Group in September 2004, Westminster agencies have demonstrated their commitment to tackling the complex issues around preventing and treating obesity. This document summarises the range of work that has been done to date on this issue and lays out the direction of travel until 2009.
National Drivers, Targets and Priorities
One of the key national drivers around obesity is encapsulated in the Public Service Agreement between the Department of Health (DH), the Department for Education and Employment (DfEE) and the Department for Culture, Sports and Media (DCSM). The target is specifically:
To halt the year on year rise in obesity among children under 11 by 2010 (from the 2002–04 baseline) in the context of a broader strategy to tackle obesity in the population as a whole.
Another relevant national PSA target for the DfEE and DCMS is:
Further enhance access to culture and sport for children and give them the opportunity to develop their talents to the full and enjoy the full benefits of participation by enhancing the take up of sporting opportunities by 5 to 16 year olds by increasing the percentage of schoolchildren who spend a minimum of two hours each week on high quality PE and school sport within and beyond the curriculum, from 25% in 2002 to 75% by 2006 and 85% by 2008 in England, and at least 75% in each School Sport Partnership, by 2008
The Department of Culture Media and Sports (DCMS) also has the following target:
By 2008, increase the take up of cultural and sporting opportunities by adults and young people aged 16 and above from priority groups by increasing the number who participate in active sports at least 12 times a year, by 3%; and increasing the number who engage in at least 30 minutes of moderate intensity level sport at least three times a week, by 3%.
Delivering Choosing Health commits the PCT, the local authority and partners to the following key targets, some of which are required in earlier guidance:
· Development of a comprehensive ‘care pathway’ for obesity, providing a model for prevention and treatment by December 2005
· Implementation of guidance on improved nutrition in schools by September 2006
· Active travel plans for all schools by 2010
· All schools to be in a school sports partnership by September 2006
· Health professionals using brief interventions with pedometers by end 2006
· All schools to participate in free fruit and vegetable scheme
· Community 5 a Day initiatives taken forward by PCT from April 2006
· PCT to reinforce national messages about healthy eating and physical activity
· Take forward Healthy Start Scheme from Spring 2006
The National Service Framework for Children, Young People and Maternity Services (Children’s NSF)[9] requires:
Children and young people who are overweight are referred to appropriate services such as family orientated therapy and exercise referral schemes.
Standard 1 of The National Service Framework for Diabetes[10] requires the NHS to work:
To develop, implement and monitor strategies to reduce the risk of developing Type 2 diabetes in the population as a whole and to reduce the inequalities in the risk of developing Type 2 diabetes.
The principal recommendation for preventing Type 2 diabetes is to prevent or reduce the prevalence of overweight and obesity, especially in ethnic minority groups at higher risk of developing diabetes.
Standard 1 of The National Service Framework for Coronary Heart Disease[11] requires the NHS and partner agencies:
To develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.
Again principal recommendations for implementation include promoting healthy eating, promoting physical activity and reducing overweight and obesity (as well as smoking).
In Tackling Health Inequalities: A Programme for Action[12], the Department of Health reiterated its commitment to reducing health inequalities through the national PSA target:
· By 2010 to reduce inequalities in health outcomes by 10 per cent as measured by infant mortality and life expectancy at birth
or the more specific objectives of:
· Starting with children under one year, by 2010 to reduce by at least 10 per cent the gap in mortality between routine and manual groups and the population as a whole
· Starting with local authorities, by 2010 to reduce by at least 10 per cent the gap between the fifth of areas with the lowest life expectancy at birth and the population as a whole.
PCTs have been asked to collect information as part of their local delivery plans as follows:
PSA10a: The proportion of all primary school children in the Reception Year and Year Six who are obese. Baseline: September 2006.
PSA10b: The proportion of the GP registered population aged 16 to 75 years who are obese. Baseline: 2004/5.
Defining and Measuring Obesity
Children
Draft NICE guidance on obesity[13] recommends the Body Mass Index (BMI) should be used at the measure for childhood obesity, for children aged 2 and older. The BMI should be compared against 1990 growth charts and BMI above 85th centile considered overweight and those above the 95th centile considered obese. SIGN guidance[14] sets the levels for referral for obesity treatment at the 98th centile, to allow for some inaccuracy in the measurement and to ensure that the most serious cases receive treatment.
Adults
BMI is recommended by the draft NICE guidance on obesity as the principal measure to be used to assess obesity, although the guidance recognises that waist measurement can form a valuable supplement for adults with BMI > 35. Key cut-off points are used to designate people who are underweight, normal, overweight, and obese (Class I-III), given in the Table below.
Table 1 - Levels of Overweight and Obesity
BMI Cut-Off Point / Obesity DesignationBMI < 20 / Underweight
BMI = 20.0-24.9 / Healthy Weight
BMI = 25.0-29.9 / Overweight
BMI = 30-34.9 / Obese, Class I
BMI = 35-39.9 / Obese, Class II
BMI > 40 / Obese, Class III
NICE guidance further recommends that lower cut-offs be used for people of South Asian origin because of the higher prevalence of central obesity, with accompanying increased health risks, amongst these ethnic groups. Specifically that people of South Asian origin should be regarded at increased risk, i.e. overweight, with a BMI of 23 and at high risk, i.e. obese, with a BMI of 27.5. The lower cut-off points for South Asian people should be used to inform both prevention and treatment programmes within Westminster.
Causes of Obesity
At a simple level, obesity is caused when individuals consume more calories than they expend in activity. However, unpicking the variety of influences on this increasing imbalance is more complex. The startling rise is obesity in the last twenty years has been caused by trends as diverse as:
· an increased consumption of energy-dense fast foods, meals taken outside the home, and snacking
· increased portion sizes
· increased consumption of soft drinks
· increased television and computer use
· decline in active commuting and walking/cycling generally
· decline in physically demanding work with the shift from manufacturing to office work
· less unsupervised play outside by children
· less outside activity by both adults and children, due to perceptions of declining personal safety
· increased traffic and priority given to cars in planning towns and street environments.
Any attempts to tackle obesity must therefore address the obesogenic environment that encourages excess calorie intake and minimal physical activity, as well as the behaviours and choices of individuals. These factors can also differentially affect those living in more deprived communities, thereby contributing to health inequalities. This obesity strategy will require the involvement of a range of partners, including transport, planning, community safety, education and children’s services from local government services and the voluntary sector, as well as the health service.
Impact and Consequences of Obesity
Health impact
Choosing Health states that being obese reduces one’s life expectancy by 9 years. The Westminster Obesity Treatment Needs Assessment[15] suggests that approximately 99 deaths a year in Westminster could be attributable to obesity. The risk of developing Type 2 diabetes, gallbladder disease, breathlessness and sleep apnoea are increased more than 3 times for obese people. The risk of developing coronary heart disease, hypertension and joint problems is increased two to three times. The risk of breast cancer in postmenopausal women, endometrial cancer and colon cancer can be double for obese people compared to people with a BMI under 25. Some of these diseases, such as Type 2 diabetes, have now been found in obese young people, where previously such diseases were thought to be diseases of middle age. Even small decreases in weight can lead to an appreciable improvement in the health risks of obesity. There is some evidence that permanent weight loss, though difficult to achieve, appears to eliminate obesity-associated co-morbidities.
Cost to health service
The most up to date estimates of the national direct costs of obesity were produced for the House of Commons Health Committee report on obesity[16], published in May 2004. Based on methodology deployed by the National Audit Office in the 1998 Tackling Obesity in England[17], the Health Committee report estimated a national cost between £46 and £49 million a year for treating obesity and related co-morbidities, between 2.3 and 2.6% of the total NHS expenditure in 2001-2. This figure is four times the original 1998 estimates, due largely to the introduction and rapid take-up of anti-obesity drugs and increase in level and cost of lipid-lowering drugs. These costs are also assumed by both reports to be an underestimate of the likely costs of treating obesity. The costs are also increasing with the increases in the cost of both obesity and lipid-lowering drugs, as well as the increase in the prevalence of obesity.
An estimate of the cost to the health service in Westminster can be calculated, using the proportion of the national budget spent on obesity treatment and applying the same proportion to the Westminster PCT budget. Westminster PCT net operating cost in 2005/6 was £364,101,000. This suggests that a conservative estimate of the cost of treating obesity and obesity-related co-morbidities in Westminster PCT is somewhere between £8.5 to £9.5 million annually.
Costs to the wider economy
The Health Committee report also looks at indirect costs of obesity, including mortality, years of life lost, premature loss of earning, as well as incapacity benefits. The Westminster Obesity Treatment Needs Assessment estimated the number of deaths per year at approximately 100, which is in line with estimates generated from the Health Committee Report.
Nationally, obesity accounts for 45,000 attributable years of working life lost and a cost of £1.05 to 1.15 billion loss of earnings from premature mortality. National data on incapacity benefit suggests that there 15.5 to 16 million attributable days of certified incapacity, equivalent to lost earnings of £1.3 to £1.45 billion. While local data is not available, the indirect cost to the local Westminster economy is likely to be substantial.
Obesity prevalence
Extensive detail on the estimated levels of overweight and obesity within Westminster, as well related health behaviours, is available in the Westminster Obesity Treatment Needs Assessment. The headlines from that report are:
· Approximately half of the adults in Westminster are likely to be overweight or obese.
· Westminster overall is likely to have a lower prevalence of obesity across the borough than the national average but individual areas may have higher levels of obesity than the national average.