South East QIPP report 1: Overweight & obesity

Department of Health South East

QIPP report 1

Overweightobesity

Department of Health South East

October 2010

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South East QIPP report 1: Overweight & obesity

Contents

1.Background

2.Outcome indicators

3.Prevalence of adult and child obesity in the South East

4.Diseases attributable to obesity

5.Estimates of the numbers of cases of obesity-attributable diseases

6.Effective prevention and treatment of obesity

7.Economic effectiveness of interventions aimed at preventing and treating obesity

8.Estimates of the financial cost of obesity

9.Selected resources

Report purpose and scope

This report is one of a series produced by the Department of Health South East to support the NHS QIPP (quality, improvement, productivity, prevention) process. It focuses on overweight and obesity and provides:

  • details of selected obesity, diet and physical activity outcome indicators
  • estimates of the prevalence of adult obesity (by Local Authority) and child obesity (by PCT) in South East England
  • a summary of the main diseases attributable to overweight and obesity
  • estimates of the numbers of cases of obesity-attributable hypertension, cardiovascular disease and diabetes by PCT
  • a summary of effective interventions aimed at preventing and treating obesity (largely derived from the National Obesity Observatory summary of the systematic reviews undertaken by NICE and the Cochrane Collaboration)
  • a summary of the available evidence on the cost effectiveness of population-level interventions aimed at preventing and treating obesity
  • estimates of the cost of treating diseases related to overweight and obesityby PCT
  • estimates of the costs to PCTs of implementing selected NICE-recommended interventions aimed at preventing and treating obesity.

What this report does not provide

The primary objective of this report is to provide an overview of the challenge presented by overweight and obesity to public health in South East England; it does not address the effectiveness of specific clinical interventions such as bariatric surgery.

While the evidence base on ‘what works’ to prevent and treat overweight and obesity is well-developed, this report makes clear that the evidence concerning the cost effectiveness of population-level interventions is less clear. While estimates of the annual cost to the NHS of diseases related to overweight and obesity, and estimates of the annual costs and savings of selected interventions are presented, it has not been possible to quantify the short-term cash-releasing savings to be gained by reducing (or reducing the rate of increase in) the prevalence of overweight and obesity at a local level across the South East. This is for several reasons.

First, the evidence base contains very little information on the scale and scope of thepublic health programmes required to produce a given change in the level of overweight and obesity. Similarly, there is little evidence on the time period required to achieve a given change in prevalence levels – the NICE costing model, for example, only provides estimates of annual cost savings atyear tenbased on the assumption of a ten percent reduction in the level of obesity.

Second, the provision, scale and scope of population-level programmes aimed at preventing and treating overweight and obesity varies considerably across the South East – there is no universal standard of NHS and Local Authority-provided services on which to base locally-specific estimates of potential cash savings.

Third, if national trends in adult and child obesity can be assumed to apply equally to the South East, then there is a clear case for increasing the current level of expenditure on prevention and treatment programmes. Accordingly, current levels of investmentare, at best, likely to be cost-reducing for the NHS rather than cash-releasing.

Fourth, it is important to note that many of the benefits of overweight and obesity prevention and treatment programmes, such as prevention of premature death and improvements in quality of life, are very difficult to quantify in financial terms. This does not, however, diminish their tangible and measurablebenefit to the health and well-being of the population.

Contact and further information

This report has been produced by Robert Kyffin and Anh Tran in the Department of Health South East. Any questions or comments can be directed to:

Robert Kyffin

Department of Health South East

Bridge House

1 Walnut Tree Close

Guildford

GU1 4GA

e.

t. 01483 882 264

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South East QIPP report 1: Overweight & obesity

1.Background

Overweight and obesity presents a major challenge to the current and future healthof the population of South East England. Higher body mass index(BMI) is associated with an increased risk of morbidity and mortality from a range of conditions including hypertension, heart disease, stroke, diabetes and several cancers. An estimated 23.7 percent of adults in the South East are obese – equivalent to over1,600,000 people – and the percentage is rising. Levels of child obesity are also of concern: 8.7percent of 4 to 5 year olds and 16percent of 10 to 11 year olds in the region are obese. Including those who are overweight increases all these figures substantially.

There is clear clinical evidence of what works to prevent and treat obesity at an individual level. However, the effectiveness of broader public health programmes aimed at addressing the population-level factors underlying increasing levels of obesity – primarily the social and economic environments which surround food consumption and physical activity – is less clear. This lack of clarity relates both to the effectiveness of public health programmes in preventing and treating overweight and obesity, and to their cost effectiveness.

2.Outcome indicators

There are a range of process and outcome indicators which can be used to measure the prevalence of obesity and its main determinants, diet and physical activity.

Obesity

  • Modelled estimates of adult and child obesity (Health Survey for England)
  • Obesity among primary school age children in Reception Year(National Indicator55, from the National Child Measurement Programme)
  • Obesity among primary school age children in Year 6(NI56,from the National Child Measurement Programme)

Diet

  • Modelled estimates of adult and childfruitand vegetable consumption(Health Survey for England)

Physical activity

  • Adult participation in sport and active recreation(NI08,from the Sport England Active People Survey)
  • Children and young people's participation in high-quality physical education and sport(NI57, from the Department for Education Annual School Sport Survey).

A series of briefings on the data sources underlying these indicators has been produced by the National Obesity Observatory (NOO)[1]. In addition, a range of outcome measures related to many of the health conditions associated with overweight and obesity such as mortality from cardiovascular disease are available from the Compendium of Population Health Indicators ( and the South East England Indicator Tool(tinyurl.com/seeitool).

3.Prevalence of adult and child obesity in the South East

There are significant variations in the prevalence of obesity across the South East. The level of adult obesity in Medway UA and Kent CC is significantly higher than the England average (Figure 1), while the percentage of children who are obese is significantly higher than the national and regional averages in Portsmouth PCT and Medway PCT (Figure 2).

Figure 1: Percentage of adults who are obese by South East Local Authority, 2006-8

Source: Department of Health. Health Surveys for England, 2006-8. (tinyurl.com/hp10data)

Figure 2: Percentage of children who are obese by South East PCT, 2008/9

Source: Information Centre for Health and Social Care. National Child Measurement Programme, 2008/9. (tinyurl.com/hp10data)

4.Diseases attributable to obesity

A large international meta-analysis of the impact of obesity on life expectancy found that moderate obesity (BMI30-35) reduces life expectancy by an average of three years, whilemorbid obesity (BMI 40-50) reduces life expectancy by eight to ten years[2].

Obesity causes insulin insensitivity which is a causal factor in diabetes, heart disease, hypertension and stroke. As a result, obesity is associated with an increased relative risk of hypertension, myocardial infarction, stroke, diabetes and a range of hormone-sensitive cancers including genitourinary and colorectal cancers(Table 1). The greater mechanical load also increases the risk of osteoarthritis and sleep apnoea.

Table 1: Proportion of selected diseases attributable to obesity

Disease / Relative risk / Attributable proportion (%)
Obesity / - / 100
Hypertension / 2.9 / 24.1
Myocardial infarction / 1.9 / 13.9
Angina pectoris / 2.5 / 20.5
Stroke / 3.1 / 25.8
Venous thrombosis / 1.5 / 7.7
Diabetes (Type 2) / 2.9 / 24.1
Hyperlipidaemia / 1.5 / 7.7
Gout / 2.5 / 20.0
Osteoarthritis / 1.8 / 11.8
Gall-bladder disease / 2.0 / 14.3
Colorectal cancer / 1.3 / 4.7
Breast cancer / 1.2 / 3.2
Genitourinary cancer / 1.6 / 9.1
Hip fracture / 0.8 / -3.5

Notes: Obese defined as adult BMI of 27 or more.

These attributable proportions differ from those contained in the National Audit OfficeTackling Obesity in England (2001) report.

Source: Health Care Needs Assessment. Obesity, 2007( in Association of Public Health Observatories. The Indicator Guide: Health Profiles 2010. (tinyurl.com/hp10guide)

5.Estimates of the numbers of cases of obesity-attributablediseases

Broad estimates of the numbers of cases of obesity-relateddiseases can be calculated by applying the attributable proportions in Table 1 to the disease prevalence models produced by APHO. The APHO models containlocal estimates of the prevalence of several commonlyoccurring diseases which have been produced by applying a risk factor model based on results from the Health Survey for England to local population estimates and projections.

The estimated numbers of adults with obesity-attributable hypertension, cardiovascular disease (which includesmyocardial infarction, angina and stroke) and Type 2 diabetes for the 17 South East PCTs are contained in Table 2. The estimate of 500,700 adults in the South East with obesity-attributable hypertension, for example, has been calculated by applying the attributable proportion for hypertension (24.1 percent) to the modelled estimate of 2.1 million persons aged 16 and over in the South East with hypertension (ie. 0.241 x 2,077,700 = 500,700).

These estimates include both diagnosed and undiagnosed disease so represent the wider impact of obesity on the health of the population of the South East. They should, however, be interpreted with a degree of caution – the attributable proportions are not age-specific so PCTs with an older population profile are likely to have larger numbers of cases (as both levels of obesity and disease prevalence increase with age).

Table 2: Estimated numbers of cases of selected diseases attributable to obesity, South East PCTs

Obese adults (2008) / Hypertension (2010) / Cardiovascular disease (2010) / Diabetes (2005)
Disease-specific attributable proportion (%) / 100 / 24.1 / 20.2 / 24.1
South East GOR / 1,606,600 / 500,700 / 85,000 / 75,800
South Central SHA / 744,100 / 229,000 / 38,900 / 34,300
Berkshire East PCT / 70,700 / 19,600 / 3,200 / 3,300
Berkshire West PCT / 81,900 / 23,400 / 3,800 / 3,400
Buckinghamshire PCT / 84,600 / 28,800 / 4,300 / 4,300
Hampshire PCT / 238,900 / 77,200 / 13,700 / 11,200
Isle Of Wight PCT / 26,500 / 10,600 / 2,000 / 1,700
Milton Keynes PCT / 48,400 / 13,000 / 1,900 / 1,700
Oxfordshire PCT / 112,200 / 33,200 / 5,600 / 4,900
Portsmouth City Teaching PCT / 37,500 / 10,900 / 2,000 / 1,700
Southampton City PCT / 43,800 / 12,400 / 2,300 / 2,000
South East Coast SHA / 862,900 / 267,300 / 46,700 / 41,500
Brighton & Hove City PCT / 47,600 / 14,300 / 2,600 / 2,300
East Sussex Downs & Weald PCT / 65,100 / 24,700 / 4,700 / 3,800
Eastern & Coastal Kent PCT / 158,500 / 48,400 / 8,700 / 7,500
Hastings & Rother PCT / 34,800 / 13,400 / 2,800 / 2,200
Medway PCT / 63,400 / 14,400 / 2,400 / 2,200
Surrey PCT / 186,800 / 63,100 / 9,500 / 9,200
West Kent PCT / 144,200 / 38,800 / 6,700 / 6,100
West Sussex PCT / 162,900 / 50,200 / 9,300 / 8,100

Notes and sources:

Obese adults: Estimated number of persons aged 16+ with BMI 30+, 2008. Health Survey for England. (tinyurl.com/hp10data)

Hypertension: Estimated number of persons aged 16+ with hypertension, 2010. ERPHO Modelled Estimates of Prevalence of Diabetes. (bit.ly/aphoprevmodels)

Cardiovascular disease: Estimated number of persons with CVD including angina, heart attack or stroke, 2010. (Attributable proportion for CVD based on average of myocardial infarction (13.9%), angina pectoris (20.5%) and stroke (25.8%) proportions weighted by the respective number of hospital admissions in England in 2008/9.) ERPHO Modelled Estimates of Prevalence of CVD (bit.ly/aphoprevmodels); Information Centre. Hospital Episode Statistics for England - Inpatient Statistics, 2008/9. (tinyurl.com/hesipstats)

Diabetes (Type 2): Estimated number of persons aged 16+ with diagnosed and undiagnosed Type 2 diabetes, 2005. YHPHO PBS Diabetes Prevalence Estimates. (bit.ly/aphoprevmodels)

The same approach can be used to produce estimates of the number of hospital inpatient finished consultant episodes (FCEs) for these diseases. While constituting a relatively small proportion of the overall number of people with diagnosed and undiagnosed hypertension, cardiovascular disease and diabetes, the numbers of inpatient admissions in Table 4 do provide a broad estimate of the impact that obesity has on secondary care services.

These estimates have been calculated by applying the attributable proportions for hypertension, cardiovascular disease and diabetes contained in Table 1 to the average annual number of hospital inpatient FCEs for these diseases among residents of the 17 South East PCTs over the three year period 2007/8 to 2009/10. The figures represent the number of admissions rather than the number of individual patients, and have been rounded to nearest ten.

Table 3: Estimated number hospital inpatient FCEs for selected diseases attributable to obesity, South East PCTs, annual average for 2007/8 to 2009/10

Hypertension / Cardiovascular disease / Diabetes
Disease-specific attributable proportion (%) / 24.1 / 20.2 / 24.1
South East GOR / 700 / 11,090 / 1,770
South Central SHA / 270 / 5,390 / 860
Berkshire East PCT / 40 / 580 / 90
Berkshire West PCT / 20 / 340 / 60
Buckinghamshire PCT / 30 / 530 / 70
Hampshire PCT / 90 / 2,060 / 320
Isle Of Wight PCT / 10 / 230 / 20
Milton Keynes PCT / 20 / 310 / 70
Oxfordshire PCT / 40 / 640 / 100
Portsmouth City Teaching PCT / 10 / 400 / 70
Southampton City PCT / 10 / 320 / 60
South East Coast SHA / 440 / 5,690 / 910
Brighton & Hove City PCT / 20 / 270 / 90
East Sussex Downs & Weald PCT / 30 / 480 / 80
Eastern & Coastal Kent PCT / 60 / 1,110 / 160
Hastings & Rother PCT / 20 / 330 / 50
Medway PCT / 20 / 310 / 60
Surrey PCT / 170 / 1,290 / 190
West Kent PCT / 50 / 810 / 150
West Sussex PCT / 70 / 1,080 / 150

Notes:

The estimated numbers of finished consultant episode (FCEs) have been calculated by applying the attributable proportions for hypertension (I10-I15), cardiovascular disease (angina I20, myocardial infarction I21-I22, stroke I61-I64) and diabetes (E10-E14) to the average annual number of FCEs for those diseases for the three years 2007/8 (HES inpatient universe v9), 2008/9 (HES inpatient universe v14) and 2009/10 (HES provisional universe m13 v13) (accessed 08-Oct-2010).

Some totals may not sum as all numbers have been rounded to the nearest ten.

Finished consultant episodes (FCEs): A FCE is defined as a continuousperiod of admitted patient care under one consultant within onehealthcare provider. FCEs are counted against the year in whichthey end. Please note that the figures do not represent the numberof different patients, as a person may have more than one episodeof care within the same stay in hospital or in different stays in thesame year.

Source: Hospital Episode Statistics (HES), The NHS InformationCentre for health and social care.

6.Effective prevention and treatment of obesity

The NOO publications Treating adult obesity through lifestyle change interventions[3] and Treating child obesity through lifestyle change interventions[4]summarise the systematic reviews of effective treatments undertaken by NICE and the Cochrane Collaboration. NOO conclude that while “there is sufficient evidence to justify well-targeted action on obesity”, the evidence base “tends to lack detail on the effectiveness of specific approaches or individual programmes, with the result that guidance tends to be somewhat general in nature”. Accordingly, when commissioning weight management services, it may “be difficult to demonstrate the effectiveness of a specific intervention within a short timescale given the complex interplay of different environmental, biological and social determinants”.

The NOO summary of the NICE and Cochrane reviews details a range of lifestyle (non-pharmacological, non-surgical) interventions that are effective in reducing obesity. These include:

  • the importance of multi-component tailored interventions: eg. interventions should be multi-component and focus on diet and physical activity together, rather than attempting to modify either diet or physical activity alone
  • physical activity component: eg. the physical activity component of interventions should focus on activities that fit easily into people’s everyday lives and are tailored to people’s individual preferences and circumstances
  • dietary component: eg. the dietary element of interventions should aim to improve diet and reduce energy intake, and should bring together a number of components such as dietary modification, targeted advice, family involvement and goal setting
  • behavioural component: eg. behavioural interventions for adults should include strategies tailored to the needs of the individual including self monitoring of behaviour and progress, stimulus control, goal setting, and so on
  • commercial and community-based weight management programmes: eg. self-help, commercial or community weight management programmes should only be commissioned if they follow best practice eg. they help people assess their weight and decide on a realistic healthy target weight (people should usually aim to lose 5-10percentof their original weight)
  • further recommendations: NOO make a number of additional recommendations eg. there is good evidence for the effectiveness of brief interventions in primary care in promoting physical activity, and these may be useful components of any coordinated obesity prevention intervention.

NOO have also published a briefing paper for commissioners on Preventing childhood obesity through lifestyle change interventions[5]. This found rather less evidence of effective approaches to preventing child obesity, but did contain some recommendations: eg. “programmes should be multi-component interventions, ideally addressingdiet and physical activity together; and should involve family and peer support where possible, usingbehavioural programmes aimed at changing diet and physical activitypatterns”.

7.Economic effectiveness of interventions aimed at preventing and treating obesity

The NHS Economic Evaluation Database (tinyurl.com/ecevda) and Health Technology Assessment Database (tinyurl.com/htadbase)both contain a number of health economics studies which attempt to evaluate the cost effectiveness of a range of interventions aimed at promoting healthy weight. The focus of the majority of these, however, is on individual-level clinical interventions; there are relatively few studies focusing on the cost effectiveness of population-level weight management programmes.

The evidence that is availablesuggeststhatthe following approachesmay be cost effective:

Children

  • School-based obesity prevention programmes that useintervention materials in the teaching of a range of subjectsand which focus on decreasing television viewing, decreasing the consumption of high-fat foods, increasing fruit and vegetable intake, and increasing moderate and vigorous physical activity[6].
  • Family-based group behaviouraltherapies that focuses on diet, activity, behavioural change techniques, parenting, and coping with psychosocial problems[7].

Adults