New JSNA: This is the test site for the new Joint Strategic Needs Assessment

Obesity - adult & child

Introduction

Overweight and obesity is now becoming a global and not just a Western World issue. In Africa, the number of children who are overweight or obese has almost doubled since 1990 from 5.4 million to 10.3 million.

Obesity is defined as carrying an excessive amount of body fat that is a risk to health and results when a person takes in more energy (calories) from food and drink than they use up through normal bodily processes (such as growth, repair, breathing, digestion and physical activity) over a prolonged period of time.

The Health Survey for England 2013 reported that 67% of men and 57% of women are now overweight or obese. Obesity is a significant factor contributing to the rise in incidence of type 2 diabetes, heart disease, fatty liver disease and some forms of cancer.

The greatest risk of being overweight or obese is Type 2 diabetes (see Diabetes JSNA section for further information), which is a progressive disease with serious co-morbidities including heart disease, stroke, blindness, kidney failure and limb amputations.

In adults, a person's weight is considered in relation to height in order to assess if it falls within a healthy range. Body Mass Index (BMI) is calculated by dividing weight in kilograms by height in metres, squared. 'Overweight' is defined as having a 'Body Mass Index' (BMI) of 25-29.9. 'Obesity' is defined as having a 'BMI' greater than 30. In Black, Asian and other ethnic minority groups, because the incidence of long-term health conditions including type 2 diabetes, coronary heart disease and stroke is up to 6 times higher (and they occur from a younger age) than in the white European population, lower BMI thresholds for the prevention of ill health have been set. For Asian (South Asian and Chinese), Black African and African-Caribbean populations, National Institute for Clinical Excellence (NICE) recommends using thresholds of 23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk. These thresholds should act as a trigger for action to prevent type 2 diabetes.

Waist circumference is another commonly used measure of adiposity. The World Health Organisation has advised that an individual's risk of obesity-related co-morbidities is more accurately described by considering BMI and waist circumference in combination. People of South Asian Origin are particularly prone to central adiposity, which in turn presents a health risk at a lower BMI.

In children, weight status if measured using age and sex appropriate growth charts. The National Obesity Observatory notes that in England the British 1990 (UK90) growth reference charts should be used, to determine the weight status of an individual child and for population surveillance purposes.

What do we know?

The causes of obesity are complex and multifaceted. The Foresight Report (2007) refers to a "complex web of societal and biological factors that have, in recent decades, exposed our inherent human vulnerability to weight gain". These include:

  • Biology: the influence of genetics and ill health;
  • Activity environment: for example, a decision to cycle to work may be influenced by road safety, air pollution or provision of a cycle shelter.
  • Physical Activity levels during the day.
  • Societal influences: such as the media, education, peer pressure or culture.
  • Individual psychology: for example the drive for particular foods or physical activity patterns or preferences.
  • Food environment: for example the availability and quality of fruit and vegetables near home may influence a decision to eat these foods.
  • Food consumption: the quality and quantity (portion sizes) of food and frequency of eating.

The risk of obesity can be passed down through generations due to both biological and behavioural influences. Malnutrition, both fetal or in early childhood (for example due to poor maternal nutrition), can affect gene function. Babies born with a low birth weight or who are 'short for age' can be at increased risk of overweight and obesity in later life, especially if exposed to an obesiogenic environment.

Conversely, a mother who is obese or who has either pre-existing or gestational diabetes when she becomes pregnant will predispose her child to carrying an increased number of fat cells which is associated with obesity and other metabolic diseases.

Children often 'inherit' socio-economic status, dietary and physical activity behaviours and norms from their families. Both maternal and paternal obesity have been identified as risk factors for childhood obesity and the effects are additive (i.e. the risk is even greater if both parents are obese).

Obesity prevalence has a strong association with socio-economic inequalities, prevalence being highest amongst those from poorer backgrounds. An increased risk of obesity has also been identified in subgroups such as migrant and indigenous children; this is thought to be due to them rapidly trying to adapt to a different culture and having poor access to public health information.

There is little data available nationally on obesity prevalence in British Minority Ethnic (BME) groups living in the UK. However, from the data available, women from Black African groups appear to have the highest prevalence of obesity and men from Chinese and Bangladeshi groups have the lowest. Women appear to have a higher prevalence in virtually all minority ethnic groups, particularly amongst Pakistani, Bangladeshi and Black African communities. These differences have been linked to diet, lower levels of physical activity and socio-economic status. In some cultures, the perception of what is a healthy weight varies, particularly in relation to children and women. Overweight and obesity can be seen as a sign of strength or wealth, which perpetuates the prevalence within these communities. Information in the ethnicity chapter of the JSNA describes the growth in South Asian and Black / Black African communities in Reading over the last 10 years; which should be considered when planning obesity service provision.

In children, data from the National Child Measuring Programme broken down by ethnicity shows that in Reception, obesity is most prevalent in Black African, Black Other and Bangladeshi boys. By year 6, boys from all BME groups have a higher prevalence of obesity than white British. In girls in Reception and Year 6, obesity prevalence is highest in Black African and Black Other groups.

Although little data is available, people with physical or learning disabilities tend to have a higher propensity to obesity and lower physical activity levels than the general population. (See the National Obesity Observatory Paper on Obesity and Disability Paper 2013 for more information)

The 'Obesity and Mental Health' paper published by the National Obesity Observatory in 2011

concluded that there are strong associations between mental health and obesity. In addition, research found correlations between obesity and significant childhood maltreatment, which tends to manifest in later life as a result or trauma and poor attachment.

Facts, Figures, Trends

  • Nationally, the prevalence of obesity among adults rose from 15% in 1993 to 25% in 2013.
  • Men have a higher prevalence of obesity than women (26% compared to 24%), and are more likely to be overweight (41% compared to 33%).
  • The proportion of adults with a raised waist circumference increased from 20% to 34% among men and from 26% to 45% among women between 1993 and 2012 (Source: The Health & Social Care Information Centre)
  • The prevalence of obesity and overweight changes with age. Prevalence of overweight and obesity is lowest in the 16-24 years age group and generally increases with age; there is a decline in prevalence among those aged 75 years and over.
  • Men and women living in low income households have the highest prevalence of obesity and those living in high income households have the lowest. These differences are particularly marked among women: women living in the lowest income households have double the prevalence of obesity (31%) compared to those living in the highest income households (15%).
  • Women from Black African groups appear to have the highest prevalence of obesity and men from Chinese and Bangladeshi groups have the lowest.

Local Data - Adult Obesity in Reading:

The GP Obesity Register in Reading includes a list of patients aged 16 or over who have a recorded body mass index (BMI) of 30 or higher in the last 12 months. People who have not been to see their GP or are not registered at a GP practice will not be included in these figures. The indicator changed slightly for 2013/14, so cannot be compared with previous year's figures.

Reading is covered by 2 different Clinical Commissioning Groups (CCG) (North & West Reading CCG and South Reading CCG).
On 31/3/2014, 6,747 patients in North & West Reading CCG were on the GP Obesity Register. This was 7.7% of the population aged 16 or over and was significantly lower than the comparator CCG Group. South Reading CCG's obesity prevalence was lower at 7.2%, which was similar to its comparator group. This included 7,911 patients. Both CCGs had a significantly lower prevalence of obesity compared with the national level of 9.4%.

Source: Health & Social Care Information Centre, Quality Outcomes Framework (2014)

Graph 1 - Prevalence of obesity for people aged 16 or over (2013/14)

image1

(Source: Health and Social Care Information Centre, (Quality Outcomes Framework 2014)

Local Data - Childhood Obesity in Reading:

Reception Year:

Data from the National Child Measuring Programme shows that the levels of childhood overweight in Reading in Reception year children remained largely in line with the England average. The prevalence of overweight peaked in 2009/10 but has since gradually declined and now sits in line with the south east England average. (See Graph 2)

Graph 2 - Prevalence of overweight children in Year R, with associated 95% confidence intervals in Reading LA, 2006/07 to 2013/14

image2

Source: National Child Measuring Programme

The prevalence of obesity in Reading in Reception year children has consistently remained above the England and South East average (See Graph 3), however, after peaking in 2009 / 10, there has been a progressive decrease towards the England average, with the exception of 2013/14, where there was a slightly higher prevalence of overweight, but figures still fell in line with the South East average.

Graph 3 - Prevalence of obese children in Year R, with associated 95% confidence intervals in Reading LA, 2006/07 to 2013/14.

image3

Source: National Child Measuring Programme.

Recently published 2014/15 figures show a slight increase (0.4%) in the prevalence of overweight in Reception but a decrease in the number of pupils whose weight falls into the obesity category (11.1% in 2013/14 to 9.7% in 2014/15). Note that a different cohort of children will be measured each year rather than comparing the same group longitudinally.

Year 6 - Reading:

Between 2008-2011, the prevalence of overweight in Year 6 children in Reading was in line with the South East and England average (see graph 4). In 2011/12, Reading figures spiked, but have since progressively decreased to again mirror the South East average.

Graph 4 - Prevalence of overweight children in Year 6, with associated 95% confidence intervals in Reading LA, 2006/07 to 2013/14.image4

Source: National Child Measuring Programme.

The prevalence of obesity in Year 6 Children in Reading increased year on year between 2006/07 and 2009/10 before making a progressive decline towards the England average, with the exception of a slight increase in 2013/14 (see graph 5). However, prevalence in Reading has consistently remained significantly higher than the average for the South East of England.

Graph 5 - Prevalence of obese children in Year 6, with associated 95% confidence intervals in Reading LA, 2006/07 to 2013/14

image5

Source: National Child Measuring Programme

Recently published data from the 2014/15 National Child Measure Programme(NCMP) shows a slight increase in the levels of overweight (14.6% to 15%) and obesity (19.9% to 20.4%) in Year 6 children in Reading. Note that a different cohort of children will be measured each year rather than comparing the same group longitudinally.

Bariatric Surgery in Berkshire:

Bariatric surgery is recommended for patients (generally only adults, not children or teenagers) where all appropriate non-surgical interventions have been ineffective and a patient has a BMI greater than or equal to 40 (morbidly obese) or a lower BMI and significant health problems related to their weight. Bariatric surgery may also be recommended as first line treatment for patients with a BMI of 50+

Based on Central Southern Commissioning Support Unit data, Berkshire has seen a 32% increase of spending over the last 5 years (2010/2011-2014/2015) on initial bariatric surgery procedures. The procedures have moved away from the Gastric band to Gastric bypass, which is more clinically effective. The cost of bypass has remained relatively stable for this period, but has seen a very slight drop in cost of the procedures from 2010/2011-2014/15.

Levels of bariatric surgery and expenditure in Reading by Clinical Commissioning Group.

CCG Name

2013-14 Admissions

2013-14

Cost

2014-15 Admissions

2014-15

Cost
 

2015-16 Admissions

(Month 1-6)

2015-16

Cost
 

Total Admissions

Total Cost

North & West Reading CCG

14

£41,183

15

£40,494

11

£45,242

40

£126,919

South Reading CCG

14

£32,989

15

£53,215

8

£21,351

37

£107,555

Source: Prepared by Berkshire West Informatics.

Current activities and services:

Children:

Breast-feeding peer support groups

Breastfeeding contributes to the health of mother and child in both the short and long term and provides all the nutrients a baby needs. There is mounting evidence that breast feeding can help to protect against overweight and obesity in childhood (WHO 2014). Current UK policy is to promote exclusive breastfeeding (feeding only breast milk) for the first 6 months, continuing for as long as the mother and baby wish while gradually introducing a more varied diet. Breast-feeding peer support groups in Reading are listed on the Breastfeeding Network website.

Health Visitors - The Health Visiting Service workforce consists of Specialist Community Public Health Nurses (SCPHN) and teams who provide expert information, assessments and interventions for babies, children and families including first time mothers and fathers and families with complex needs. Health visitors help to empower parents to make decisions that affect their family's health and wellbeing and their role is central to improving the health outcomes of populations and reducing inequalities. This includes advice on; Breastfeeding (initiation and duration), healthy weight, healthy nutrition and physical activity.

School Nurses - The School Nursing (SN) Service in delivers an evidence based service that provides public health interventions and health care support to school age children and their families to enable children to make the most of their education and wider social opportunities to improve health and health outcomes for children and families. The SN service leads, co-ordinates and provides services for children and young people as set out in the Healthy Child Programme 5 - 19 years, including working with others to deliver universal services. Priorities include; Weight and height measurements to be offered to all children attending state funded primary school children who are in Reception Year (age 5) and Year 6 (aged 10, 11) in accordance with NCMP guidance. Also, SN offer tier 1 targeted support and advice to families with overweight/obese children on diet /healthy lifestyles and onward referral if required for children in Reception.

Let's Get Going: Public Health commissions a weight management and healthy lifestyle service for children aged 7-12 years which offers family based advice on healthy eating, behaviour change and a practical physical activity element in local schools and a community site. The programme follows NICE guidance on community based weight management interventions for children.

Adults:

A wide range of opportunities to be physically active are available in Reading as detailed in the physical activity module. These include a health walks programme, exercise on referral programme, cycle training (for adults and children) and the 'Beat the Street' walking and cycling project.

Tier 2 weight management:

Eat 4 Health is a tier 2, evidence-based programme commissioned across West Berkshire for adults (over 16 years) with a BMI below 25. The programme includes health eating, behaviour change and a physical activity element as recommended in NICE guidance.

Tier 4 Bariatric Surgery:

Commissioned by NHS England and provided at Royal Berkshire Hospital for Berkshire.

NICE recommends that bariatric surgery should be considered for patients who meet the following criteria:

  1. Patients have a BMI of 40kg/m2 or more, or between 35kg/m2 and 40kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
  2. All appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss
  3. The patient has been receiving or will receive intensive management in a tier 3 service.

National & Local Strategies (Current best practices)

What is this telling us?

Obesity is a largely preventable condition, the prevalence of which has increased rapidly in the last twenty years. Obesity has been likened to smoking in terms of its associated disease burden ('Securing good health for the whole population'; Wanless 2004) significantly increasing the risk of numerous long term conditions including type 2 diabetes, heart disease and high blood pressure. Obesity is also known to negatively impact on educational attainment, mental health, respiratory and musculoskeletal disorders and for those with a BMI over 40, it can shorten a person's lifespan by 8-10 years.

Obesity has an estimated socio-economic impact totalling an estimated £27 billion a year.

In Reading, £234,474 was spent on admissions for bariatric surgery; this equates to £1,523 per patient. In contrast, sending a person to a 10 week, local authority tier 2 programme before their weight becomes severe enough to necessitate surgery would cost less than £160 per person.

Prevention and early intervention are key strategies for reversing the tide of obesity.

Due to the multi-faceted causes of overweight and obesity, a cohesive approach supported by multi-agency working and tailored to the needs of the local population is needed in order to reverse the trend of rising obesity prevalence. Interventions at all levels from primary prevention through to surgical intervention with clear referral pathways play an important role in tackling overweight and obesity at an individual and population level as described below:

Tier 1 / Primary prevention - Commissioned by Local Authorities,

  • Raising awareness of why a healthy weight is important, what a healthy weight is for adults and children and how to maintain this. For example through supporting National campaigns (e.g. Change 4 Life, One You), the NCMP and a Making Every Contact Count-style approach to raising the issue.
  • Action throughout the life course to enable and encourage people to move more on a daily basis through structured or unstructured physical activity, in line with Chief Medical Officer Guidelines.  This includes active play, walking, cycling and other forms of active travel, exercise and sport; both through healthy school / workplace initiatives and during leisure time. In addition, encouraging children and adults to minimise prolonged periods of sedentary behaviour such as screen time.
  • Appropriate information about healthy weight, the impact of maternal obesity and appropriate infant feeding; ideally given to parents before conception, but also during pregnancy and in infancy may help to reduce the risk of excess weight or inappropriate feeding behaviours during a child's early developmental stages.
  • Action to ensure that residents can access affordable, culturally acceptable, healthy food inside and outside the home and know how to prepare basic meals from scratch.

Tier 2 services: Commissioned by Local Authorities.

  • Lifestyle based programmes for adults and children in community settings, which adhere to NICE guidance; including advice on healthy eating, physical activity opportunities and behaviour change.
  • These programmes should aim to reach people who have become overweight, with a view to preventing them from becoming obese and suffering from the associated increased risk of co-morbidities and economic impact.

Tier 3 services: Commissioned by CCGs

  • Specialist interventions delivered by a multidisciplinary team for individuals who have higher BMIs, co-morbidities or have generally been unsuccessful in undergoing tier 1 or 2 interventions. Tier 3 interventions will include Dietetic, physical activity and psychological support services.
  • Tier 3 services can help to reduce the number of patients who go on to require costly, invasive bariatric surgery and provide intensive lifestyle support for those who do undergo surgery to support the behaviour changes required for the procedure to have long-term success.

Tier 4 services: Commissioned by NHS England.

There are 3 main procedures used in the UK; these are adjustable gastric banding, gastric bypass and sleeve gastrectomy. In cases of morbid obesity, surgery is often the most effective intervention for achieving sustained weight loss; however, the risks associated with the procedure and occurrence of adverse events following surgery are much greater than with non-surgical interventions.

Clear, consistent, two-directional referral pathways need to be developed between providers of different tiers of service in order to ensure that people follow an appropriate and effective programme of long term support to help them achieve and maintain a healthier weight.

What are the key inequalities?

Reading mirrors National trends in terms of the relationship between obesity prevalence and deprivation. Obesity prevalence has a strong association with socio-economic inequalities, the prevalence being highest amongst those from poorer backgrounds. Men and women in unskilled, manual occupations are more likely to be obese than those in professional occupations. Work to prevent and reduce obesity needs to take account of and be accessible to those living in deprivation in order to help narrow the inequality gap.

Obesity prevalence varies with age; the lowest levels in adults are seen in the 16-24 age group, after which, prevalence increases with age, up until 75+ years, where there is a decline. This pattern is evident in both males and females (Health Survey for England 2008-2012).

What are the unmet needs / service gaps?

Currently the prevalence of overweight and obesity amongst adults and children in Reading by far exceeds the capacity of intervention programmes to tackle the issue. A multi-organisational approach encouraging societal movement towards healthy eating and physical activity is required. This needs to start in early years settings and extend across the lifespan to help ensure that behaviours which support the attainment of a healthy weight are established from a young age and supported by parents, carers, in educational settings and by healthcare professionals.

Currently, there are tier 2 weight management programmes commissioned for school aged children and adults in Reading, but places are limited. In addition, a range of active play, active travel and physical activity / sporting opportunities support the maintenance of a healthy weight throughout life (see physical activity chapter of JSNA).

There are currently no commissioned programmes for parents / carers focused on healthy growth and weight for children in early years settings; although the opportunity for families and young people to be supported and get advice on healthy child growth is accessible through health visiting and school nursing services. Physical activity, play and some food related sessions are timetabled in children's centres.

There are currently no dedicated healthy lifestyle / weight management programmes targeted at teenagers, this is an important life stage where young people are becoming increasingly more independent and making choices about their eating and exercise habits.

There is currently a gap in the provision of Tier 3 (non-surgical, specialist) obesity services across Berkshire; which are recommended as a pre-surgical intervention for a 12-24 month period. Tier 3 services include psychological behaviour change, Dietetic and Physical Activity elements.

In some cases, a tier 3 intervention may prevent the need for referral to tier 4. However, even for patients who are subsequently referred for surgery, the long-term success of their treatment still depends on their ability to make lifestyle changes, which can be supported through a tier 3 programme. At the time of writing, Public Health teams in the West of Berkshire are working with CCGs to explore how this gap can be addressed.

This section links to the following sections in the JSNA:

Diabetes

Cardiovascular Disease

Cancer

Liver Disease

Physical Activity

References

Report of the Commission on Ending Childhood Obesity.

National Obesity Observatory

NCMP Local Authority Profile - Public Health England

NICE: Walking and cycling: local measures to promote walking and cycling (November 2012)

NICE: Managing overweight and obesity among children and young people (October 2013)

NICE: Managing overweight and obesity in adults (May 2104)

NICE: Behaviour change: individual approaches (January 2014)

NICE: Obesity: working with local communities (November 2012)

NICE: Obesity: identification, assessment and management in children, young people and adults (November 2014)

Reis JP, Loria CM, Sorlie PD, et al. Lifestyle factors and risk for new-onset diabetes: a population-based cohort study. Ann Intern Med 2011;155(5):292-9. doi: 10.7326/0003-4819-155-5-201109060-00006.

Report of the commission on ending childhood obesity (2016)

Switch To High Contrast Mode