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HEALTHY WEIGHT, HEALTHY LIVES: A TOOLKIT FOR DEVELOPING LOCAL STRATEGIES
DHInformatIonreaDerBoX
PolicyHR/Workforce Management Planning Clinical
Estates Commissioning IM & T Finance Social Care/Partnership Working
Documentpurpose Best Practice Guidance
Gatewayreference 10224
title Healthy Weight, Healthy Lives: A toolkit for developing local strategies
author Dr Kerry Swanton for the National Heart Forum/Cross-Government Obesity Unit/Faculty of Public Health
Publicationdate October 2008
targetaudience PCT CEs, Directors of PH, Directors of Nursing, Local Authority CEs, Directors of Children’s SSs
Circulationlist SHA CEs
Description This toolkit is intended as a resource to help those working at a local level to plan and coordinate comprehensive strategies to prevent and manage overweight and obesity.
Crossreference Healthy Weight, Healthy Lives: A cross government strategy for England; Healthy Weight, Healthy Lives: Guidance for local areas
Supersededdocuments Lightening the Load: Tackling overweight and obesity
actionrequired N/A
timing N/A
Contactdetails National Heart Forum Tavistock House South Tavistock Square London WC1H 9LG www.heartforum.org.uk
Cross-Government Obesity Unit Wellington House 133-155 Waterloo Road London SE1 8UG www.dh.gov.uk
Faculty of Public Health 4 St Andrews Place London NW1 4LB www.fph.org.uk
forrecipientuse
HealtHy weigHt, HealtHy lives: a toolkit for developing local strategies
WrittenbyDrKerrySwantonConsultanteditor:Professoralanmaryon-DavisFFPHFRCPFFSEMEditedbyWordworks
ProducedbythenationalHeartforuminassociationwiththefacultyofPublicHealth,theDepartmentofHealth,theDepartmentforChildren,Schoolsandfamiliesandforesight,GovernmentofficeforScience
Contents iii
Contentsforeword 1
executivesummary 2
Sectionaoverweightandobesity:thepublichealthproblem 7
Whatare‘overweight’and‘obesity’? 8Prevalenceandtrendsofoverweightandobesity 9Thehealthrisksofoverweightandobesity 22Thehealthbenefitsoflosingexcessweight 28Theeconomiccostsofoverweightandobesity 29Causesofoverweightandobesity 30
SectionBtacklingoverweightandobesity 33
Governmentactiononoverweightandobesity 35Children:healthygrowthandhealthyweight 37Promotinghealthierfoodchoices 40Buildingphysicalactivityintoourlives 43Creatingincentivesforbetterhealth 46Personalisedsupportforoverweightandobeseindividuals 47
SectionCDevelopingalocaloverweightandobesitystrategy 53
Understandingtheprobleminyourareaandsettinglocalgoals 58Localleadership 61Choosinginterventions 63Monitoringandevaluation 68Buildinglocalcapabilities 70Toolsforhealthcareprofessionals 72
SectionDresourcesforcommissioners 75
ToolD1 Commissioningforhealthandwellbeing:achecklist 79ToolD2 Obesityprevalenceready-reckoner 91ToolD3 Estimatingthelocalcostofobesity 95ToolD4 Identifyingprioritygroups 101ToolD5 Settinglocalgoals 105ToolD6 Localleadership 109ToolD7 Whatsuccesslookslike–changingbehaviour 117ToolD8 Choosinginterventions 119ToolD9 Targetingbehaviours 133ToolD10 Communicatingwithtargetgroups–keymessages 139ToolD11 Guidetotheprocurementprocess 145ToolD12 Commissioningweightmanagementservicesforchildren,
youngpeopleandfamilies 151ToolD13 Commissioningsocialmarketing 155ToolD14 Monitoringandevaluation:aframework 159ToolD15 Usefulresources 171
iv Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Sectioneresourcesforhealthcareprofessionals 191
ToolE1 Clinicalcarepathways 195ToolE2 Earlyidentificationofpatients 201ToolE3 Measurementandassessmentofoverweightandobesity–ADULTS 203ToolE4 Measurementandassessmentofoverweightandobesity–CHILDREN 211ToolE5 Raisingtheissueofweight–DepartmentofHealthadvice 217ToolE6 Raisingtheissueofweight–perceptionsofoverweighthealthcare
professionalsandoverweightpeople 221ToolE7 Leafletsandbookletsforpatients 225ToolE8 FAQsonchildhoodobesity 227ToolE9 TheNationalChildMeasurementProgramme(NCMP) 231
references 233
acronyms 243
Index 245
acknowledgements 248
ListoffiguresFigure1 Prevalenceofoverweightandobesityamongadults,byageandsex,
England,2006 11Figure2 Futuretrendsinobesityamongadults,2004-2050 14Figure3 Prevalenceofoverweightandobesityamongchildrenaged2–15,
byageandsex,England,2006 17Figure4 Obesitytrendsamongchildrenaged2-15,England,bysex,1995-2006 20Figure5 Futuretrendsinobesityamongchildrenandyoungpeopleagedunder
20years,2004-2050 21Figure6 EstimatedfutureNHScostsofelevatedBodyMassIndex,2007-2050 29Figure7 Theeatwellplate 41Figure8 A‘roadmap’fordevelopingalocaloverweightandobesitystrategy 56
ListoftablesTable1 Prevalenceofobesityandcentralobesityamongadultsaged16
andoverlivinginEngland,byethnicgroup,2003/2004 12Table2 Prevalenceofobesityamongchildrenaged2-15livinginEngland,
byethnicgroup,2004 18Table3 Relativerisksofhealthproblemsassociatedwithobesity 22Table4 Thebenefitsofa10kgweightloss 28Table5 FuturecostsofelevatedBodyMassIndex 29Table6 Criticalopportunitiesinthelifecoursetoinfluencebehaviour 36Table7 Standardpopulationdietaryrecommendations 40Table8 Physicalactivitygovernmentrecommendations 43Table9 Clinicalguidanceformanagingoverweightandobesityinadults,
childrenandyoungpeople 48
Contents v
this toolkit is intended as a resource to help those working at local level to plan, coordinate and implement comprehensive strategies to prevent and manage overweight and obesity. It focuses on multi-sector partnership approaches. although specifically tailored for england, much of the information and guidance in the toolkit applies equally to Scotland, Wales and northern Ireland.
this toolkit and updates can be downloaded from www.heartforum.org.uk or www.fph.org.uk or www.dh.gov.uk. these websites provide up-to-date information about developments in the area of overweight and obesity.
Foreword 1
forewordWeareallawarefrommediareportsthatoverweightandobesityareontheincrease.InEnglandalmosttwo-thirdsofadultsandathirdofchildrenareeitheroverweightorobese.FuturetrendsprovidedbytheGovernmentOfficeforScience’sForesightmakeitclearthatwithouteffectiveactionthiscouldrisetoalmostnineintenadultsandtwo-thirdsofchildrenbeingoverweightorobeseby2050.
Thisiswhytacklingoverweightandobesityisanationalgovernmentpriority.Thenationalobesitystrategy,Healthy Weight, Healthy Lives: A cross-government strategy for England,1setoutthefirststepstomeetingthechallengeofexcessweightinthepopulationwithanewambition:to be the first major country to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to 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.
However,thisambitionwillonlybemetifthewholeofsocietyisengaged.Primarycaretrustsandlocalauthoritieswillneedtoplayakeyroleinempoweringtheircommunitiestosucceedintacklingtheobesityepidemic.TheGovernmenthasalreadyprovidedlocalareaswithguidanceonwhattheycandotopromotehealthyweightandtackleobesity.Healthy Weight, Healthy Lives: Guidance for local areas2setsoutaframeworkthatprimarycaretrustsandlocalauthoritiescanusetodeveloplocalplans.Thistoolkit,Healthy Weight, Healthy Lives: A toolkit for developing local strategies,willprovidemoredetailedsupportforlocalareasandwillhelpyoutoconsiderthebestapproachestotacklingoverweightandobesityinyourlocalarea,takingintoaccountthespecificneedsofyourlocalpopulationandthesocioeconomicandpsychologicalexperiencestheymayface.
Thisisafast-movingarena.Thatiswhywearecommittedtoensuringthatlocalareasarekeptuptodatewiththelatestdevelopmentsbyregularonlineupdates.Wehopethatthetoolkitwillhelpyoutodevelopthemostappropriateandsuccessfulstrategyfortheneedsofyourcommunity.
Let’smakeEnglandthefirstcountrytosuccessfullycurbtheobesityepidemic.
SirLiamDonaldsonChief Medical Officer
ProfessorKlimmcPhersonChair NationalHeartForum
Professoralanmaryon-DavisPresident FacultyofPublicHealth
2 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
executivesummaryNearlyaquarterofpeopleinEnglandareobese.3Unlesswetakeeffectiveaction,ithasbeenestimatedthataboutone-thirdofadultsandone-fifthofchildrenaged2-10yearswillbeobeseby2010,4andnearly60%oftheUKpopulationcouldbeobeseby2050.5Thiscouldmeanadoublinginthedirecthealthcarecostsofoverweightandobesity,withthewidercoststosocietyandbusinessreaching£49.9billionby2050.5
Therapidincreaseinlevelsofoverweightandobesitycannotbeattributedtogeneticchangesasithasoccurredintooshortatimeperiod.Thismeansthatthegrowinghealthproblemsarelikelytobecausedbybehaviouralandenvironmentalchangesinoursociety.Addedtothis,overweightandobesityarehealthinequalitiesissues,withpeoplefromthelowestsocioeconomicgroupsmostatrisk.
ThistoolkithasbeendesignedtofollowonfromHealthy Weight, Healthy Lives: Guidance for local areas2andtoprovidefurthersupportfordevelopingalocalstrategytotackleoverweightandobesity.Itisprimarilyaimedatcommissionersofpublichealthservicesinbothprimarycaretrustsandlocalauthorities.Thedocumentisnotcompulsorybutisintendedtohelplocalmulti-agencyteams–includingpublichealth,healthpromotionandprimarycareprofessionals,andstrategicplannersinboththeNHSandlocalgovernmentinEngland–todevelopandimplementstrategiesandactionplanstotackletheyear-on-yearriseofoverweightandobesitythroughpreventionandmanagement.
Thetoolkitprovidesacomprehensivecollectionofinformationandtoolstoassistwithdeliveringcurrentnationalandlocalpolicies.Itpurposefullydoesnotprovidedetailedinformationaboutcareandtreatmentofoverweightandobesity,butratherofferssignpoststowellestablishedandcomprehensivematerialcoveredelsewhere.ThetoolkitcomplementstheNationalInstituteforHealthandClinicalExcellence(NICE)clinicalguidelineObesity: The prevention, identification, assessment and management of overweight and obesity in adults and children,6theForesightprogrammeTackling obesities: Future choices,5andtheGovernment’sobesitystrategy,Healthy Weight, Healthy Lives: A cross-government strategy for England.1ItsupersedesLightening the Load: Tackling overweight and obesity. A toolkit for developing local strategies to tackle overweight and obesity in children and adults.7
Thetoolkitisdesignedtoequiplocalactionteamswithusefulinformationandtoolstomeetandaddressthechallengeoftacklingoverweightandobesity.Ithasfivesections:
Section A Overweight and obesity: the public health problem Thissectionfocusesonthepublichealthcasefordevelopingalocaloverweightandobesitystrategy.Itdiscussesthetermsoverweightandobesity;providesdataontheprevalenceandtrendsofoverweightandobesityinchildrenandadults;discussesthehealthrisksofexcessweightandthehealthbenefitsoflosingexcessweight;givescurrentandpredictedfuturedirectandindirectcostsofoverweightandobesity;andfinallyexaminesthecausesofoverweightandobesityasdetailedbyForesight.5
Executive summary 3
Section B Tackling overweight and obesity Thissectionofthetoolkitlooksatwaysoftacklingoverweightandobesity.ItfocusesonthefivekeythemeshighlightedinHealthy Weight, Healthy Lives: A cross-government strategy for England1asthebasisfortacklingexcessweight:
• Children:healthygrowthandhealthyweightfocusesontheimportanceofpreventionofobesityfromchildhood.Itlooksatrecommendedgovernmentactionduringthefollowinglifestages–pre-conceptionandantenatalcare,breastfeedingandinfantnutrition,earlyyearsandschools.Importantly,italsodiscussesthepsychologicalissuesthatimpactonoverweightandobesity.
• Promotinghealthierfoodchoicesdetailsthegovernmentrecommendationsforpromotingahealthy,balanceddiettopreventoverweightandobesity.ItprovidesstandardpopulationdietaryrecommendationsandThe eatwell plate recommendationsforindividualsovertheageoffiveyears.
• Buildingphysicalactivityintoourlivesprovidesdetailsofgovernmentrecommendationsforactivelivingthroughoutthelifecourse.Itfocusesonactiontopreventoverweightandobesitybyeverydayparticipationinphysicalactivity,thepromotionofasupportivebuiltenvironmentandtheprovisionofadvicetodecreasesedentarybehaviour.
• Creatingincentivesforbetterhealthfocusesonactiontomaintainahealthyweightintheworkplacebytheprovisionofhealthyeatingchoicesandopportunitiesforphysicalactivity.ItprovidesdetailsofrecommendationsfromNICEguidance.6
• Personalisedsupportforoverweightandobeseindividualsfocusesonrecommendedgovernmentactiontomanageoverweightandobesitythroughweightmanagementservices(NHSandnon-NHSbased).Itprovidesinformationonclinicalguidanceandexamplesofappropriateservicesforchildrenandadults,andalsoreferscommissionerstotoolsfromsectionEwhichcanbesharedwiththeirlocalhealthcareprofessionals.
Section C Developing a local overweight and obesity strategy Thissectionofthetoolkitprovidesapracticalguidetohelpcommissionersinprimarycaretrusts(PCTs)andlocalauthoritiesdevelopalocalstrategythatfitsintotheframeworkforlocalactionpublishedinHealthy Weight, Healthy Lives: Guidance for local areas.2Theframeworkissplitintofivesections:
• Understandingtheprobleminyourareaandsettinglocalgoalsoutlineshowtoestimatelocalprevalenceofobesityamongchildrenandadults,howtoestimatethelocalcostofobesityandhowtoidentifyprioritygroupsandsetlocalgoals.
• Localleadershipoutlinestheimportanceofamulti-agencyapproachtotacklingobesity.Italsodiscussesthesignificanceofasenior-levelleadtocoordinateactivityanddetailshowtobringpartnerstogetherthroughasub-committeeorpartnershipboard.
• Choosinginterventionsprovidesdetailsonhowtoplanspecificinterventionstoachievelocaltargetsofreducingoverweightandobesitybychangingfamilies’attitudesandbehaviours.Italsoprovidesdetailsonhowtocommissionservices.
• monitoringandevaluationoutlinestheimportanceofmonitoringandevaluationanddetailsthekeyelementsofasuccessfulevaluationstrategy.
• Buildinglocalcapabilitiesprovidesdetailsonhowtocommissiontrainingtosupportstafftopromotephysicalactivity,goodnutritionandthebenefitsofahealthyweight.
Importantly,thissectionexplainshowthetoolsinsectionsDandEfitwithinthisframework.
4 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Section D Resources for commissioners Thissectioncontains15toolsforcommissionersofpublichealthservicesinprimarycaretrustsandlocalauthoritiesdevelopinglocalplansfortacklingchildobesity.ItfollowstheframeworkforlocalactionoutlinedinHealthy Weight, Healthy Lives: Guidance for local areas.2
Section E Resources for healthcare professionals Thissectioncontainstoolsthatpublichealthcommissionerscanprovidetohealthcareprofessionals.Ithasbeendividedintothreesub-sections:toolstohelphealthcareprofessionalsassessweightproblems,toolstohelpthemraisetheissueofweightwiththeirpatients,andtoolstohelpprofessionalsgainaccesstofurtherresources.
Executive summary 5
KEY FACTS
Overweight and obesity in England • Overweight and obesity increase the risk of a wide range of diseases and illnesses,
including coronary heart disease and stroke, type 2 diabetes, high blood pressure, metabolic syndrome, osteoarthritis and cancer.5, 6
• Obesity reduces life expectancy on average by 11 years (this is an average for white men and women who have a BMI of 45kg/m2 or over from between 20 and 30 years of age) and is responsible for 9,000 premature deaths a year.8
• The prevalence of obesity has trebled since the 1980s.8, 9 In 2006, 23.7% of men and 24.2% of women were obese and almost two-thirds of all adults (61.6%) – approximately 31 million adults – were either overweight or obese.10 (For definitions of ‘overweight’ and ‘obese’, see page 8.)
• Overweight and obesity are also increasing in children. The most recent figures (2006) show that, among children aged 2-15, almost one-third – nearly 3 million – are overweight (including obese) (29.7%) and approximately one-sixth – about 1.5 million – are obese (16%).11
• It has been estimated that, if current trends continue, about one-third of adults and one-fifth of children aged 2-10 years will be obese by 2010,4 and 60% of adult men, 50% of adult women and about 25% of all children under 16 could be obese by 2050.5
• There are social group differences in obesity, particularly for women and children – 18.7% of women in managerial and professional households are obese compared with 29.1% in routine and semi-routine households.12 A similar pattern is seen among children, with 12.4% in managerial and professional households classified as obese compared with 17.1% in semi-routine households.3
• Most evidence suggests that the main reason for the rising prevalence of overweight and obesity is a combination of less active lifestyles and changes in eating patterns.8
• Overweight and obesity have a substantial human cost by contributing to the onset of disease and premature death. They also have serious financial consequences for the NHS and for the economy. In 2007, it was estimated that the total annual cost to the NHS was £4.2 billion, and to the wider economy £15.8 billion. By 2050, it has been estimated that overweight and obesity could cost the NHS £9.7 billion and the wider economy £49.9 billion (at 2007 prices).5
AOverweight and obesity: the public health problem
8 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Thissectionofthetoolkitfocusesonthepublichealthcasefordevelopingalocaloverweightandobesitystrategy.Itdiscussesthetermsoverweightandobesity;providesdataontheprevalenceandtrendsofoverweightandobesityinchildrenandadults;discussesthehealthrisksofexcessweightandthehealthbenefitsoflosingexcessweight;givescurrentandpredictedfuturedirectandindirectcostsofoverweightandobesity;andexaminesthecausesofoverweightandobesityasdetailedbyForesight.5
What are ‘overweight’ and ‘obesity’? Overweightandobesityaretermsusedtodescribeincreasingdegreesofexcessbodyfatness.
Energy imbalance – the cause of overweight and obesity
Essentially,excessweightiscausedbyanimbalancebetween‘energyin’–whatisconsumedthrougheating–and‘energyexpenditure’–whatisusedbythebody.Henceitisanindividual’sbiology(eggeneticsandmetabolism)and/orbehaviour(eatingandphysicalactivityhabits)thatareprimarilyresponsibleformaintainingahealthybodyweight.However,therearealsosignificantexternalinfluencessuchasenvironmentalandsocialfactors(egchangesinfoodproduction,motorisedtransportandwork/homelifestylepatterns)thatpredisposebodyweight.Thus,thecausesofobesitycanbegroupedintofourmainareas:humanbiology,cultureandindividualpsychology(behaviour),thefoodenvironmentandthephysicalenvironment.5(Moreinformationonthisisprovidedonpage30.)
Effects of excess weight on health
Overweightandobesitycanleadtoincreasinglyadverseeffectsonhealthandwellbeing.Potentialproblemsincluderespiratorydifficulties,chronicmusculoskeletalproblems,depression,relationshipproblemsandinfertility.Themorelifethreateningproblemsfallintofourmainareas:cardiovasculardiseaseproblems;conditionsassociatedwithinsulinresistancesuchastype2diabetes;certaintypesofcancers,especiallythehormonallyrelatedandlargebowelcancers;andgallbladderdisease.13(Formoreontheconditionsassociatedwithobesity,seepage23.)Thelikelihoodofdevelopinglifethreateningproblemssuchastype2diabetesrisessteeplywithincreasingbodyfatness.Hence,thereisaneedtoidentifytherangesofweightatwhichhealthriskstoindividualsincrease,usingsimpleassessmentmethodssuchasBodyMassIndex(BMI).
Measuring excess weight
OverweightandobesityinchildrenandadultsarecommonlyassessedbyusingBodyMassIndex(BMI),whichisdefinedastheperson’sweightinkilogramsdividedbythesquareoftheirheightinmetres(kg/m2).However,inadultsthewaistcircumferencemeasurementisalsousedtoassessapatient’sabdominalfatcontentor‘central’fatdistribution.
ToolsE3andE4providefurtherdetailedinformationaboutthevariousmethodsformeasuringandassessingoverweightandobesityinadultsandchildren.
Overweight and obesity: the public health problem 9
Prevalence and trends of overweight and obesity Prevalence of overweight and obesity among adults
KEY FACTS
Prevalence
• Accordingtothelatestfigures(2006),23.7%ofmenand24.2%ofwomenareobeseandalmosttwothirdsofalladults(61.6%)–approximately31millionadults–areeitheroverweightorobese.Theproportionwhoareseverely(morbidly)obese(withaBMIover40kg/m2)is1.5%inmenand2.7%inwomen.10
Age
• Inbothmenandwomen,meanBMI(kg/m2)generallyincreaseswithage,apartfromintheoldestagegroup(thoseaged75plus).10
• Inbothmenandwomenaged1674years,prevalenceofraisedwaistcircumferenceincreaseswithage.10
Gender
• MenhaveahighermeanBMIthanwomen(27.2kg/m2incomparisonto26.8kg/m2).10
• Agreaterpercentageofmenthanwomenareeitheroverweightorobese(67.1%ofmencomparedto56.1%ofwomen).10
• Alargerproportionofmen(43.4%)areoverweightthanwomen(31.9%).10
• Thereisverylittledifferenceintheproportionofmenandwomenwhoareobese(23.7%versus24.2%respectively).10
• Approximatelytwiceasmanywomen(2.7%)asmen(1.5%)areseverelyobese.10
• Raisedwaistcircumferenceismoreprevalentinwomen(41%)thaninmen(32%).10
Socioculturalpatterns
• Overweightandobesityaremorecommoninlowersocioeconomicandsociallydisadvantagedgroups,particularlyamongwomen.14
• Women’sobesityprevalenceisfarlowerinmanagerialandprofessionalhouseholds(18.7%)thaninhouseholdswithroutineorsemiroutineoccupations(29.1%).12
• Theprevalenceofmorbidobesity(BMIover40kg/m2)amongwomenisalsolowerinmanagerialandprofessionalhouseholds(1.6%)thaninhouseholdswithroutineorsemiroutineoccupations(4.1%).12
Ethnicdifferences
• Inwomen,themeanBMIismarkedlyhigherinBlackCaribbeans(28.0kg/m2)andBlackAfricans(28.8kg/m2)thaninthegeneralpopulation(26.8kg/m2),andmarkedlylowerinChinese(23.2kg/m2).15
• Inmen,themeanBMIofthoseofChinese(24.1kg/m2),Bangladeshi(24.7kg/m2)andIndianorigin(25.8kg/m2)issignificantlylowerthanthatofthegeneralpopulation(27.1kg/m2).15
• Theincreaseinwaistcircumferencewithageoccursinallethnicgroupsforbothmenandwomen.15
10 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Regionaldifferences
• Inbothmenandwomen,theprevalenceofobesityisgreatestintheWestMidlandsGovernmentOfficeRegion(GOR)(both29%),andlowestintheLondonGOR(19%and21%respectively).Inwomen,theprevalenceofmorbidobesityishighestintheWestMidlandsGOR(4%).However,levelsareconsistentacrosstherestofEngland(rangingfrom2%to3%).Inmen,levelsofmorbidobesityarealsoconsistentacrossEngland(range1%to2%).10
• TheWestMidlandsGORhasthehighestprevalenceofoverweight(includingobese)inmenandwomen(76%and62%respectively).TheLondonGORhasthelowestlevelsofoverweight(includingobese)inEngland(61%and49%respectively).10
• TheprevalenceofoverweightamongmenisgreatestintheEastofEnglandGOR(48%),WestMidlandsGOR(47%)andSouthEastGOR(46%).ThelowestprevalencecanbefoundintheNorthEastGOR(35%).Amongwomen,theEastofEnglandGORhasthehighestprevalenceofoverweight(36%),andLondonhasthelowest(28%).10
Prevalenceofcombinedhealthriskassociatedwithoverweightandobesity*
• Amongmen,20%areestimatedtobeatincreasedrisk,13%athighriskand21%atveryhighriskofhealthproblemsassociatedwithoverweightandobesity.Theequivalentpercentagesforwomenare14%atincreasedrisk,16%athighriskand23%atveryhighrisk.10
Notes:TheHealthSurveyforEngland(HSE)figuresareweightedtocompensatefornonresponse.(BeforetheHSE2003,datawerenotweightedfornonresponse.)Araisedwaistcircumferenceisdefinedas102cmormoreformen,and88cmormoreforwomen.12
*NICEguidelinesdefinelow,highandveryhighwaistmeasurementsformenandwomen.AhighorveryhighwaistcircumferenceisassociatedwithincreasedhealthrisksforthosewithaBMIbelow35kg/m2.HealthrisksareveryhighforthosewithaBMIof35kg/m2ormorewithanywaistcircumference.6
Overweight and obesity: the public health problem 11
Figure1Prevalenceofoverweightandobesityamongadults,byageandsex,England,2006
Men
60
50
40
16–75+75+65–7455–6445–5435–4425–3416–24
Perc
enta
ge
30
20
10
0
AgeOverweight Obese
Women
60
50
40
16–75+75+65–7455–6445–5435–4425–3416–24
Perc
enta
ge
30
20
10
0
Age
ObeseOverweight
Note:Figure1usestheHealthSurveyforEnglandfigureswhichareweightedtocompensatefornonresponse.
Source:HealthSurveyforEngland200610
12 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Table1Prevalenceofobesityandcentralobesityamongadultsaged16andoverlivinginEngland,byethnicgroup,2003/2004
Black Black Indian Pakistani Bangladeshi Chinese GeneralGENDER Caribbean African population
(2003)
MEN
Overweight 67% 62% 53% 55% 44% 37% 67%(including obese)
Obese (including severely obese)
25% 17% 14% 15% 6% 6% 23%
Severely obese 0% 0% 0% 1% 0% 0% 1%
Raised waist-hip ratio
25% 16% 38% 36% 32% 17% 33%
Raised waist circumference
22% 19% 20% 30% 12% 8% 31%
WOMEN
Overweight 65% 70% 55% 62% 51% 25% 57%(including obese)
Obese (including severely obese)
32% 38% 20% 28% 17% 8% 23%
Severely obese 4% 5% 1% 2% 1% 0% 2%
Raised waist-hip ratio
37% 32% 30% 39% 50% 22% 30%
Raised waist circumference
47% 53% 38% 48% 43% 16% 41%
Note:Theprevalencefiguresinthistableareweightedtocompensatefornonresponseindifferentgroups.
Source:Health Survey for England 2004. Volume 1: The health of minority ethnic groups15andHealth Survey for England 2003. Volume 2: Risk factors for cardiovascular disease12
Trends in overweight and obesity among adults
KEY FACTS
• Therehasbeenamarkedincreaseinthelevelsofobesity(BMIabove30kg/m2)amongadultsinEngland.Theproportionofmenclassifiedasobeseincreasedfrom13.2%in1993to24.9%in2006–arelativeincreaseof89%;andfrom16.4%ofwomenin1993to25.2%in2006–arelativeincreaseof54%.10
• Theprevalenceofoverweightincludingobesityhasincreasedinmenfrom57.6%in1993to69.5%in2006–a21%increase–andamongwomenfrom48.6%to58%–a19%increase.10
• Theproportionofmenwhoaremorbidlyobese(BMIabove40kg/m2)rosefrom0.2%in1993to1.4%in2006–ieasevenfoldincrease.Forwomenitrosefrom1.4%to2.7%–ieitalmostdoubled.10
• MeanBMIincreasedby1.5kg/m2inmenandby1.3kg/m2inwomenbetween1993and2006.10
Note:Foraccuracy,unweightedfigureshavebeenusedfortimecomparisons.(BeforetheHealthSurveyforEngland2003,HSEdatawerenotweightedfornonresponse.)
Overweight and obesity: the public health problem 13
Future trends in overweight and obesity among adults5, 16
KEY FACTS
Gendera
• By2015,ithasbeenestimatedthat36%ofmenand28%ofwomeninEnglandwillbeobese.
• By2025,ithasbeenestimatedthat47%ofmenand36%ofwomenwillbeobese.
• By2050,ithasbeenestimatedthat60%ofmenand50%ofwomencouldbeobese.
• TheproportionofmenhavingahealthyBMI(18.524.9kg/m2)hasbeenestimatedtodeclinefromabout30%in2004tolessthan10%by2050.
• Itisestimatedthattheproportionofwomeninthe‘healthyweight’category(BMI18.524.9kg/m2)willfallfromabout40%in2004toapproximately15%by2050.
Socioculturalpatternsa,b
• Theprevalenceofobesityamongmenin2004wasabout18%insocialclassIand28%insocialclassV.Thereisnoevidenceforawideningofsocialclassdifferenceby2050–itisestimatedthat,by2050,52%ofmeninsocialclassIand60%insocialclassVwillbeobese.
• Forwomen,10%insocialclassIand25%insocialclassVwereobesein2004.Ithasbeenestimatedthatthisgapwillwidenby2050with15%insocialclassIand62%insocialclassVbeingclassifiedasobese.
Ethnicdifferencesa,c
• BlackCaribbean,BangladeshiandChinesemenareestimatedtobelessobeseby2050(from2006to2050:18%to3%,26%to17%,and3%to1%respectively).
• BlackCaribbeanandChinesewomenarepredictedtobecomelessobeseby2050(from2006to2050:14%to1%,and3%to1%respectively).
• BlackAfrican,IndianandPakistanimenareestimatedtobemoreobeseby2050(from2006to2050:17%to37%,12%to23%,and16%to50%respectively).
• BlackAfrican,Indian,PakistaniandBangladeshiwomenareestimatedtobemoreobeseby2050(from2006to2050:30%to50%,16%to18%,22%to50%,and24%to30%respectively).
Regionaldifferencesa
• ItisestimatedthattheincidenceofobesitywillgenerallybegreaterinthenorthofEnglandthaninthesouthwestofEngland.
• AmongwomeninYorkshireandHumberside,obesitylevelsareestimatedtoreach65%by2050comparedwiththesouthwestofEnglandwherethepredictedlevelis7%,areductionfrom17%currently.
• AmongmeninYorkshireandHumberside,WestMidlandsandthenortheastofEngland,obesitylevelsarepredictedtoreachabout70%by2050,comparedwithLondonwherethepredictedriseisto38%.
Notes:aFutureobesitytrendshavebeenextrapolatedbyForesightusingHealthSurveyforEnglandunweighteddatafor19942004.Althoughthe
10yeardatasetonwhichtheextrapolationsarebuiltdemonstratesclearandstabletrends,predictedfiguresshouldbeviewedwithcautionasconfidenceintervals(CIs)associatedwiththesefiguresgrowlargerasoneprojectsintothefuture.
bSocialclass(IV)ratherthansocioeconomiccategory(professional/routineoccupations)datawereusedbyForesightfortimecomparisons.Figuresfoundelsewhereinthisreportaresocioeconomiccategorydata.
cSomesamplesizes(ieChineseandBangladeshi)areverysmall,soextrapolationsshouldbetreatedwithparticularcaution.
14 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Figure2Futuretrendsinobesityamongadults,20042050
20
40
60
80
100
Perc
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2004 2015 2025 2050Year
Men Women
Note:Thegraphexcludesconfidenceintervals(CIs),sothefiguresshouldbeviewedwithcaution.CIsgrowlargerasoneprojectsintothefuture.By2050,the95%CIsarefrequently10ormorepercentagepoints.2004dataareunweightedHSEdata,foradultsaged1675+years.Estimateddatafor20152050(fromForesight)areforadultsaged2160years.
Source:HealthSurveyforEngland2005;9andButlandetal,20075
Overweight and obesity: the public health problem 15
Prevalence of overweight and obesity among children aged 2-15 years
KEY FACTS
Prevalence
• Themostrecentfigures(2006)showthat,amongchildrenaged215,almostonethird–nearly3million–areoverweight(includingobese)(29.7%)andapproximatelyonesixth–about1.5million–areobese(16%).ThemeanBMI(kg/m2)forchildrenaged015is18.4kg/m2.11
Age
• Amongchildrenaged1115years,theprevalenceofobesity(17.4%)andoverweight(includingobesity)(32.9%)isgreaterthanamongchildrenaged210years(15.2%and27.7%respectively).11
• Thereisamarkeddifferenceinobesitylevelsforgirlsagedbetween210years(13.2%)and1115years(17%).Forboys,thereislittledifference(17.1%and17.7%respectively).11
• Boysandgirlsaged1115years(boys32.6%,girls33.2%)haveagreaterprevalenceofoverweight(includingobesity)thanboysandgirlsaged210years(boys29.3%,girls25.9%).11
• Betweentheagesof2and15,themeanBMI(kg/m2)increasessteadilywithage.11
Gender
• ThemeanBMI(kg/m2)forboysandgirlsaged215yearsissimilar(18.3kg/m2and18.5kg/m2
respectively).11
• Agreaterpercentageofboys(17.3%)thangirls(14.7%)aged215yearsareobese.Butasimilarproportion–aroundthreeinten–ofboys(30.6%)andgirls(28.7%)areoverweight(includingobese).11
• Amongchildrenaged1115years,asimilarpercentageofboysandgirlsareoverweight(includingobese)(32.6%and33.2%respectively)andobese(17.7%and17%respectively).11
• Amongchildrenaged210years,agreaterproportionofboys(17.1%)thangirls(13.2%)areobese.Ahigherpercentageofboys(29.3%)thangirls(25.9%)arealsooverweight(includingobese).11
Socioculturalpatterns
• Amongboysandgirlsaged215,theprevalenceofobesityishigherinthelowestincomegroup–boys20%comparedto15%inhighestincomegroup,andgirls20%comparedto9%inhighestincomegroup.Theprevalencegapbetweenincomegroupsiswidestforgirls(11%comparedto5%forboys).11
Ethnicdifferences
• MeanBMIsaresignificantlyhigheramongBlackCaribbeanandBlackAfricanboys(19.3kg/m2
and19.0kg/m2respectively)andgirls(20.0kg/m2and19.6kg/m2respectively)15thaninthegeneralchildpopulation.(In20012002boysinEnglandhadameanBMIof18.3kg/m2andgirlshadameanBMIof18.7kg/m2.)17
16 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
• Prevalenceofoverweight(includingobese)amongBlackAfrican(42%),BlackCaribbean(39%)andPakistani(39%)boysissignificantlyhigherthanthatofthegeneralpopulation(30%).ThesameistrueofBlackCaribbean(42%)andBlackAfrican(40%)girlswhohaveamarkedlyhigherprevalencethanthatofthegeneralpopulation(31%).15
• ObesityisalmostfourtimesmorecommoninAsianchildrenthaninwhitechildren.18
Regionaldifferences
• Amongboys,theLondonGovernmentOfficeRegion(GOR)hasthehighestprevalenceratesofobesity(24%)andtheEastofEnglandGORandNorthWestGORhavethelowestrates(both14%).Amonggirls,EastMidlandsGORhasthehighestrates(18%)andtheEastofEnglandGORhasthelowest(10%).11
• LondonGORandtheNorthEastGORhavethehighestratesofoverweight(includingobese)forboys(36%and37%respectively)andYorkshireandtheHumberGORhasthelowestrates(26%).Forgirls,NorthWestGORhasthehighestprevalenceofoverweight(includingobese)(34%)andtheEastofEnglandGORhasthelowestprevalence(22%).11
Note:TheHealthSurveyforEngland(HSE)figuresareweightedtocompensatefornonresponse.(BeforetheHSE2003,datawerenotweightedfornonresponse.)
Overweight and obesity: the public health problem 17
Figure3Prevalenceofoverweightandobesityamongchildrenaged215,byageandsex,England,2006
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Source:HealthSurveyforEngland200611
18 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Table2Prevalenceofobesityamongchildrenaged215livinginEngland,byethnicgroup,2004
Black Black Indian Pakistani Bangladeshi Chinese GeneralGENDER Caribbean African population
(2001-02)
BOYS
Overweight 11% 11% 12% 14% 12% 8% 14%
Obese 28% 31% 14% 25% 22% 14% 16%
Overweight 39% 42% 26% 39% 34% 22% 30%including obese
GIRLS
Overweight 15% 13% 11% 10% 14% 22% 15%
Obese 27% 27% 21% 15% 20% 12% 16%
Overweight 42% 40% 31% 25% 33% 34% 31%including obese
Source:Health Survey for England 2004: The health of ethnic minority groups15
Prevalence of overweight and obesity among children in Reception and Year 6 in England, 2006/07
KEY FACTS
Prevalence
• InReceptionyearchildren(aged45years),almostoneinfourofthechildrenmeasuredwaseitheroverweightorobese(22.9%).InYear6children(aged1011years),thisratewasnearlyoneinthree(31.6%).19
Age
• TheprevalenceofobesityissignificantlyhigherinYear6thaninReception–17.5%comparedto9.9%respectively.19
• ThepercentageofchildrenwhoareoverweightisonlyslightlyhigherinYear6thaninReception(14.2%and13%respectively).19
Gender
• Theprevalenceofobesityissignificantlyhigherinboysthaningirlsinbothagegroups:Receptionboys10.7%,girls9%;Year6boys19%,girls15.8%.19
• Thepercentageofchildrenwhoareoverweightissimilarforboys(14.2%)andgirls(14.1%)inYear6.InReception,thisrateisslightlyhigherforboys(13.6%)thanforgirls(12.4%).19
Note:Childrenweremeasuredintheschoolyear2006/07aspartoftheNationalChildMeasurementProgramme(NCMP).
Overweight and obesity: the public health problem 19
Trends in overweight and obesity among children
KEY FACTS
• MeanBMI(kg/m2)amongchildrenaged215increasedbetween1995and2006.ForboysmeanBMIrosefrom17.7kg/m2to18.2kg/m2(0.5kg/m2growth),andforgirlsmeanBMIrosefrom18.1kg/m2to18.4kg/m2(0.3kg/m2growth).11
• Obesityamongchildrenaged215rosefrom11.5%in1995to15.9%in2006–arelativeincreaseof38%.Amoremarkedincreasewasobservedinobesitylevelsamongboys(57%)–from10.9%in1995to17.1%in2006.Amonggirls,obesitylevelsrosefrom12%in1995to14.7%in2006–anincreaseof23%.11
• Theproportionofchildrenaged215whowereclassifiedasoverweight(includingobese)roseby20%between1995and2006(from24.5%to29.5%respectively).Forboys,therewasa27%increase(from24%in1995to30.4%in2006)andforgirls,therewasa14%increase(from25%in1995to28.6%in2006).11
• Forchildrenaged210,obesityroseby53%from9.9%in1995to15.1%in2006.Obesityamongboysroseby75%(from9.6%in1995to16.8%in2006)butamonggirlsthegrowthwasnoticeablyslowerat29%(from10.3%to13.3%respectively).11
• Childrenaged210classifiedasoverweight(includingobese)increasedfrom22.7%in1995to27.6%in2006–anincreaseof22%.Amongboys,therewasa30%riseintheprevalenceofoverweight(includingobese)from22.5%in1995to29.2%in2006;andamonggirlstherewasa13%increasefrom22.9%to25.9%respectively.11
• Among1115yearolds,obesityroseby21%(14.4%in1995to17.4%in2006).Forboys,therewasa30%increaseinthelevelsofobesity(13.5%and17.6%respectively)andamonggirls,an11%increase(15.4%and17.1%respectively).11
• Thelevelsofoverweight(includingobese)among1115yearoldsincreasedfrom28.1%in1995to32.9%in2006–anincreaseof17%.Forboys,theprevalenceofoverweight(includingobese)roseby20%(26.9%and32.4%respectively)andforgirlsby14%(29.3%and33.3%respectively).11
Note:Foraccuracy,unweightedfigureshavebeenusedfortimecomparisons.(BeforetheHealthSurveyforEngland2003,HSEdatawerenotweightedfornonresponse.)
20 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Figure4Obesitytrendsamongchildrenaged215,England,bysex,19952006
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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
YearBoys Girls
Note:Foraccuracy,Figure4usesunweightedfigures.(BeforetheHSE2003,datawerenotweightedfornonresponse.)
Source:HealthSurveyforEngland200611
Future trends in overweight and obesity among children and young people aged under 20 years5, 16
KEY FACTS
Prevalence
• Theproportionofchildrenwhoareobeseintheunder20agegroupwillrisetoapproximately15%in2025(withslightlylowerprevalenceinboysthaningirls).
• By2050,itisestimatedthat25%ofunder20yearoldswillbeobese.
• By2050,itispredictedthat70%ofgirlscouldbeoverweightorobese,withonly30%inthehealthyBMIrange.Forboys,itisestimatedthat55%couldbeoverweightorobeseandaround45%couldbeinthehealthyrange.
Age
• Amongchildrenaged610years,boyswillbemoreobesethangirls,withanestimateof35%ofboysbeingobeseby2050,comparedwith20%ofgirls.*
• Amongchildrenaged1115years,moregirlsthanboyswillbeobeseby2050–23%ofboysand35%ofgirls.
Notes:FutureobesitytrendswereextrapolatedbyForesightin2007usingHealthSurveyforEnglandunweighteddatafor19952004.TheestimateswerebasedontheInternationalObesityTaskForce(IOTF)definitionofchildhoodobesity,sodatafoundherewillbedifferentfromfiguresfoundelsewhereinthistoolkit.Predictedfiguresshouldbeviewedwithcautionasconfidenceintervals(CIs)associatedwiththesefiguresgrowlargerasoneprojectsintothefuture.*TheCIsonthe2050extrapolationforgirlsaged610areverylarge.
Figure5Futuretrendsinobesityamongchildrenandyoungpeopleagedunder20years,20042050
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Overweight and obesity: the public health problem 21
Note:DatahavebeenestimatedusingtheInternationalObesityTaskForce(IOTF)childhoodobesitydefinition.Thegraphexcludesconfidenceintervals(CIs),sofiguresshouldbeviewedwithcaution.CIsgrowlargerasoneprojectsintothefuture.TheCIsonthe2050extrapolationforgirlsaged610isverywide.
Source:Butlandetal,20075
22 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
The health risks of overweight and obesity Premature mortality
Ithaslongbeenknownthatobesityisassociatedwithprematuredeath.Obesityincreasestheriskofanumberofdiseasesincludingthetwomajorkillers–cardiovasculardiseaseandcancer.Itisestimatedthat,onaverage,obesityreduceslifeexpectancybybetween3and13years–theexcessmortalitybeinggreaterthemoreseveretheobesityandtheearlieritdevelops.20
Obesity-related morbidity
Inpublichealthterms,thegreatestburdenofdiseasearisesfromobesityrelatedmorbidity.Table3givesdetailsofthehealthproblemsassociatedwithobesity.
Table3Relativerisksofhealthproblemsassociatedwithobesity
Greatlyincreasedrisk(Relativeriskmuchgreaterthan3)
Moderatelyincreasedrisk(Relativerisk23)
Slightlyincreasedrisk(Relativerisk12)
Type2diabetes•Insulinresistance•Gallbladderdisease•Dyslipidaemia(imbalanceof•fattysubstancesintheblood,eghighcholesterol)Breathlessness•Sleepapnoea(disturbanceof•breathing)
Coronaryheartdisease•Hypertension(highblood•pressure)Stroke•Osteoarthritis(knees)•Hyperuricaemia(highlevels•ofuricacidintheblood)andgoutPyschologicalfactors•
Cancer(coloncancer,breastcancerin•postmenopausalwomen,endometrial[womb]cancer)Reproductivehormoneabnormalities•Polycysticovarysyndrome•Impairedfertility•Lowbackpain•Anaestheticrisk•Foetaldefectsassociatedwith•maternalobesity
Note:Allrelativeriskestimatesareapproximate.Therelativeriskindicatestheriskmeasuredagainstthatofanonobesepersonofthesameageandsex.Forexample,anobesepersonistwotothreetimesmorelikelytosufferfromhypertensionthananonobeseperson.
Source:AdaptedfromWorldHealthOrganization,200021
Theassociatedhealthoutcomesofchildhoodobesityaresimilartothoseofadultsandinclude:22,23
• hypertension(highbloodpressure)• dyslipidaemia(imbalanceoffattysubstancesintheblood)• hyperinsulinaemia(abnormallyhighlevelsofinsulinintheblood).
(Theabovethreeabnormalfindingsconstitutethe‘metabolicsyndrome’–seepage25.)
Otherpossibleconsequencesforchildrenandyoungpeopleinclude:
• mechanicalproblemssuchasbackpainandfootstrain• exacerbationofasthma• psychologicalproblemssuchaspoorselfesteem,beingperceivedasunattractive,depression,
disorderedeatingandbulimia• type2diabetes.
Someoftheseproblemsappearinchildhood,whileothersappearinearlyadulthoodasaconsequenceofchildhoodobesity.Themostimportantlongtermconsequenceofchildhoodobesityisitspersistenceintoadulthoodandtheearlyappearanceofobesityrelateddisordersanddiseasesnormallyassociatedwithmiddleage,suchastype2diabetesandhypertension.Studieshaveshownthatthehigherachild’sBMI(kg/m2)andtheolderthechild,themorelikelytheywillbeanoverweightorobeseadult.24Furthermore,researchhasdemonstratedthattheoffspringofobeseparentshaveagreaterriskofbecomingoverweightorobeseadults,25increasingthelikelihoodofdevelopingsuchhealthproblemslaterinlife.
Overweight and obesity: the public health problem 23
Conditions associated with obesity
KEY FACTS
Type2diabetes
• Ninetypercentoftype2diabeticshaveaBMIofmorethan23kg/m2.
Cardiovasculardisease
• Amongthoseagedunder50years,thereis2.4foldincreaseinriskofcoronaryheartdiseaseinobesewomencomparedwithnonobesewomen,andatwofoldincreaseinriskinobesemencomparedwithnonobesemen.26
• Seventypercentofobesewomenwithhypertensionhaveleftventricularhypertrophy(thickeningoftheheartmuscle’smainpumpingchamber,theleftventricle).
• Obesityisacontributingfactortoheartfailureinmorethan10%ofpatients.
Hypertension(highbloodpressure)andstroke
• Obesepeoplehaveafivefoldriskofhypertensioncomparedwithnonobesepeople.
• Sixtysixpercentofcasesofhypertensionoccurinoverweightpeople(BMI2529.9kg/m2).
• EightyfivepercentofcasesofhypertensionoccurinpeoplewithaBMIofmorethan25kg/m2.
• Thosewhoareoverweightorobeseandwhoalsohavehypertensionhaveanincreasedriskofischaemicstroke.
Metabolicsyndrome
• Thedevelopmentandseverityofallthecomponentriskfactorsofthemetabolicsyndrome(seepage25)arelinkedtothepredominantriskfactorofcentralobesity.27
• IntheUK,itisestimatedthat25%oftheadultpopulationshowclearsignsofthemetabolicsyndrome.27
Dyslipidaemia
• DyslipidaemiaprogressivelydevelopsasBMIincreasesfrom21kg/m2withariseinlowdensitylipoprotein(LDL).
Cancer
• Tenpercentofallcancerdeathsamongnonsmokersarerelatedtoobesity(and30%ofendometrialcancers).
• Obesityincreasestheriskofcoloncancerbynearlythreetimesinbothmenandwomen.28
Gallbladderdisease
• Thirtypercentofoverweightandobesepeoplehavegallstonescomparedwith10%ofnonobesepeople.
Non-alcoholicfattyliverdisease(NAFLD)
• Ithasbeenreportedthat1020%ofobesechildrenandover75%ofobeseadultshavebeendiagnosedwithNAFLD.2932
24 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Reproductivefunction
• Sixpercentofprimaryinfertilityinwomenisattributabletoobesity.26
• Impotencyandinfertilityarefrequentlyassociatedwithobesityinmen.
Mechanicaldisorderssuchasosteoarthritisandlowbackpain
• Amongelderlypeople,theseconditionsarefrequentlyassociatedwithincreasingbodyweight.Amongolderpeople,theriskofdisabilityattributabletoosteoarthritisisequaltotheriskofdisabilityattributabletoheartdisease,andisgreaterthanforanyothermedicaldisorderoftheelderly.
Respiratoryeffects
• Neckcircumferenceofmorethan43cminmenandmorethan40.5cminwomenisassociatedwithobstructivesleepapnoea(OSA),daytimesomnolenceanddevelopmentofpulmonaryhypertension.
• Between60%and70%ofpeoplesufferingfromOSAareobese.33
Source:AdaptedfromKopelman200734
Type 2 diabetes Perhapsthemostcommonobesityrelatedcomorbidity,andthatwhichislikelytocausethegreatesthealthburden,istype2diabetes.35Ninetypercentoftype2diabeticshaveaBMIofmorethan23kg/m2.Diabetesisabout20timesmorelikelytooccurinpeoplewhoareveryobese(BMIover35kg/m2)comparedtoindividualswithaBMIofbetween18.5and24.9kg/m2(healthyweight).34
Forwomen,theNurses’HealthStudyshowedthatthesinglemostimportantriskfactorfortype2diabeteswasoverweightandobesity.36Theriskisespeciallyhighforwomenwithacentralpatternoffatdistribution,characterisedbyalargewaistcircumference(oftendescribedas‘appleshaped’)andoftenmediatedthroughthemetabolicsyndrome(seethenextpage).TheriskislessforwomenwithasimilarBMIwhotendtodeposittheirexcessfatonthehipsandthighs(‘pearshaped’).20Formen,datafromtheHealthProfessionalsFollowupStudyindicatedthatawesterndiet(highconsumptionofredmeat,processedmeat,highfatdairyproducts,Frenchfries,refinedgrains,andsweetsanddesserts),combinedwithlackofphysicalactivityandexcessweight(BMIinexcessof30kg/m2),dramaticallyincreasestheriskofdevelopingtype2diabetes.37
Coronary heart disease Coronaryheartdiseaseisoftenassociatedwithweightgainandobesity.Ingeneral,therelationshipbetweenBMIandcoronaryheartdiseaseisstrongerforwomenthanformen.TheFraminghamHeartStudyfoundthat,amongthoseundertheageof50years,theincidenceofcoronaryheartdiseaseincreased2.4foldinobesewomen(BMIover30kg/m2),andtwofoldinobesemen.26
Forwomen,theNurses’HealthStudyshowedaclearrelationshipbetweencoronaryheartdiseaseandelevatedBMIevenaftercontrollingforotherfactorssuchasage,smoking,menopausalstatusandfamilyhistory.TheriskofcoronaryheartdiseaseincreasedtwofoldwithaBMIbetween25and28.9kg/m2,andthreefold(3.6)foraBMIabove29kg/m2,comparedwithwomenwithaBMIoflessthan21kg/m2.20,38
Formenyoungerthan65years,aUSstudyshowedthattherewasanincreasedriskofcoronaryheartdiseasethehighertheBMI.AtaBMIof2528.9kg/m2,menwereoneandahalftimes(1.72)
Overweight and obesity: the public health problem 25
atrisk,ataBMIof29.032.9kg/m2menweretwoandahalftimes(2.61)atrisk,andataBMIofmorethan33kg/m2menwerethreeandahalftimesatrisk,comparedwiththeriskataBMIoflessthan23kg/m2.39
Hypertension (high blood pressure) and stroke Obesityisamajorcontributortothedevelopmentofhypertension–apersonwithaBMIof30kg/m2ormore(obese)isfivetimesmorelikelytodevelophypertensioncomparedwithnonobesepeople.Sixtysixpercentofhypertensioncasesarelinkedwithexcessweight(BMI2529.9kg/m2),and85%areassociatedwithaBMIofmorethan25kg/m2(overweight).34TheFraminghamHeartStudyestimatedthat75%ofthecasesofhypertensioninmenand65%ofthecasesinwomenaredirectlyattributabletooverweight/obesity.40Longdurationobesitydoesnotappearnecessarytoelevatebloodpressureastherelationshipbetweenobesityandhypertensionisevidentinchildren.41
Overweight/obesityisthoughttobeamajorriskfactorinstroke.SeveralstudieshaveshownanincreasedriskforstrokewithincreasingBMI(kg/m2)butothershavefoundnoassociation.Insomestudiestherewasanassociationwithwaisttohipratio,butnotBMI,suggestingthatcentralobesityratherthangeneralobesityisthekeyfactor.42Ina28yearstudyofmeninmidlife,itwasfoundthatobesitycanhaveasignificantimpactonstrokerisk,doublingitslikelihoodlaterinlife.MenwithaBMIofbetween20kg/m2and22.49kg/m2weresignificantlylesslikelytosufferastrokethanthosewithaBMIofmorethan30kg/m2.42
Metabolic syndrome Metabolicsyndromereferstoaclusterofriskfactorsrelatedtoastateofinsulinresistance,inwhichthebodygraduallybecomeslessabletorespondtothemetabolichormoneinsulin.Peoplewiththemetabolicsyndromehaveanincreasedriskofdevelopingcoronaryheartdisease,strokeandtype2diabetes.43Thecomponentriskfactorsrelatedtoinsulinresistanceare:
• increasedwaistcircumference
• highbloodpressure
• highbloodglucose
• highserumtriglyceride
• lowbloodHDLcholesterol(the‘good’cholesterol).
Thedevelopmentandseverityofallthecomponentsarelinkedtothepredominantriskfactorofcentralobesity.PreviouslyknownasSyndromeX,metabolicsyndromeisbecomingincreasinglycommonalthoughthetrueprevalenceofthediseaseisunknown.IntheUK,itisestimatedthatasmuchas25%oftheadultpopulationshowclearsignsofthemetabolicsyndrome,27afigurewhichisexpectedtoincreaseinparallelwiththerisingepidemicofobesity.44IncidencehasbeenfoundtobehigherincertainethnicsubgroupssuchasAsianandAfricanCaribbeangroups.45Inaddition,ithasbeennotedthatinpeoplewithnormalglucosetolerance,theprevalenceofthemetabolicsyndromeincreaseswithageandishigherinmenthanwomen,butthesedifferencesarenotseenindiabeticpatients.46Childhoodobesityisapowerfulpredictorofthemetabolicsyndromeinearlyadulthood.14
Dyslipidaemia Obesityisassociatedwithdyslipidaemia.Dyslipidaemiaischaracterisedbyincreasedtriglycerides,elevatedlevelsofLDLcholesterol(the‘bad’cholesterol)anddecreasedconcentrationsofHDLcholesterol(the‘good’cholesterol).47DyslipidaemiaprogressivelydevelopsasBMIincreasesfrom21kg/m2,withariseinLDL.34Onaverage,themorefat,themorelikelyanindividualwillbedyslipidaemicandtoexpresselementsofthemetabolicsyndrome.However,locationoffat,ageandgenderareimportantmodifiersoftheimpactofobesityonbloodlipids:
26 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
• Location of fat –Fatcellsexertthemostdamagingimpactwhentheyarecentrallylocatedbecause,comparedtoperipheralfat,centralfatisinsulinresistantandmorerapidlyrecyclesfattyacids.48
• Age –Amongtheobese,youngerpeoplehaverelativelylargerchangesinbloodlipidsatanygivenlevelofobesity.47
• Gender –Amongoverweightwomen,excessbodyweightseemstobeassociatedwithhighertotal,nonHDLandLDLcholesterollevels,highertriglyceridelevels,andlowerHDLcholesterollevels.TotalcholesteroltoHDLcholesterolratiosseemtobehighestinobesepostmenopausalwomen,duetothemuchlowerHDLcholesterolconcentrations.47
Cancer Tenpercentofallcancerdeathsamongnonsmokersarerelatedtoobesity.34Researchsuggeststhat,forwomen,obesityincreasestheriskofvarioustypesofcancer,includingcolon,breast(postmenopausal),endometrial(womb),cervical,ovarianandgallbladdercancers.Obesityisestimatedtoaccountfor30%ofendometrialcancerdeaths34andfor20%ofallcancerdeathsinwomen.49Formen,obesityincreasestheriskofcolorectalandprostatecancer.Aclearassociationisseenwithcancerofthecolon:obesityincreasestheriskofthistypeofcancerbynearlythreetimesinbothmenandwomen.28
Gallbladder disease Obesityisanestablishedpredictorofgallbladderdisease.Theriskofdevelopingthediseaseincreaseswithweightgainalthoughitisunclearhowbeingoverweightorobesemaycausegallbladderdisease.However,themostcommonreasonforgallbladderdiseaseisgallstones,forwhichobesityisaknownriskfactor.Researchsuggeststhat30%ofoverweightandobesepeoplehavegallstonescomparedto10%ofnonobesepeople.50
Non-alcoholic fatty liver disease Nonalcoholicfattyliverdisease(NAFLD),thelivermanifestationofthemetabolicsyndrome,isnowconsideredtobethemostcommonliverprobleminthewesternworld.AsignificantproportionofpatientswithNAFLDcanprogresstocirrhosis,liverfailure,andhepatocellularcarcinoma(livertumour).51Ithasbeenreportedthatover75%ofobeseadultshavebeendiagnosedwithNAFLD.29Forchildren,withtheriseinchildhoodobesity,therehasbeenanincreaseintheprevalence,recognitionandseverityofpaediatricNAFLDwithabout1020%ofobesechildrenbeingdiagnosedwiththecondition.3032Itisthemostcommonformofchronicliverdiseaseamongchildren.52
Reproductive function Forwomen,obesityhasasignificantadverseimpactonreproductiveoutcome.Itinfluencesnotonlythechanceofconception–6%ofprimaryinfertilityinwomenisattributabletoobesity26–butalsotheresponsetofertilitytreatment.Inaddition,obesityincreasestheriskofmiscarriage,congenitalabnormalities(suchasneuraltubedefects)andpregnancycomplicationsincludinghypertension,preeclampsiaandgestationaldiabetes.Therearealsopotentialadverseeffectsonthelongtermhealthofbothmotherandinfant.53Formen,impotencyandinfertilityarefrequentlyassociatedwithobesity.34
Mechanical disorders such as osteoarthritis and low back pain Osteoarthritis(OA),ordegenerativediseaseoftheweightbearingjointssuchastheknee,isaverycommoncomplicationofobesity,andcausesagreatdealofdisability.28ThereisafrequentassociationbetweenincreasingbodyweightandOAintheelderly,andtheriskofdisabilityattributabletoOAisequaltotheriskofdisabilityattributabletoheartdisease,andisgreaterthan
Overweight and obesity: the public health problem 27
foranyothermedicaldisorderoftheelderly.34Paininthelowerbackisalsofrequentlysufferedbyobesepeople,andmaybeoneofthemajorcontributorstoobesityrelatedabsencesfromwork.Itislikelythattheexcessweightalone,ratherthananymetaboliceffect,isthecauseoftheseproblems.28
Respiratory effects Anumberofrespiratorydisordersareexacerbatedbyobesity.Aneckcircumferenceofmorethan43cminmenandmorethan40.5cminwomenisassociatedwithobstructivesleepapnoea(OSA),daytimesomnolenceanddevelopmentofpulmonaryhypertension.OneofthemostseriousoftheseisOSA,aconditioncharacterisedbyshort,repetitiveepisodesofimpairedbreathingduringsleep.Ithasbeenestimatedthatasmanyas6070%ofpeoplesufferingfromOSAareobese.33
Obesity,especiallyintheupperbody,increasestheriskofOSAbynarrowingtheindividual’supperairway.OSAcanincreasetheriskofhighbloodpressure,angina,cardiacarrhythmia,heartattackandstroke.
Breathlessness Breathlessnessonexertionisaverycommonsymptominobesepeople.54Forexample,inalargeepidemiologicalsurvey,80%ofobesemiddleagedsubjectsreportedshortnessofbreathafterclimbingtwoflightsofstairscomparedwithonly16%ofsimilarlyagednonobesecontrols,andthiswasdespitesmokingbeingsignificantlylessfrequentintheobese.55Inanotherstudyofpatientswithtype2diabetes,onethirdreportedtroublesomeshortnessofbreathanditsseverityincreasedwithBMI.56Importantly,breathlessnessintheobesemaybeduetoanyofseveralfactorsincludingcoexistent(butoftenobesityrelated)cardiacdisease,unrelatedrespiratorydiseaseortheeffectsofobesityitselfonbreathing,althoughitisnotclearwhetherbreathlessnessatrestcanbeattributabletoobesity.54
Psychological factors Psychologicaldamagecausedbyoverweightandobesityisahugehealthburden.57
Inchildhood,overweightandobesityareknowntohaveasignificantimpactonpsychologicalwellbeing,withmanychildrendevelopinganegativeselfimage,loweredselfesteemandahigherriskofdepression.Inaddition,almostallobesechildrenhaveexperiencesofteasing,socialexclusion,discriminationandprejudice.5862Inonestudy,itwasshownthatchildrenasyoungassixyearsdemonstratednegativeperceptionsoftheirobesepeers.63
Inadults,theconsequencesofoverweightandobesityhaveledtoclinicaldepression,withratesofanxietyanddepressionbeingthreetofourtimeshigheramongobeseindividuals.64Obesewomenarearound37%morelikelytocommitsuicidethanwomenofnormalweight.57Stigmaisafundamentalproblem.Manystudies(forexample:Gortmakeretal,1993,65WaddenandStunkard,198563)havereportedwidespreadnegativityregardingobesepeople,particularlyintermsofsexualrelations.Thepsychologicalexperiencesofoverweightandobesityareextremelycomplexandarelinkedtocultureandsocietalvaluesand‘norms’.
Impact of overweight and obesity on incidence of disease in the future
AnalysisofBMIpredictionsfrom2005to2050indicatethatthegreatestincreaseintheincidenceofdiseasewouldbefortype2diabetes(anincreaseofmorethan70%from2004to2050)withincreasesof30%forstrokeand20%forcoronaryheartdiseaseoverthesameperiod.5,16
28 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
The health benefits of losing excess weight Weightlossinoverweightandobeseindividualscanimprovephysical,psychologicalandsocialhealth.Thereisgoodevidencetosuggestthatamoderateweightlossof510%ofbodyweightinobeseindividualsisassociatedwithimportanthealthbenefits,particularlyinareductioninbloodpressureandareducedriskofdevelopingtype2diabetesandcoronaryheartdisease.66,67
Table4showstheresultsoflosing10kg.22,68
Table4Thebenefitsofa10kgweightloss
Benefit
Mortality •••
Morethan20%fallintotalmortalityMorethan30%fallindiabetesrelateddeathsMorethan40%fallinobesityrelatedcancerdeaths
Blood pressure (in hypertensive people)
••
Fallof10mmHgsystolicbloodpressureFallof20mmHgdiastolicbloodpressure
Diabetes (in newly diagnosed people)
• Fallof50%infastingglucose
Lipids ••••
Fallof10%oftotalcholesterolFallof15%oflowdensitylipoprotein(LDL)cholesterolFallof30%oftriglyceridesIncreaseof8%ofhighdensitylipoprotein(HDL)cholesterol
Other benefits •
•
Improvedlungfunction,andreducedbackandjointpain,breathlessness,andfrequencyofsleepapnoeaImprovedinsulinsensitivityandovarianfunction
Source:AdaptedfromJung,1997;68MulvihillandQuigley,200322
Inrelationtoreductionincomorbidities,theDiabetesPreventionProgramintheUShasshownthat,amongindividualswithimpairedglucosetolerance,a57%decreaseininitialweightreducestheriskofdevelopingtype2diabetesby58%.69
Itisimportanttorecognisethat,forveryobesepeople,suchchangeswillnotnecessarilybringthemoutofthe‘atrisk’category,butthereareneverthelessworthwhilehealthgains.Acontinuousprogrammeofweightreductionshouldbemaintainedtohelpcontinuetoreducetherisks.
Weightreductioninoverweightandobesepeoplecanimproveselfesteemandcanhelptacklesomeoftheassociatedpsychosocialconditions.Itshouldnotbeforgottenthatsmallchangescanhaveapositiveimpactontheoverallhealthandwellbeingofindividualsbyincreasingmobility,energyandconfidence.
Overweight and obesity: the public health problem 29
The economic costs of overweight and obesity Thecostsofobesityareverylikelytogrowsignificantlyinthenextfewdecades.Apartfromthepersonalandsocialcostssuchasmorbidity,mortality,discriminationandsocialexclusion,therearesignificanthealthandsocialcarecostsassociatedwiththetreatmentofobesityanditsconsequences,aswellascoststothewidereconomyarisingfromchronicillhealth.5TheForesightprogramme5,16 forecastthedirectcoststotheNHSoftreatingobesityanditsconsequencesandtheindirectcostssuchasabsencefromwork,morbiditynottreatedinthehealthserviceandreductioninqualityoflife.Theseforecastswereestimatedfrom2007to2050(seeTable5andFigure6).16
In2007,thetotalannualcosttotheNHSofdiseasesforwhichelevatedBMIisariskfactor(directhealthcarecosts)wasestimatedtobe£17.4billion,ofwhichoverweightandobesitywereestimatedtoaccountfor£4.2billion,andobesityalonefor£2.3billion.By2050,ithasbeenestimatedthatthetotalNHScosts(ofrelateddiseases)couldriseto£22.9billion,ofwhichoverweightandobesityarepredictedtocosttheNHS£9.7billionandobesityalone£7.1billion.16
In2007,theindirectcostsofoverweightandobesitywereestimatedtobeasmuchas£15.8billion.Thewidercostofoverweightandobesitytosocietyby2050isestimatedtobe£49.9billion.16
Table5FuturecostsofelevatedBodyMassIndex
£billionperyear
2007 2015 2025 2050
Total NHS cost (of related diseases) 17.4 19.5 21.5 22.9
NHS costs directly attributable to overweight and obesity
4.2 6.3 8.3 9.7
NHS costs directly attributable to obesity 2.3 3.9 5.3 7.1
Wider total costs of overweight and obesity 15.8 27 37.2 49.9
Projected percentage of NHS costs at £70 billion 6% 9.1% 11.9% 13.9%
Source:Butlandetal,2007;5McCormicketal,200770
Figure6EstimatedfutureNHScostsofelevatedBodyMassIndex,20072050
heart disease diseases
0
5
10
15
20
25
2007 2015 2025 2050
Coronary
Type 2 diabetes
Other related
NHS costs (all obesity-related diseases)
Stroke
Cos
t pe
r ye
ar (£
bill
ion)
Source:Butlandetal,2007;5McCormicketal,200770
30 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Causes of overweight and obesity Thecausesofoverweightandobesityarecomplex.Butinessencetheaccumulationofexcessbodyfatoveraperiodoftimeiscausedbymoreenergy(‘calories’)takeninthrougheatinganddrinkingthanisusedupthroughmetabolismandphysicalactivity–animbalancebetween‘energyin’and‘energyout’.
Thus,anindividual’sbiology(genetics)andbehaviour(eatingandphysicalactivityhabits)primarilyinfluenceenergybalanceinthebody:
• Genesmayplayanimportantroleininfluencingmetabolismandtheamountandpositionoffattytissueinthebody.Itisalsolikelythatanindividual’seatingandphysicalactivitybehaviourmay,atleastinpart,begeneticallydetermined.5
• Eating(anddrinking)behaviouriskey–anindividual’senergyintakeisdeterminedbytheirdriveandopportunitytoeat,andmayvaryfromzerotoseveralthousandcaloriesaday.5
• Physicalactivitybehaviourisalsocrucial.Energyexpenditureislargelydeterminedbythefrequency,intensityanddurationofactivityaswellasanindividual’smetabolicpredisposition.5
However,theseprimarydeterminantsofanindividual’senergybalancemaythemselvesbestronglyinfluencedbyarangeofsecondarypsychological,socialandenvironmentaldeterminants–forexample:parentsrewardingchildrenwithsweetsorcrisps,theavailabilityofinexpensivetakeawayfriedfoods,andtheincreaseincarownership,TVviewingandcomputergames.5
Human biology
Thereisarangeofspecificgenesassociatedwithexcessweight.Obesityrelatedgenescouldaffecthowfoodismetabolisedandhowfatisstored,andtheycouldalsoaffectanindividual’sbehaviour,inclininganindividualtowardslifestylechoicesthatmayincreasetheriskofobesity:
• Somegenesmaycontrolappetite,makinganindividuallessabletosensefullness.71,72
• Somegenesmaymakeanindividualmoreresponsivetothetaste,smellorsightoffood.73
• Somegenesmayaffectthesenseoftaste,givingpreferencesforhighfatfoodsandrepellinghealthyfoods.74
• Somegenesmayforceanindividualtobelesslikelytoengageinphysicalactivity.74
Peoplewithobesityrelatedgenesarenotdestinedtobeobesebuttheywillhaveahigherriskofobesity.Inthemodernenvironment,theymayneedtoworkharderthanotherstomaintainahealthybodyweightbymakinglongterm,sustainedlifestylechanges.
Thepatternofgrowthduringearlylifealsocontributestotheriskofexcessweight.Ababy’sgrowthrateinthewombandfollowingbirthisinpartdeterminedbyparentalfactors,especiallywithregardtothemother’sdiet,andwhatandhowshefeedsherbaby.Breastfedbabiesshowslowergrowthratesthanformulafedbabiesandthismaycontributetothereducedriskofobesitylaterinlifeshownbybreastfedbabies.75Weaningpracticesarealsothoughttobeimportant,giventheassociationbetweencharacteristicweightgainseeninearlychildhoodatabout5yearsandlaterobesity.5
Overweight and obesity: the public health problem 31
The food environment
Systemsoffoodproduction,storageanddistributionhavecreatedanincreasinglyattractive,diverseandenergydensefoodsupply.Foodiswidelyavailable,andpromotionandadvertisingprovideadditionalexposuretofoodcues(thesightorsmelloffoodwhichcanstimulatetheappetiteandpromotehigherconsumption).Thecostoffood,whichmightotherwisebeabarriertoconsumption,islowinhistoricaltermsdespiterecentrises,withthecheapestlinesoftenbeingprocessed,energydensefoodsservedinlargeportions.73Highfatmealsareparticularlyenergydenseasfatcontainsmorethantwiceasmanycaloriespergramasproteinorcarbohydrate.(Fatcontains9kcalpergram,comparedwith4kcalpergramforproteinorcarbohydrate.)
Inparallelwiththetransformationofthefoodsupply,socialnormsrelatedtoeatinghavechanged.Childrenaregivenmorecontroloverfoodchoices.Grazing,snacking,eatingonthegoandeatingoutsideofthehomearecommonandcontributeasubstantialproportionoftotalcalorieintake.73From1940to2006,theaveragehouseholdenergyintake(caloriesconsumedinthehome)showedadeclineofapproximately12%.76Howeveritisonlysince1992thattheNationalFoodSurveyhastakenaccountofalcoholicdrinks,softdrinksandconfectionerybroughthome,andonlysince1994thatithasincludedfoodanddrinkpurchasedandeatenoutsidethehome.76In2006,thesecomponentsaccountedforanextra13%ofenergyintake.
Eatingoutsidethehomeisbecomingincreasinglypopular,28andsurveysindicatethatfoodeatenouttendstobehigherinfatsandaddedsugarsthanfoodconsumedinthehome.20,28,76Foodeatenoutsidethehomeisalsofrequentlyofferedinextralargeportions–notablysoftdrinks,savourysnacksandconfectionery–oftenatminimaladditionalcost.Thereisgrowingevidencethatpeopleeatmorewhenpresentedwithlargerportions77andcalorieintakeisincreasedwithoutnecessarilymakingtheindividualfeelfull.28
Themodernfoodenvironmenthasthereforecontributedtotoomuchsaturatedfat,addedsugarandsaltandnotenoughfruitandvegetablesintheUKdiet.(Seepage40fordietaryrecommendationsandcurrentintakelevels.)
The physical environment
Overthepast50years,physicalactivityhasdeclinedsignificantlyintheUK.Therearemanyreasonsforthis,including:
• fewerjobsrequiringphysicalworkastheUKhaschangedfromanindustrialtoaservicebasedeconomy
• increasedlaboursavingtechnologyinthehome,workandretailenvironments
• changesinworkandshoppingpatterns–fromlocaltodistant–thathaveresultedingreaterrelianceonmotorisedtransport
• increasedselfsufficiencyinthehome,includingentertainment,foodstorageandpreparation,controlledclimatesandgreatercomfort78
• poorurbanplanningwhereprovisionforpedestriansandcyclistshasbeengivenamuchlowerprioritythanformotorvehicles79,80
• creationoftransportsystemswhichfavourthecarandnotwalkersandcyclists79,80
• adeclineinqualityofurbanpublicparks–only18%areingoodcondition–andlossofrecreationaloutdoorfacilities.79,80
32 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Themodernphysicalenvironmenthasthereforecontributedtoincreasinglysedentarylifestyles.DatafromtheNationalTravelSurvey81showthatinEnglandbetween1975/76and2007theaveragenumberofmilesperyeartravelledbyfootfellbyaroundaquarterandbycyclebyaroundathird.(However,thesedataexcludewalkingandcyclingforleisure.)Overthesameperiodtheaveragenumberofmilesperyeartravelledbycarincreasedbyjustunder70%,withthenumberofpeopleinahouseholdwithoutacarfallingfrom41%to19%.81
Physicalactivityisaparticularissueinchildren.SchoolsinEnglandareatthebottomoftheEuropeanleagueintermsoftimeallocatedtophysicaleducationinprimaryandsecondaryschools.Only5%ofchildrenusetheirbicyclesasaformoftransportintheUKcomparedwith6070%intheNetherlands,and41%ofprimaryschoolchildrenand20%ofsecondaryschoolchildrenarenowtakentoschoolbycar,comparedwith9%in1971.81,82Furthermore,Britishchildrenareincreasinglyspendingmoretimeinfrontofthetelevisionorcomputerscreen–anaverageof5hoursand20minutesaday,upfrom4hoursand40minutesfiveyearsago.83
Culture and individual psychology
Oureating,drinkingandexercisehabitsaregreatlyinfluencedbysocialandpsychologicalfactors.84Highconsumptionoffattyfoodsandlowconsumptionoffruitandvegetablesarestronglylinkedtothoseinroutineandmanualoccupations.Overconsumptionofsweetfoodsanddrinkscanbeareactiontomorenegativefeelingsincludinglowselfesteemordepression.Socalled‘comfortfoods’(iefoodshighinsugar,fatandcalories)seemtocalmthebody’sresponsetochronicstress.Theremaybealinkbetweensocalledmodernlifeandincreasingratesofovereating,overweight,andobesity.85Onestudyshowedthatmenweremorelikelytoeatwhenstressediftheyweresingle,divorcedorfrequentlyunemployed.Amongwomen,thosewhofeltalackofemotionalsupportintheirliveshadagreatertendencytoeattocopewithstress.86
Understandingthesebehaviouraldeterminantsingreaterdepthiscriticalinengagingwithindividualsandhelpingtodeviserationaltreatmentstrategies.20
SeeToolD4Identifying priority groups.
B Tackling overweight and obesity
34 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
This section of the toolkit looks at ways of tackling overweight and obesity. It focuses on the five key themes highlighted in Healthy Weight, Healthy Lives: A cross-government strategy for England 1 as the basis of tackling excess weight:
• Children: healthy growth and healthy weight focuses on the importance of prevention of obesity from childhood. It looks at recommended government action during the following life stages – pre-conception and antenatal care, breastfeeding and infant nutrition, early years and schools. Importantly, it also discusses the psychological issues that impact on overweight and obesity.
• Promoting healthier food choices details the government recommendations for promoting a healthy, balanced diet to prevent overweight and obesity. It provides standard population dietary recommendations and The eatwell plate recommendations for individuals over the age of five years.
• Building physical activity into our lives provides details of government recommendations for active living throughout the life course. It focuses on action to prevent overweight and obesity by everyday participation in physical activity, the promotion of a supportive built environment and the provision of advice to decrease sedentary behaviour.
• Creating incentives for better health focuses on action to maintain a healthy weight in the workplace by the provision of healthy eating choices and opportunities for physical activity. It provides details of recommendations from the National Institute for Health and Clinical Excellence (NICE) guidance.6
• Personalised support for overweight and obese individuals focuses on recommended government action to manage overweight and obesity through weight management services (NHS and non-NHS based). It provides clinical guidance and examples of appropriate services for children and adults.
Tackling overweight and obesity 35
Government action on overweight and obesity Tacklingoverweightandobesityisanationalgovernmentpriority.In2007,anewambitionwasannouncedforEnglandtobethefirstmajorcountrytoreversetherisingtideofobesityandoverweightinthepopulationbyensuringthatallindividualsareabletomaintainahealthyweight.Ourinitialfocusisonchildren:by2020wewillhavereducedtheproportionofoverweightandobesechildrento2000levels.ThisnewambitionformspartoftheGovernment’snewpublicserviceagreement(PSA)onChildHealth–PSA12:toimprovethehealthandwellbeingofchildrenandyoungpeopleunder11.87TheDepartmentofHealthisresponsiblefortheoverallambitiononhealthyweightandisjointlyresponsiblewiththeDepartmentforChildren,SchoolsandFamiliesfordeliveringthePSAonChildHealth.
SettingouttheGovernment’simmediateplanstowardsthenewambition,acomprehensivestrategyonobesity,HealthyWeight,HealthyLives:AcrossgovernmentstrategyforEngland1hasbeendeveloped.BasedontheevidenceprovidedbytheGovernmentOfficeforScience’sForesightreport,5thestrategyhighlightsfivekeythemesfortacklingexcessweight:
1 Children: healthy growth and healthy weight–earlypreventionofweightproblemstoavoidthe‘conveyor-belt’effectintoadulthood
2 Promoting healthier food choices –reducingtheconsumptionoffoodsthatarehighinfat,sugarandsaltandincreasingtheconsumptionoffruitandvegetables
3 Building physical activity into our lives –gettingpeoplemovingasanormalpartoftheirday
4 Creating incentives for better health –increasingtheunderstandingandvaluepeopleplaceonthelong-termimpactofdecisions
5 Personalised support for overweight and obese individuals–complementingpreventivecarewithtreatmentforthosewhoalreadyhaveweightproblems.
(Seepages37–52forfurtherdiscussionofthesethemes.)
Althoughtheambitioncoversaperiodof12years,progressforthefirstthreeyears(2008/09to2010/2011)willfocusondeliveringthePSAonChildHealth,87andsoactionswithinthefirsttheme,thehealthygrowthandhealthyweightofchildren,areparticularlyimportant.Theseinclude:
• identificationofat-riskfamiliesasearlyaspossibleandpromotionofbreastfeedingasthenormformothers
• investmenttoensureallschoolsarehealthyschools
• investing£75millioninanevidence-basedsocialmarketingprogrammethatwillinform,supportandempowerparentsinmakingchangestotheirchildren’sdietandlevelsofphysicalactivity.
Theinitialfocuswillbeonchildren,howeverthestrategyemphasisesthatanypreventiveactiontotackleoverweightandobesityneedstotakealifecourseapproach.Theevidencetodateindicatesanumberofpointsinthelifecoursewheretheremaybespecificopportunitiestoinfluencebehaviour(seeTable6onthenextpage).Theserelatetocriticalperiodsofmetabolicchange(egearlylife,pregnancyandmenopause),timeslinkedtospontaneouschangesinbehaviour(egleavinghome,orbecomingaparent),orperiodsofsignificantshiftsinattitudes(egpeergroupinfluences,ordiagnosisofillhealth).5
36 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Table 6 Criticalopportunitiesinthelifecoursetoinfluencebehaviour
LIFE
CO
UR
SE
Age Stage lssue
PreconceptionInutero
Maternalnutritionprogrammesfoetus
0–6 months Post-natal Breastversusbottle-feedingtoprogrammelaterhealth
6–24 months Weaning Growthaccelerationhypothesis(slowerpatternofgrowthinbreastfedcomparedwithformula-fedinfants)
2–5 years Pre–school Adiposityreboundhypothesis(periodoftimeinearlychildhoodwhentheamountoffatinthebodyfallsandthenrisesagain,whichcausesBMItodothesame)
5–11 years 1stschool DevelopmentofphysicalskillsDevelopmentoffoodpreferences
11–16 years 2ndschool Developmentofindependentbehaviours
16–20 years Leavinghome Exposuretoalternativecultures/behaviour/lifestylepatterns(egworkpatterns,livingwithfriendsetc)
16+ years Smokingcessation Healthawarenesspromptingdevelopmentofnewbehaviours
16–40 years Pregnancy Maternalnutrition
16–40 years Parenting Developmentofnewbehavioursassociatedwithchild-rearing
45–55 years Menopause BiologicalchangesGrowingimportanceofphysicalhealthpromptedbydiagnosisordiseaseinselforothers
60+ years Ageing Lifestylechangepromptedbychangesintimeavailability,budget,work-lifebalanceOccurrenceofillhealth
Source:Foresight,20075
Tackling overweight and obesity 37
Children: healthy growth and healthy weight Thebestlong-termapproachtotacklingoverweightandobesityispreventionfromchildhood.Preventingoverweightandobesityinchildreniscritical,particularlythroughimprovingdietandincreasingphysicalactivitylevels.TheNationalHeartForum’syoung@heartinitiativehighlightedthelinksbetweenoverweightandobesityinchildrenandthesubsequentdevelopmentofdiabetesandcoronaryheartdisease.88Itemphasisedtheimportanceofalifecourseapproachwhichfocusesonensuringgoodinfantfeeding(breastfedbabiesmaybelesslikelytodevelopobesitylaterinchildhood89)andnutritionduringpregnancy,aswellasworkingwithadolescentstosupportthehealthyphysicaldevelopmentoffuturemothers.88
Pre-conception and antenatal care
Upto50%ofpregnanciesarelikelytobeunplanned,90soallwomenofchildbearingageneedtobeawareoftheimportanceofahealthydiet.Nutritionalinterventionsforwomenwhoare–orwhoplantobecome–pregnantarelikelytohavethegreatesteffectifdeliveredbeforeconceptionandduringthefirst12weeks.Ahealthydietisimportantforboththebabyandmotherthroughoutpregnancyandafterthebirth.90Actionshouldthereforeincludeprovidingwomenwithinformationonthebenefitsofahealthydiet.
Womenwhoareoverweightorobesebeforetheyconceivehaveanincreasedriskofcomplicationsduringpregnancyandbirth.Thisposeshealthrisksforbothmotherandbabyinthelongerterm.91Thereisalsoevidencethatmaternalobesityisrelatedtohealthinequalities,particularlysocioeconomicdeprivation,inequalitieswithinminorityethnicgroupsandpooraccesstomaternityservices.92Actionshouldthereforeincludepromoting,towomenwhoaretryingtoconceive,thebenefitsofahealthyweight,informingthemabouttherisksassociatedwithobesityduringpregnancy,andsignpostingwomentoserviceswhereappropriate.
Tohelpsupportoverweight/obesepregnantwomen,theChildHealthPromotionProgramme(CHPP)includesmeasuresfortheearlyidentificationofriskfactorsandpreventionofobesityinpregnancyandthefirstyearsoflife.Inaddition,theFamilyNursePartnershipoffersadvice,toparentswhoaremostatriskofexcessweight,onhowtoadoptahealthierlifestyle.
Breastfeeding and infant nutrition
TheWorldHealthOrganizationandtheDepartmentofHealthrecommendexclusivebreastfeedingforthefirstsixmonthsofaninfant’slife.93Evidencesuggeststhatmotherswhobreastfeedprovidetheirchildwithprotectionagainstexcessweightinlaterlife,94andthattheirchildrenarelesslikelytodeveloptype1diabetes,andgastric,respiratoryandurinarytractinfections,andarelesslikelytosufferfromallergiessuchaseczema,orasthma.95-97Forthemother,thereisevidencetosuggestthatbreastfeedingincreasesthelikelihoodofreturningtotheirpre-pregnancyweight.98Actionshouldthereforeincludetheencouragementofexclusivebreastfeedingforsixmonthsofaninfant’slifeandtheprovisionofbreastfeedinginformationandsupportfornewmothers.ToimprovetheUK’sbreastfeedingrate,theDepartmentofHealthhassetuptheNationalBreastfeedingHelplinewhichofferssupportforbreastfeedingmothers,andthroughextrafundingishelpingtosupporthospitalsindisadvantagedareastoachieveUnicefBabyFriendlyStatus,asetofbestpracticestandardsformaternityunitsandcommunityservicesonimprovingpracticetopromote,protectandsupportbreastfeeding.
38 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Sixmonthsistherecommendedagefortheintroductionofsolidfoodsbecausebythatageinfantsneedmoreironandothernutrientsthanmilkalonecanprovide.99GuidancefromNICE90
makesthefollowingrecommendationsforhealthprofessionalsonhowtohelpparentsandcarersprovideahealthy,balanceddietforbabiesandyoungchildren.
• Supportmotherstocontinuebreastfeedingforaslongastheychoose.
• Encourageparentsandcarerstoofferinfantsagedsixmonthsandoverhome-preparedfoods,withoutaddingsalt,sugarorhoney,andsnacksfreeofsaltandaddedsugarbetweenmeals.
• Encourageparentsandcarerstosetagoodexamplebythefoodchoicestheymakeforthemselves.Alsoencouragefamiliestoeattogether.Adviseparentsandcarersnottoleaveinfantsalonewhentheyareeatingordrinking.
• Discourageparentsandcarersfromaddingsugaroranysolidfoodtobottlefeeds.Discouragethemfromofferingbabyjuicesorsugarydrinksatbedtime.
• Provideparentsandcarerswithpracticalsupportandadviceonhowtointroducetheinfanttoavarietyofnutritiousfoods(inadditiontomilk)aspartofaprogressivelyvarieddiet,whentheyaresixmonthsandover.
Early years
Thepre-schoolyearsareanidealtimetoestablishthefoundationforahealthylifestyle.Parentsareprimarilyresponsiblefortheirchild’snutritionandactivityduringtheseyears,butchildcareprovidersalsoplayanimportantrole.
Generaldietaryguidelinesforadultsdonotapplytochildrenunder2years.Between2and5yearsthetimingandextentofdietarychangeisflexible.By5years,childrenshouldbeconsumingadietconsistentwiththegeneralrecommendationsforadults(exceptforportionsizes).(SeeTable7onpage40.)
Providinghealthy,balancedandnutritiousmeals,controllingportionsizesandlimitingsnackingonfoodshighinfatandsugarintheearlyyearscanallhelptopreventchildrenbecomingoverweightorobese.TheCarolineWalkerTrustprovidesguidelinesforfoodprovisioninchildcaresettings(suchasday-carecentres,crèches,childmindersandnurseryschools)toencouragehealthyeatingfromanearlyage.100TheEarlyYearsFoundationStage(EYFS)101setsdownarequirementthat,wherechildrenareprovidedwithmeals,snacksanddrinks,thesemustbehealthy,balancedandnutritious.Inaddition,NICEguidance90setsoutthefollowingrecommendationsforhealthyeatinginchildcareandpre-schoolsettings.
• Offerbreastfeedingmotherstheopportunitytobreastfeedandencouragethemtobringinexpressedbreastmilk.
• Ensurefoodanddrinkmadeavailableduringthedayreinforcesteachingabouthealthyeating.Betweenmealsoffersnacksthatarelowinaddedsugar,honeyandsalt(forexample,fruit,milk,bread,andsandwicheswithsavouryfillings).
• Encouragechildrentohandleandtasteawiderangeoffoodsmakingupahealthydiet.
• Ensurecarerseatwithchildrenwheneverpossible.
Therearenogovernmentguidelinesfortheprovisionofphysicalactivityinpre-schools.However,recommendationshavebeenmadebytheDepartmentofHealth1andNICE6toencourageregularopportunitiesforenjoyableactiveplayandstructuredphysicalactivitysessionswithinnurseriesandotherchildcarefacilitiestohelppreventoverweightandobesity.Furthermore,theEYFSincludesarequirementthatchildrenmustbesupportedindevelopinganunderstandingoftheimportanceofphysicalactivityandmakinghealthychoicesinrelationtofood.101
Tackling overweight and obesity 39
Schools
Duringtheirschoolyears,peopleoftendeveloplife-longpatternsofbehaviourthataffecttheirabilitytokeeptoahealthyweight.Schoolsplayanimportantroleinthisbyprovidingopportunitiesforchildrentobeactiveandtodevelophealthyeatinghabits.NICErecommendsthatoverweightandobesitycanbetackledinschoolsbyassessingthewhole-schoolenvironmentandensuringthattheethosofallschoolpolicieshelpschildrenandyoungpeopletomaintainahealthyweight,eatahealthydietandbephysicallyactive,inlinewithexistingstandardsandguidance.Thisincludespoliciesrelatingtobuildinglayoutandrecreationalspaces,catering(includingvendingmachines)andthefoodanddrinkchildrenbringintoschool,thetaughtcurriculum(includingPE),schooltravelplansandprovisionforcycling,andpoliciesrelatingtotheNationalHealthySchoolsProgrammeandextendedschools.6Inpromotinghealthyweightthroughawhole-schoolapproach,allschoolsareexpectedtoofferaccesstoextendedschoolsby2010,providingacorerangeofactivitiesfrom8amto6pm,allyearround.Thiscanincludebreakfastclubs,parentingclasses,cookeryclasses,foodco-ops,sportsclubsanduseofleisurefacilities.
Psychological issues
Anumberofpsychologicalissuesimpactonoverweightandobesity.Thesecanincludelowself-esteemandpoorself-conceptandbodyimage.Itisimportanttotacklethebehaviourwhichincreasesoverweightandobesity,andprogrammedesignersshouldbeverycarefulnottoinadvertentlystigmatiseindividuals.18Studieshaveshownthatoverweightandobesityarefrequentlystigmatisedinindustrialisedsocieties,andtheyemphasisetheimportanceoffamilyandpeerattitudesinthegenerationofpsychologicaldistressinoverweightandobesechildren.102
Whenworkingwithchildren,itisparticularlyimportanttoworkwiththewholefamily,notjustthechild.102Childrenoftendonotmaketheirowndecisionsaboutwhatandhowmuchtheyeat.Theirparentswillinfluencewhattheyeatandanyoftheparents’ownfoodissues(suchasover-eating,anorexiaorbodyimage)canimpactonthefoodavailabletothechildandonthechild’ssubsequentrelationshipwithfood.Inmanycaseschildrenmaybequitehappybeingoverweightandnotexperiencinganypsychologicalilleffectsfromit,untiltheyaretakenbytheirparentstoseektreatment,whentheymaybegintofeelthatthereissomethingwrongwiththem,triggeringemotionalproblems.103
40 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Promoting healthier food choices Therecommendationsforpromotingahealthy,balanceddietarepresentedinChoosingabetterdiet:Afoodandhealthactionplan89andalsointheNICEguidelineObesity:theprevention,identification,assessmentandmanagementofoverweightandobesityinadultsandchildren.6
TheyarebasedontherecommendationsoftheCommitteeonMedicalAspectsofFoodandNutritionPolicy(COMA),theScientificAdvisoryCommitteeonNutrition(SACN),andtheWorldHealthOrganization(WHO).(SeeTable7below.)
Table 7 Standardpopulationdietaryrecommendations
Recommendation Current levels
Total fat89 Reducetonomorethan35%offoodenergy 38.5%104
Saturated fat89 Reducetonomorethan11%offoodenergy 14.7%104
Total carbohydrate89
Increasetomorethan50%offoodenergy 47.2%104
Sugars (added)89 Reducetomorethan11%offoodenergy(nomorethan10%oftotaldietaryenergy)
14.2%offoodenergy104
Dietary fibre89 Increasetheaverageintakeofdietaryfibreto18gperday
15.6gperday104
Salt105 Adults:Nomorethan6gofsaltperday 8.6gperday106
Infantsandchildren:Dailyrecommendedmaximumsaltintakes:
Boys Girls
0-6months–lessthan1gperday Breastmilkwillprovideallthesodiumnecessary107
7-12months–maximumof1gperday 0.8gperday107
1-3years–maximumof2gperday 1.4gperday108
4-6years–maximumof3gperday 5.3gperday109 4.7gperday109
7-10years–maximumof5gperday 6.1gperday109 5.5gperday109
11-14years–maximumof6gperday 6.9gperday109 5.8gperday109
Fruit and vegetables89
Increasetoatleast5portionsofavarietyoffruitandvegetablesperday
Adults: 3.8portionsperday10
Men:3.6portionsperday
Women:3.9portionsperday
Children(515years):3.3portionsperday11
Boys:3.2portionsaday
Girls:3.4portionsaday
Alcohol110, 111 Men:Amaximumofbetween3and4unitsofalcoholaday
Women:Amaximumofbetween2and3unitsofalcoholaday
Men:18.1meanunitsperweek9
Women:7.4meanunitsperweek9
Note: Withtheexceptionofalcohol,standardUKpopulationrecommendationsonhealthyeatingarebasedontherecommendationsoftheCommitteeonMedicalAspectsofFoodPolicy(COMA),theScientificAdvisoryCommitteeonNutrition(SACN)andtheWorldHealthOrganization(WHO).
Tackling overweight and obesity 41
Actiontopreventoverweightandobesityshouldincludethepromotionoflower-caloriealternatives(iereducingtotalfatandsugarconsumption),andtheconsumptionofmorefruitandvegetables,asthisnotonlyoffersawayofstokinguponlessenergy-densefoodbutalsohasimportanthealthbenefitsparticularlyintermsofhelpingtopreventsomeofthemainco-morbiditiesofobesity–namelycardiovasculardiseaseandcancer.Areductioninsaltisalsoimportant.Saltisoftenusedtomakefattyfoodsmorepalatable,socuttingbackonsaltwillhelppeopletocutbackonfats,andwillalsocontributetoloweringhighbloodpressure,whichisanotherco-morbidityofobesity.Thisadviceonhealthyeatingisreflectedinthenationalfoodguide,inTheeatwellplate(seeFigure7below).
TheGovernmentrecommendsthatallhealthyindividualsovertheageoffiveyearseatahealthy,balanceddietthatisrichinfruits,vegetablesandstarchyfoods.TheeatwellplateshowninFigure7isapictorialrepresentationoftherecommendedbalanceofthedifferentfoodgroupsinthediet.Itaimstoencouragepeopletochoosetherightbalanceandvarietyoffoodstohelpthemobtainthewiderangeofnutrientstheyneedtostayhealthy.Ahealthy,balanceddietshould:
• includeplentyoffruitandvegetables–aimforatleast5portionsadayofavarietyofdifferenttypes
• includemealsbasedonstarchyfoods,suchasbread,pasta,riceandpotatoes(includinghigh-fibrevarietieswherepossible)
• includemoderateamountsofmilkanddairyproducts–choosinglow-fatoptionswherepossible
• includemoderateamountsoffoodsthataregoodsourcesofprotein–suchasmeat,fish,eggs,beansandlentils,and
• belowinfoodsthatarehighinfat,especiallysaturatedfat,highinsugarandhighinsalt.
Figure 7 Theeatwellplate
The eatwell plate Use the eatwell plate to help you get the balance right. It shows how
much of what you eat should come from each food group.
Fruit and vegetables
Bread, rice potatoes, pasta
and other starchy foods
Meat, fish eggs, beans
and other non-dairy sources of protein
Foods and drinks high in fat and/or sugar
Milk and dairy foods
©CrowncopyrightmaterialisreproducedwiththepermissionoftheControllerandQueen’sPrinterforScotland.Source:FoodStandardsAgency
42 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
National action
Examplesofcurrentnationalactionincludethe5ADAYprogrammewhichaimstoincreaseaccesstoandconsumptionoffruitandvegetables;theFoodinSchoolsprogrammewhichpromotesawhole-schoolapproachandencouragesgreateraccesstohealthierchoiceswithinschools;andworkwithindustrytoaddresstheamountoffat,saltandaddedsugarinthediet(egthroughfoodlabelling,andsignpostingthenutrientcontentoffoodonpackaginglabels).
Forfurtherinformation,seeHealthyWeight,HealthyLives:Guidanceforlocalareas.2
Local action
Thereisawiderangeofpotentiallyeffectivepopulation-basedinterventionsinavarietyofsettings,frompromotingbreastfeedingbynewmotherstocampaignstopersuadeshopkeeperstostockfruitandvegetablesinareaswhereaccesswouldotherwisebedifficult(so-called‘fooddeserts’).
Tool D8providesdetailsofinterventionstopromotehealthierfoodchoicesinavarietyofdifferentsettings.
Tackling overweight and obesity 43
Building physical activity into our lives TherecommendationsforactivelivingthroughoutthelifecoursearepresentedinChoosingactivity:Aphysicalactivityactionplan,112whichaimstopromoteactivityforall,inaccordancewiththeevidenceandrecommendationssetoutintheChiefMedicalOfficer’sreport,Atleastfiveaweek.113(SeeTable8below.)
Table 8Physicalactivitygovernmentrecommendations
Recommendation Percentage meeting current recommendations
Children and young people113
For general health benefits from a physically active lifestyle, children and young people should achieve a total of at least 60 minutes of at least moderate intensity physical activity each day.
Atleasttwiceaweekthisshouldincludeactivitiestoimprovebonehealth(activitiesthatproducehighphysicalstressesonthebones),musclestrengthandflexibility.
ThePSAtargetfortheDepartmentforCulture,MediaandSportandtheDepartmentforEducationandSkills(nowtheDepartmentforChildren,SchoolsandFamilies)toincreasethepercentageofschoolchildrendoing2hours’high-qualityPEeachweekto85%by2008hasbeenmet.114TheGovernmentisnowaimingtooffereverychildandyoungperson(aged5-19)anextra3hoursperweekofsportingactivitiesprovidedthroughschools,colleges,clubsandcommunityproviders,by2011.115
Children (2-15 years)11
Allchildren:65%Boys:70%Girls:59%
Adults113
For cardiovascular health, adults should achieve a total of at least 30 minutes of at least moderate intensity physical activity a day, on five or more days a week.
Morespecificactivityrecommendationsforadultsaremadeforbeneficialeffectsforindividualdiseasesandconditions.Allmovementcontributestoenergyexpenditureandisimportantforweightmanagement.
To prevent obesity, in the absence of an energy intake reduction, 45-60 minutes of moderate intensity physical activity on at least five days of the week may be needed.
Forbonehealth,activitiesthatproducehighphysicalstressesonthebonesarenecessary.
TheLegacyActionPlansetagoalofseeingtwomillionpeoplemoreactiveby2012throughfocusedinvestmentinsportinginfrastructureandbettersupportandinformationforpeoplewantingtobemoreactive.116
Adults (16-75+ years)10
Alladults:34%Men:40%Women:28%
Older people113
The recommendations given above for adults are also appropriate for older adults.
Olderpeopleshouldtakeparticularcaretokeepmovingandretaintheirmobilitythroughdailyactivity.Additionally,specificactivitiesthatpromoteimprovedstrength,coordinationandbalanceareparticularlybeneficialforolderpeople.
Adults aged 65-74 years11
Alladults:19%Men:21%Women:16%
Adults aged 75+ years11
Alladults:6%Men:9%Women:4%
Therecommendedlevelsofactivitycanbeachievedeitherbydoingallthedailyactivityinonesession,orthroughseveralshorterboutsofactivityof10minutesormore.Theactivitycanbelifestyleactivity(activitiesthatareperformedaspartofeverydaylife),orstructuredexerciseorsport,oracombinationofthese.113
44 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Actiontopreventoverweightandobesityshouldincludepromotingeverydayparticipationinphysicalactivitysuchasbriskwalking,stair-climbingoractivetravel(buildinginawalk,cyclingtowork,orgettingoffabusortrainastopearlier).Otheractivitiessuchasactiveconservation,gardeningandactivitiesthattakeplaceinthenaturalenvironmenthavepsychologicalaswellasphysicalhealthbenefits.
Actionshouldalsoincludethepromotionofasupportivebuiltenvironmenttoencourageactivetravelsuchascyclingandwalking,toencouragetheuseofparksandgreenspaces,andtoencourageopportunitiesforactiveandunstructuredplay.GuidancefromNICEsetsoutrecommendationsonhowtoimprovethephysicalenvironmentinordertoencourageandsupportphysicalactivity.117Theguidanceemphasisesthatenvironmentalfactorsneedtobetackledinordertomakeiteasierforpeopletobeactiveintheirdailylives.Therecommendationsincludeensuringthat:
• planningapplicationsfornewdevelopmentsalwaysprioritisetheneedforpeople(includingthosewhosemobilityisimpaired)tobephysicallyactiveasaroutinepartoftheirdailylife
• pedestrians,cyclistsandusersofothermodesoftransportthatinvolvephysicalactivityaregiventhehighestprioritywhendevelopingormaintainingstreetsandroads(thisincludespeoplewhosemobilityisimpaired)
• openspacesandpublicpathscanbereachedonfootorbybicycle,andaremaintainedtoahighstandard
• newworkplacesarelinkedtowalkingandcyclingnetworks
• staircasesareattractivetouseandclearlysignpostedtoencouragepeopletousethem,and
• playgroundsaredesignedtoencouragevariedandphysicallyactiveplay.
Otherimportantactionincludesadvicetodecreasesedentarybehavioursuchaswatchingtelevisionorplayingcomputergamesandtoconsideralternativessuchasdance,footballorwalking.
Recommendationstosupportpractitionersindeliveringeffectiveinterventionstoincreasephysicalactivity,includingbriefadviceinprimarycare,havebeendevelopedbyNICE.6Actionalreadyunderwayinprimarycareincludesthefollowing.
• PatientswholeadinactivelifestylesandareatriskofcardiovasculardiseasecanreceiveadviceandsupportonphysicalactivityduringvisitstotheirlocalGP,aspartofanewapproachthatisbeingpilotedinLondonsurgeries.
• TheDepartmentofHealthisdevelopingaLet’sgetmovingsupportpackforpatientswhichreliesoncollaborativeworkbetweenlocalauthoritiesandPCTstomeettheneedsofpeopleinthecommunity.Thispacksupportsbehaviourchangeandsignpostspeopletobothoutdoorandindooropportunitiesforphysicalactivity,inanefforttoencouragethosemostatriskofinactivelifestylestobecomemoreactive.BasedonevidencefromtheNICEguidanceonbriefinterventionstoincreasephysicalactivity,andusingtheGeneralPractitioners’PhysicalActivityQuestionnaireandmotivationalinterviewingtechniques,theLet’sgetmovingphysicalactivitycarepathwaymodelisbeingevaluatedintermsofcostandfeasibility.ThisiswithaviewtoadoptingthecarepathwayinGPpracticesthroughoutEnglandfromearly2009.
National action
ExamplesofcurrentnationalactionincludetheNationalStep-o-MeterProgrammewhichaimstoincreaselevelsofwalkinginsedentary,hard-to-reachand‘at-risk’groups,andthefreeswimminginitiativewhichisdesignedtoextendopportunitiestoswimandtomaximisethehealthbenefitsofwiderparticipationinswimming.116Inaddition,theGovernmentispromotingactiveplaythroughthePlayStrategy.118
Tackling overweight and obesity 45
Forfurtherinformation,seeHealthyWeight,HealthyLives:Guidanceforlocalareas.2
Local action
Population-basedapproachesatlocallevelrangefromtargetingchildrenathomeandschoolbypromotingactiveplayandbuildingmorephysicaleducationandsportssessionsintothecurriculumandafterschool,totargetingadultsintheworkplacebyprovidingfacilitiessuchasshowersandbikeparkstoencouragewalkingorcyclingtowork.
Cycletrainingisanimportantlifeskill.TheGovernmentwantsparents,schoolsandlocalauthoritiestoplaytheirpartinhelpingasmanychildrenaspossibletogettheirBikeabilityaward.CyclingEnglandgrantshavebeengiventolocalauthoritiesandschoolsportspartnershipstosupportLevel2Bikeabilitytrainingforsome46,000children.AkeypartofthenextphaseofCyclingEngland’sprogrammewillbetoworkwithmorelocalauthoritiestoincreaseBikeabilitytrainingacrossEngland.
LocalExerciseActionPilots(LEAPs)werelocallyrunpilotprogrammestotestandevaluatenewwaysofencouragingpeopletotakeupmorephysicalactivity.Usefulevaluationinformationonthedifferentpilotsisavailableatwww.dh.gov.uk
Tool D8providesdetailsofinterventionstoincreasephysicalactivityinavarietyofdifferentsettings.
46 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Creating incentives for better health Theworkplacemayhaveanimpactonaperson’sabilitytomaintainahealthyweightbothdirectly,byprovidinghealthyeatingchoicesandopportunitiesforphysicalactivity(suchastheoptiontousestairsinsteadoflifts,staffgym,cycleparkingandchangingandshowerfacilities),andindirectly,throughtheoverallcultureoftheorganisation(forexample,throughpoliciesandincentiveschemes).Takingactionmayresultinsignificantbenefitforemployersaswellasemployees.6
GuidancefromNICEsetsoutrecommendationsonhowworkplacescanprovideopportunitiesforstafftoeatahealthydietandbephysicallyactive,through:
• activeandcontinuouspromotionofhealthychoicesinrestaurants,hospitality,vendingmachinesandshopsforstaffandclients,inlinewithexistingFoodStandardsAgencyguidance
• workingpracticesandpolicies,suchasactivetravelpoliciesforstaffandvisitors
• asupportivephysicalenvironment,suchasimprovementstostairwellsandprovidingshowersandsecurecycleparking
• recreationalopportunities,suchassupportingout-of-hourssocialactivities,lunchtimewalksanduseoflocalleisurefacilities.6
NICErecommendedthatincentiveschemes(suchaspoliciesontravelexpenses,thepriceoffoodanddrinkssoldintheworkplaceandcontributionstogymmembership)thatareusedinaworkplaceshouldbesustainedandbepartofawiderprogrammetosupportstaffinmanagingweight,improvingdietandincreasingactivitylevels.6
National action
Well@Workpilotshavebeensetuptotestwaysofmakingworkplaceshealthierandmoreactive.Also,theDepartmentforTransportispromotingtravelplanningwhichencouragesschools,workplacesandcommunitiestoconsidersustainabletraveloptionswhichalsoincreasephysicalactivity.
Tackling overweight and obesity 47
Personalised support for overweight and obese individuals Aswellaspreventivemeasures,thesituationofthosewhoarealreadyoverweightorobesealsoneedstobeconsideredasacrucialelementofanystrategy.Thenumberofoverweightandobeseindividualsisforecasttocontinuerising,soitisimperativethateffectiveservicesareavailabletohelpthesepeopletomeetthepersonalchallengeofreducingtheirBMIandmaintainingahealthyweight.2
Manypeoplecurrentlychoosetofacethechallengeoflosingormaintainingweightaloneorwiththeassistanceofcommercialweightmanagementorganisations.However,theNHSisperfectlyplacedtoidentifyoverweightandobesity,provideadviceonhealthylifestylesandreferindividualstoweightmanagementservices(NHSandnon-NHSbased).Inaddition,thethirdsector,socialenterprises(businesseswithprimarilysocialobjectives)andotherprovidersareincreasinglyplayinganimportantroleinensuringthatmoreindividualscanaccesseffectiveweightmanagementservices.
However,primarycaretrustsandlocalauthoritiesneedtocommissionmoreweightmanagementservicesinordertosupportoverweightandobeseindividuals,particularlychildren,inmovingtowardsahealthyweight.Thiswillensurethatagreaternumberofchildrenandtheirfamilieshaveaccesstoappropriatesupport.2
Identification of overweight and obesity
AssessingwhetheranindividualisoverweightorobeseisundertakenprimarilybyprimarycarepractitionerssuchasGPs,practicenurses,healthvisitors,communitynurses,communitydietitians,midwivesandcommunitypharmacists.Toensurethatthereisasystematicapproachtotheassessmentandmanagementofoverweightandobesity,clinicalguidancehasbeenestablished.
ClinicalguidanceExamplesofguidanceavailableareshowninTable9onthenextpage.However,twotonoteinEnglandarefromtheNationalInstituteforHealthandClinicalExcellence(NICE)andtheDepartmentofHealth:
• NICEhasdevelopedevidence-basedguidancefortheprevention,identification,assessmentandmanagementofoverweightandobesityinchildrenandadults.6Theguidanceisbroad,focusingonclinicalandnon-clinicalmanagementwiththefollowingaims:a)tostemtherisingprevalenceofobesityanddiseasesassociatedwithit;b)toincreasetheeffectivenessofinterventionstopreventoverweightandobesity;andc)toimprovethecareprovidedtoobeseadultsandchildren,particularlyinprimarycare.TheNICEguidelineonobesityalsoprovidesguidanceontheuseoftheanti-obesitydrugsorlistatandsibutramine,andontheplaceofsurgicaltreatmentforchildrenandadults.(Drugtreatmentisgenerallynotrecommendedforchildrenunder12years.)6Guidanceontheanti-obesitydrugrimonabantforadultsonlyisalsoavailableinaseparatedocument.119
• TheDepartmentofHealthhasalsodevelopedevidence-basedguidanceforuseinEngland.Thishasbeenproducedtosupportprimarycareclinicianstoidentifyandtreatchildren,youngpeopleandadultswhoareoverweightorobese.120
Clinicalcarepathwaysareincludedwithinthesesetsofguidance.Theydirecthealthcareprofessionalstoappropriatemeasuresforassessingandmanagingoverweightandobesity.TheDepartmentofHealth’scarepathwaysaretargetedexclusivelyatprimarycarecliniciansinEngland.Thereisoneforusewithchildrenandyoungpeopleandoneforusewithadults.120NICEhasdevelopedmuchbroaderclinicalcarepathways,oneforusewithchildrenandoneforuse
48 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
withadults.6Thesepathwaysfocusontheassessmentandmanagementofoverweightandobesityinprimary,secondaryandtertiarycare.NICEhasalsotakenintoaccountthepreventionandmanagementofoverweightandobesityinnon-NHSsettingssuchasschools,workplacesandthebroaderenvironment.
ReferhealthcareprofessionalstoTool E1 Clinicalcarepathways
Table 9 Clinicalguidanceformanagingoverweightandobesityinadults,childrenandyoungpeople
Adults Children and young people
England NationalInstituteforHealthandClinicalExcellence(NICE)(2006)6
www.nice.org.uk
DepartmentofHealth(2006)120
www.dh.gov.uk
NationalInstituteforHealthandClinicalExcellence(NICE)(2006)6
www.nice.org.uk
DepartmentofHealth(2006)120
www.dh.gov.uk
United Kingdom
ProdigyKnowlege(2001)121
www.prodigy.nhs.uk/obesity
NationalObesityForum(2004)123
www.nationalobesityforum.org.uk
NationalObesityForum(2005)124
www.nationalobesityforum.org.uk
RoyalCollegeofPaediatricsandChildHealthandNationalObesityForum(2004)122
www.rcpch.ac.uk
Scotland ScottishIntercollegiateGuidelinesNetwork(SIGN)(1996)66
www.sign.ac.uk
Note:Thisguidanceiscurrentlyunderreview.
ScottishIntercollegiateGuidelinesNetwork(SIGN)(2003)23
www.sign.ac.uk
United States NationalHeart,LungandBloodInstitute(1998)125
www.nhlbi.nih.gov
Australia NationalHealthandMedicalResearchCouncil(2003)126
www.health.gov.au
NationalHealthandMedicalResearchCouncil(2003)127
www.health.gov.au
AssessmentTheimportantaspectofassessmentisthatpeoplewithgreatestclinicalneedareprioritisedandofferedsystematicweightmanagement.ThiscanbeinbothNHSandnon-NHSsettings.ThisisasubstantialtaskandpracticeswillneedappropriatesupportfromPCTsandstrategichealthauthorities.
Itisessentialthatpracticesnotonlyrecordpatients’weightdetailsasoutlinedinclinicalguidance,butalsomaintainaregisterofthesepatientsincludingtheirriskfactors.Asanincentivetorecordandstorethisinformation,participatingpracticescanusetheQualityManagementandAnalysisSystem(QMAS)centraldatabase.Thiscanalsobeusedforlocalepidemiologicalanalysis.Furthermore,theadditionofobesitytotheQualityandOutcomesFramework(QOF)isanotherincentiveforGPsurgeriestomaintainaregisterofpatientswhoareobese.Eightpointsareofferedtothosesurgerieswhodorecordadults’weightdetails.
Tackling overweight and obesity 49
Referhealthcareprofessionalsto:
Tool E2 Earlyidentificationofpatients
Tool E3 Measurementandassessmentofoverweightandobesity–ADULTS
Tool E4 Measurementandassessmentofoverweightandobesity–CHILDREN
ProvisionofadviceTheGovernmentislookingtoprovidegeneralhealthcareadvicetothepopulationthroughupdatingtheNHSChoiceswebsite(seewww.nhs.uk),andalsothroughthenationalsocialmarketingcampaign(seepage142).However,healthcareprofessionalsclearlyhaveanextremelyimportantroletoplayintheprovisionofadviceonhealthierlifestyles,andcommissionerswillwanttobeassuredthatthisadviceisbeinggiven.
NICEhasidentifiedthathealthcareprofessionalsplayanimportantandhighlycost-effectiveroleinprovidingbriefadviceonphysicalactivityinprimarycare.Theyrecommendthatprimarycarepractitionersshouldtaketheopportunity,wheneverpossible,toidentifyinactiveadultsandtoadvisethemtoaimfor30minutesofmoderateactivityonfivedaysoftheweek(ormore).128
ItisnotonlyGPswhocanprovideadvicetooverweightorobeseindividuals.Healthcareprofessionalsinarangeofsettingsplayanimportantrole.Examplesmayinclude:practicenurses;dentistswhoprovidesupportrelatingtooralhealth;healthtrainerswhoworkwithincommunitiespromotinghealthylifestyles;andpharmacistswhocomeintocontactwithpatientswhomaynotseekadvicefromtheirGP.TheRoyalPharmaceuticalSocietyofGreatBritain129hasproducedguidanceforcommunitypharmacistswhoprovideadviceonoverweightandobesity.Seewww.rpsgb.org.uk
TheGovernmenthasrecognisedtheimportanceofdevelopingtheadvice-givingroleofhealthprofessionals,inordertoimprovelocalservicestopatients.ResearchundertakenfortheChoosinghealth8consultationfoundthatsomehealthcareprofessionals,includingGPs,wereuncomfortableaboutraisingtheissueofweightwithpatients.Theylackedconfidencewhenitcametogivingpatientsadviceandalsotheywereunawareofwhatweightlossserviceswereavailable.Improvingthetrainingoffront-lineprimarycarestaff–intermsofnutrition,physicalactivityandhelpingpatientstochangelifestyles–isanimportantrequirement.Inaddition,knowingwheretoaccessresourcesforpatients,supplyingusefulliteratureandprovidingcorrectinformationarecrucialforaneffectiveandefficientadviceservice.
Referhealthcareprofessionalsto:
Tool E5 Raisingtheissueofweight–DepartmentofHealthadvice
Tool E6 Raisingtheissueofweight–perceptionsofoverweighthealthcareprofessionalsandoverweightpeople
Tool E7 Leafletsandbookletsforpatients
Tool E8 FAQsonchildhoodobesity
Tool E9 TheNationalChildMeasurementProgramme(NCMP)
50 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
Note:DietitiansinObesityManagementUK(DOMUK)130haveproducedadirectoryprovidingdetailsofarangeoftraining.Thedirectoryspecificallytargetsobesitymanagementandprovidescontactdetailsoftrainers.Thisdirectoryiscurrentlybeingupdated.ThenewversionwillbeavailablebySpring2009.
Referral to services
Arangeofpractitionersarerequiredtoreferoverweightandobesechildrenandadultstoappropriateservices,suchasweightmanagementprogrammes.Threeexamplesofprogrammesandschemestowhichpractitionersmightreferoverweightorobesechildrenandadultsaregivenbelow,followedbytherelevantNICEguidanceaboutthem.
1 ExercisereferralschemesFollowingonfromassessment,somepatientsmaybenefitfromanexercisereferral.TheDepartmentofHealthhaspublishedaNationalQualityAssuranceFrameworkforexercisereferralschemes.131Thisprovidesguidelineswiththeaimofimprovingstandardsamongexistingexercisereferralschemes,andhelpingthedevelopmentofnewones.TheFrameworkfocusesprimarilyonthemostcommonmodelofexercisereferralsystem,wheretheGPorpracticenursereferspatientstofacilitiessuchasleisurecentresorgymsforsupervisedexerciseprogrammes.TheNationalQualityAssuranceFrameworkprovidesarangeoftoolsforuseinbothprimaryandsecondaryprevention.Seewww.dh.gov.uk
Note:NICEguidanceonexercisereferralschemes128–ThePublicHealthIndependentAdvisoryCommittee(PHIAC)determinedthattherewasinsufficientevidencetorecommendtheuseofexercisereferralschemestopromotephysicalactivityotherthanaspartofresearchstudieswheretheireffectivenesscanbeevaluated.NICErecommendsthatpractitioners,policymakersandcommissionersshouldonlyendorseexercisereferralschemestopromotephysicalactivityiftheyarepartofaproperlydesignedandcontrolledresearchstudytodetermineeffectiveness.Measuresshouldincludeintermediateoutcomessuchasknowledge,attitudesandskills,aswellasmeasuresofphysicalactivitylevels.Individualsshouldonlybereferredtoschemesthatarepartofsuchastudy.128
2 WalkingandcyclingschemesPrimarycareteamsmayalsoconsiderreferringpatientsdirectlytowalkingorcyclingprogrammes.
TheWalkingtheWaytoHealthInitiative(WHI)oftheBritishHeartFoundationandtheCountrysideAgencyaimstoimprovethehealthandfitnessofpeoplewhodolittleexerciseorwholiveinareasofpoorhealth.Theschemeofferslocalwalksinawidevarietyofareas.TheNationalStep-O-MeterProgramme(NSP),managedbytheCountrysideAgency,aimstomakeitpossibleforNHSpatients(especiallythosewhotakelittleexercise)tohavetheuseofastep-o-meter(pedometer)freeofchargeforalimitedloanperiod.Step-o-metersarebeingmadeavailabletopatientsthroughhealthprofessionals.FormoreinformationaboutWHIandNSPseewww.whi.org.uk
Cyclingreferralprogrammesarearelativelynewinnovation,butcanbeusefulforpeoplewhoprefercyclingtowalkingorgym-basedexercise.Formoreinformation,Healthonwheels:Aguidetodevelopingcyclingreferralprojects132isavailablefromCyclingEngland.Seewww.cyclingengland.co.uk
Note:NICEguidanceonpedometers,walkingandcyclingschemes128–PHIACdeterminedthattherewasinsufficientevidencetorecommendtheuseofpedometersandwalkingandcyclingschemestopromotephysicalactivity,otherthanaspartofresearchstudieswhereeffectiveness
Tackling overweight and obesity 51
canbeevaluated.However,theyconcludedthatprofessionalsshouldcontinuetopromotewalkingandcycling(alongwithotherformsofphysicalactivitysuchasgardening,householdactivitiesandrecreationalactivities),asameansofincorporatingregularphysicalactivityintopeople’sdailylives.
NICErecommendsthatpractitioners,policymakersandcommissionersshouldonlyendorsepedometerschemesandwalkingandcyclingschemestopromotephysicalactivityiftheyarepartofaproperlydesignedandcontrolledresearchstudytodetermineeffectiveness.Measuresshouldincludeintermediateoutcomessuchasknowledge,attitudesandskills,aswellasmeasuresofphysicalactivitylevels.
3 Weightcontrolgroupsand‘weightmanagementonreferral’(or‘slimmingonreferral’)
Otherexamplesofinterventionstomanageoverweightandobesityareweightcontrolgroupsand,morerecently,weightmanagementonreferralschemes.ManyweightcontrolgroupshavebeensetupaspartofPCTlocalobesityprogrammes.Followinganassessmentofthepatientandifappropriate,theGPrefersthepatienttoalocalgroup.
AnumberofPCTsarealsoworkingwithcommercialslimmingorganisationstoimplementweightmanagementonreferralschemesforadults.
Note:NICEguidanceonweightmanagementonreferralschemes6–NICEsuggeststhatprimarycareorganisationsandlocalauthoritiesshouldrecommendtopatients,orconsiderendorsing,self-help,commercialandcommunityweightmanagementprogrammesonlyiftheyfollowbestpracticeby:
• helpingpeopleassesstheirweightanddecideonarealistichealthytargetweight(peopleshouldusuallyaimtolose5-10%oftheiroriginalweight)
• aimingforamaximumweeklyweightlossof0.5-1kg
• focusingonlong-termlifestylechangesratherthanashort-term,quick-fixapproach
• beingmulti-component,addressingbothdietandactivity,andofferingavarietyofapproachesusingabalanced,healthy-eatingapproach
• recommendingregularphysicalactivity(particularlyactivitiesthatcanbepartofdailylife,suchasbriskwalkingandgardening)andofferingpractical,safeadviceaboutbeingmoreactive
• includingsomebehaviour-changetechniques,suchaskeepingadiary,andadviceonhowtocopewith‘lapses’and‘high-risk’situations
• recommendingand/orprovidingongoingsupport.
Commissioning and delivery of interventions
TheGovernmentissupportingthecommissioningofmoreweightmanagementservicesinlocalareas.Moreservicesareneededtosupportoverweightandobeseindividuals,particularlychildren,inmovingtowardsahealthierweight.NICEprovidesguidanceonthetypesofservicestobecommissioned.Itstatesthatinterventionsforchildrenshouldbemulti-component–coveringhealthyeating,increasedphysicalactivityandbehaviourchange–andshouldalsoinvolveparentsandcarers.6Theseguidelinesshouldbefollowed.Someexamplesofservicesthatpractitionerscanreferchildrenandadultstoaregivenonpage50.
RefertoTool D12 Commissioningweightmanagementservicesforchildren,youngpeopleandfamilies.
52 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
The challenge and the opportunities
• Oneofthegreatestchallengesistomaketherapeuticweightmanagementineverydayprimarycarepracticable,effectiveandsustainable.ResearchintoprimarycaremanagementintheUK133foundthat,although55%ofrespondentsbelievedthatobesitywasoneoftheirtoppriorities,fewerthanhalfhadbeeninvolvedinsettingupweightmanagementclinics,andthemajorityofgeneralpractices(69%)hadnotestablishedsuchclinics.
• TheQualityandOutcomesFramework(QOF)fortheGPcontract134,135providesincentivesforassessingBMIandassociatedriskfactors.
• Choosinghealththroughpharmacy:Aprogrammeforpharmaceuticalpublichealth20052015136lists10keypublichealthrolesforpharmacy,oneofwhichistoreduceobesityamongchildrenandthepopulationasawhole.Communitypharmacistsandtheirstaffcanplayanimportantroleinprovidingtargetedinformationandadviceondietandphysicalactivityandofferingweightreductionprogrammes.Pharmacieswillalsobeabletoreferpeopledirectlyonto‘exerciseonreferralschemes’ratherthanindirectlythroughGPs.129Overweightandobesityareissuesrelatedtoinequalities,andcommunitypharmaciesareparticularlywelllocatedtoassistwithweightmanagement,asmanyofthemarebasedclosetoresidentialareasandhavefewphysicalandpsychologicalbarriersrelatedtoaccess.
• Theroleofhealthtrainers,asoutlinedinChoosinghealth:Makinghealthychoiceseasier8 istoprovidepersonalisedhealthylifestyleplansforindividualstoimprovetheirhealthandpreventdisease.Healthtrainerswillbeeitherlaypeopledrawnfromthemoredisadvantagedcommunities,orhealthandotherprofessionalsspeciallytrainedinofferingbasicadviceonhealthylifestyles,andmotivationalcounselling.
• TheGovernmentalsorecognisesthevitalroleplayedbythecommercialsector,thethirdsector,socialenterprisesandotherprovidersinensuringthatmorepeoplecanaccesseffectiveservicesandinincreasingnationalunderstandingofwhatworks.
C Developing a local overweight and obesity strategy
54 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
This section of the toolkit provides a practical guide to help commissioners in primary care trusts (PCTs) and local authorities develop a local strategy that fits into the framework for local action published in Healthy Weight, Healthy Lives: Guidance for local areas.2
The framework has five sections:
• Understanding the problem in your area and setting local goals outlines how to estimate local prevalence of obesity among children and adults, how to estimate the local cost of obesity and how to identify priority groups and set local goals.
• Local leadership outlines the importance of a multi-agency approach to tackling obesity. It also discusses the significance of a senior-level lead to coordinate activity and details how to bring partners together through a sub-committee or partnership board.
• Choosing interventions provides details on how to plan specific interventions to achieve local targets of reducing overweight and obesity by changing families’ attitudes and behaviours. It also provides details on how to commission services.
• Monitoring and evaluation outlines the importance of monitoring and evaluation and details the key elements of a successful evaluation strategy.
• Building local capabilities provides details on how to commission training to support staff in promoting physical activity, good nutrition and the benefits of a healthy weight.
Figure 8 on page 56 indicates how the tools in section D can help commissioners to further develop each section.
Developingalocaloverweightandobesitystrategy 55
WorldClassCommissioningThistoolkitisaimedatcommissionersandassuchallthetoolsinsectionDaredesignedtosupportdifferentstagesofthecommissioningprocess.IndeedthefivestepsthataresetoutinHealthy Weight, Healthy Lives: Guidance for local areas2 representasimplifiedversionofthedifferentstagesofcommissioningthattheWorldClassCommissioningprogrammesetsout.
LocalareaswillfinditvaluabletoreadthistoolkitinconjunctionwithWorldClassCommissioningpublications,whichcanbefoundatwww.dh.gov.uk
ToolD1isachecklistofstepstotaketohelpensuretheWorldClassCommissioningofhealthandwellbeingservices.
56 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Figure8A‘roadmap’fordevelopingalocaloverweightandobesitystrategy
Tool D1 Commissioning for health and
wellbeing: a checklist
Understanding the problem in your area and setting local goals page 58
Tool D2 Obesity prevalence
ready-reckoner
Tool D3 Estimating the local
cost of obesity
Tool D4 Identifying priority
groups
Tool D5 Setting local
goals
Local leadership page 61
Tool D6 Local
leadership
Choosing interventions page 63
Tool D7 What success looks like – changing behaviour
Tool D8
Choosing interventions
Tool D9
Targeting behaviours
Tool D10 Communicating
with target groups – key
messages
Tool D11
Guide to the procurement
process
Tool D12 Commissioning weight management services for children, young people and families
Tool D13
Commissioning social marketing
Monitoring and evaluation page 68
Tool D14 Monitoring and
evaluation: a framework
Building local capabilities page 70
Tool D15
Useful resources
Developingalocaloverweightandobesitystrategy 57
Childobesity:alocalpriorityTheNHSOperatingFrameworkrequiresallPCTstodevelopplanstotacklechildobesity,andtoagreelocalplanswithstrategichealthauthorities(SHAs).Inaddition,withintheLocalAreaAgreement(LAA)NationalIndicatorSet(NIS),137therearetwoindicatorsspecificallyonchildobesity:
• NI55–obesityamongprimaryschoolagechildreninReception,and
• NI56–obesityamongprimaryschoolagechildreninYear6.
ThesealignwiththeVitalSigns138indicatoronchildobesity.
TherearealsootherindicatorswithintheNISthatarerelevanttotacklingchildobesityandthatworktowardsthenationalambition.Theseinclude:breastfeeding(NI53),take-upofschoollunches(NI52),theemotionalhealthofchildren(NI50),childrenandyoungpeople’sparticipationinhigh-qualityphysicaleducationandsport(NI57),andtraveltoschool(NI198).
SeveralindicatorswithintheNISarerelevanttoadultweightissues,includingadultparticipationinsport(NI8).Indicatorsrelatingtoareductioninroadtrafficaccidents(NI47andNI48)arerelevanttoproducingasafeenvironmentandthustophysicalactivityandweightmanagementinbothchildrenandadults.
ToolD5Setting local goalsprovidesalistofnationalindicatorsrelevanttotacklingobesity.
58 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Understandingtheprobleminyourareaandsettinglocalgoals
Atthestartofdevelopingalocalstrategytotackleoverweightandobesity,localareasneedtoknowwhattheproblemisintermsofprevalenceandcosts,whotheprioritygroupsareandwhatreductioninprevalencetheyneedtoaimfor.
Anobesitystrategyshouldbebuiltonanunderstandingoftheprobleminyourarea.Localorganisationsshouldthereforeseektoobtaininsighton:
• thelocalprevalenceofoverweightandobesity
• thelocalcostofoverweightandobesitynow,andinthefutureifnofurtherstepsaretaken,and
• theprioritygroupswhodrivethecosts.
Completingthesestepswillhelpprimarycaretrusts(PCTs)andlocalauthoritiestosetclearlocalgoals.
Thelocalprevalenceofoverweightandobesity
Estimating the prevalence of overweight and obesity among children Local(PCTandlocalauthority)prevalencedataforchildreninReceptionandYear6canbeobtainedthroughtheNationalChildMeasurementProgramme(NCMP).Establishedin2005,theNCMPisoneelementoftheGovernment’sworkprogrammeonchildhoodobesity,andisoperatedjointlybytheDepartmentofHealthandtheDepartmentforChildren,SchoolsandFamilies.Everyschoolyear,childreninReception(4-5yearolds)andYear6(10-11yearolds)areweighedandmeasuredtoinformlocalplanninganddeliveryservicesforchildren,andtogatherpopulation-levelsurveillancedatatoallowanalysisoftrendsingrowthpatternsandobesity.Theprogrammealsoseekstoraiseawarenessoftheimportanceofhealthyweightinchildren.Themostrecentresults,whicharebrokendowntoPCTlevel,canbedownloadedfromwww.ic.nhs.uk
Note:Seewww.dh.gov.ukforguidancetoPCTsonarrangementsformeasuringtheheightandweightofprimaryandmiddleschoolchildrenaspartoftheNCMP,andforadviceonhowtouploadtheinformationtotheInformationCentreforhealthandsocialcare.139Guidancehasbeendevelopedforschools140andisavailableatwww.teachernet.gov.uk
TheNCMPonlyprovidesdataforchildrenaged4-5and10-11.Toestimatethelocalprevalenceofobesityacrossdifferentageranges,childoverweightandobesityprevalencedataforstrategichealthauthorities/governmentofficeregionscanbeobtainedthroughtheHealthSurveyforEnglandstartingfrom2006.11
ToolD2isaready-reckonerwhichwillhelpyouestimatetheprevalenceofobesityamongchildrenaged1-15yearsinyourlocalarea,usingtheUKNationalBMIPercentileClassification.
Estimating the prevalence of overweight and obesity among adults TheHealthSurveyforEnglandprovidesdataontheproportionofadultswhoareoverweightandobese.Robustestimatesofadultobesityatstrategichealthauthoritylevelareavailablebasedonthree-yearrollingaverages.ThesedatacanbeappliedtothelocaldemographicprofileofaPCTtocalculateanestimateofprevalence.
Developingalocaloverweightandobesitystrategy 59
ToolD2isaready-reckonertohelpyouestimatetheprevalenceofobesityamongadultsinyourlocalarea.
Localcostofobesity
Estimating the local cost of obesity Aswithallpublichealthchallenges,themajorityofthecostsofobesity(andalsothebenefitsfromtacklingit)fallinthefuture.Thereforetomakethecaseforinvestingnowtoachievebenefitinthefuture,itisnecessarytoestimatethesefuturecosts.However,estimatingthecostsofoverweightandobesityatlocallevelisdifficult,anddependson:
• thedegreeofcomplexityusedinmodelling
• thevalidityofthevariousassumptionsusedincalculations
• theclinicalguidelinesandprescribingregimesfollowed,and
• thecurrentcostsofdrugs.
Approximatevaluescanbederivedbyapplyingnationalfigurestothelocalestimatesofprevalence,ascalculatedusingtheprocessdescribedinToolD2.
ToolD3providesthecostsofobesityandelevatedBMI(overweightplusobesity)toprimarycaretrusts,basedonnationalestimatesofcostscalculatedbyForesight(selectedyears2007,2010and2015)andthenationalresourceallocationformulawhichisbasedonlocalneeds.
Identifyingprioritygroups
Prioritising families with children aged 2-11 Localpriorityshouldbegiventochildrenandyoungpeopleunder11,asstatedintheChildHealthPSA(seepage35).DatafromtheNationalChildMeasurementProgramme(NCMP)willenablePCTs,localauthoritiesandotherpartnerstogainabetterunderstandingofchildren’sneedsintheirarea.Thiswillenablelocalorganisationstotargetresourcesandinterventionstothosepartsoftheirlocalareawhereresourcesandinterventionsaremostneeded,andensureeffortsaredirectedmoreeffectively.Thedatawillalsoallowfornationalanalysisoftrendsinobesity.Gotowww.dh.gov.ukforguidanceonhowtoweighandmeasurechildren,otherNCMPresources,andforinformationongivingparentstheirchild’sresults.
AnotherwayofhelpingtoprioritisegroupslocallyisbyusingtheDepartmentofHealth’sresearchintofamilybehaviourinrelationtodietandactivity.Thepurposeofthisresearchistobetterunderstandthebehavioursthatcanleadtoobesity,andsofutureill-health,andtounderstandwhichbehavioursarecommonwithindifferentgroupsorclustersinsociety.This‘segmentation’analysisshowedthatchildrenaged2-11yearsandtheirfamiliescouldbedividedintosixclustersbasedontheirbehaviours.Ofthese,threeclusterswerefoundtobemost‘atrisk’ofdevelopingobesity–andindeedtheseclustershadthehighestratesofadultandchildobesity–andhavebeenprioritisedfornationalactionwithinthenationalsocialmarketingprogramme(seepage142).
Thethree‘atrisk’clusterscanalsobeusedbylocalareastobettertargetinterventionstopromotehealthyweight,leadingtomoreeffectiveinterventionsanduseofpublicresources.LocalauthoritiesandPCTscanaccessadraftreportthatdescribesthesixclustersindetailviatheobesityleadintheirRegionalPublicHealthGroup,orbyemailinghealthyweight@dh.gsi.gov.uk.Afinalversionofthereportwillbepublishedinlate2008,informedbycontinuingresearch,andtheCross-GovernmentObesityUnitwelcomesfeedbackonthedraftreport.
60 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
ToolD4presentsastep-by-stepguideonhowtousethenationalsegmentationanalysisatalocallevel,includinginformationonwhocanassistinmappinghigh-riskgroups.
Settinglocalgoals
Alllocalareashavealreadysettheirgoalsfortacklingobesityovertheperiod2008/09to2010/11,eitherthroughPCTplans,oradditionallyinLocalAreaAgreements(LAAs).However,thistoolkitsummarisestheDepartmentofHealth’sguidanceonsettinglocalgoals,141asitisusefultorememberwhatunderpinsthosetargets.
ToolD5providesguidanceforPCTsandlocalauthoritiesonhowthegoalsforalocaloverweightandobesitystrategyweresetusingNCMPlocalprevalencedata.
Itisalsoimportanttonotethat,althoughtheguidanceinToolD5setsouthowPCTsandlocalauthoritieshavesettargetsthatareinlinewiththenational2020goaltoreducetheproportionofobeseandoverweightchildrento2000levelsassetoutinHealthy Weight, Healthy Lives: A cross-government strategy for England,1itdoesnotincludeanydetailsonhowPCTsandlocalauthoritiescantranslatethe2020goaldowntoalocallevel.Thisisbecausethe2020goalisbasedonHealthSurveyforEnglanddataand,unlessanareahasaccesstodatasourcesotherthantheNCMP,itwillnothaveanydataonthelevelsofchildobesityandoverweightfortheyear2000.ThereforethereisnonationalexpectationthatPCTsorlocalauthoritiesshouldsettheirowntargetstoreducelevelsofobesityandoverweightto2000levels–theGovernmentwillinsteadcontinuetoprovideguidancetolocalareasthatisconsistentwithachievingthenational2020goal.
Settingobjectives
Oncethelocalgoalhasbeenset,localareasshouldthinkaboutinterventionobjectivesusingotherrelevantlocalinformation,suchasprevalenceofbreastfeeding.TheNationalIndicatorsofsuccessrelevanttoobesitycanhelplocalareassetobjectiveswhichcanthenalsobeusedintheevaluationoftheprogramme.
ToolD5providesdetailsonsettingobjectives.ItprovidesalistofNationalIndicatorsrelevanttoobesitywhichcanhelplocalareassetinterventionobjectivestoreachtheirlocalgoal.
SeealsoToolD14Monitoring and evaluation: a frameworkforfurtherdetailsontheimportanceofsettingobjectivesforevaluationpurposes.
Developingalocaloverweightandobesitystrategy 61
Localleadership
Localareasneedtoidentifyandagreeoverallleadershipandgovernance,thelocalleaders,theirrolesinpromotinghealthyweightandhowtoensurestrongandcontinuingcommunicationacrossallparties.
Amulti-agencyapproachiscriticaltotacklingobesity.Primarycaretrusts(PCTs),localauthoritiesandtheirpartnersintheprivateandthirdsector(thenon-profitorvoluntarysector)shouldworkcloselytogetherthroughtheirChildren’sTrustpartnershiparrangementswithintheirlocalstrategicpartnerships(LSPs)todeterminehowtheywillcontributetotacklingthechallengeofrisinglevelsofoverweightandobesity.Anystrategyrequires‘oftenandearly’engagementwithallstakeholderstoensurethatthePCTOperationalPlan,theChildrenandYoungPeople’sPlan(CYPP),and,whereobesityhasbeenidentifiedasapriority,theLocalAreaAgreements(LAAs)arealigned.Theseshouldalsoalignwithplansthatthelocalauthorityhasontransport,community,playandplanning.Thelocalauthority’sOverviewandScrutinyCommitteewillhaveanimportantroletoplay.
Establishingasenior-levellead
Theexperienceofmulti-agencyprogrammesinthiscountryandothers(egtheEPODEprogrammeinEurope)isthatitiscriticaltodesignateasenior-levelofficertocoordinateactivityacrossallsectors–apersonwhohasthe‘clout’tobringpartnerstogetheranddriveforwardimplementation.ThedesignatedseniorleadislikelytobenefitfromajointappointmentbetweenthePCTandlocalauthorityastheywillneedtojoinuppartnersacrossthedeliverychain.
Bringingpartnerstogether
Localareaswillneedtodecidethemostappropriatearrangementsforbringingtogetherallofthepartnerswithinthedeliverychain,bothtodevelopalocalplanandtomonitoritsimplementation.Thiswillincludeensuringthatinformation,especiallyongoodpractice,flowsbothupanddownthedeliverychain.
Onewayofbringingtogetherpartnersistoestablishasub-committeeorpartnershipboard,withsenior-levelrepresentationfromkeypartners,reportingregularlytoahigherlevelstrategicbodysuchastheLSPorChildren’sTrust.Thissub-committeedoesnotneedtobelargeandunwieldy.Coremembershipislikelytobedrawnfrom:
• healthpromotion
• publichealth
• nutritionanddietetics
• leisure/physicalactivity
• schoolnursing,midwiferyandhealthvisiting
• education
• transport,and
• townplanning.
Itisessentialtoincludeinthesub-committeeorpartnershipboardsomeonewithexpertiseintheevaluationofcommunityinterventions.
62 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Otherteammemberscanbeincludedasandwhenappropriate.Forexample,ifthefocusisondetectionandmanagementofexistingcases,theteammightalsoinclude:
• patientorcarer
• GPand/orpracticenurse
• primarycarequalityfacilitator
• commissioner
• hospitalspecialist.
Anotherwayofbringingpartnerstogetherisbyincludingobesityasastandingitemonexistingboards.
Financialconsiderations
Itisimperativethatthearrangementsdetailedaboveincludefinancialconsiderations.Thiscouldinvolveestablishingapooledbudgetoragreeingservicelevelagreements(SLAs)onthecontributionsofdifferentpartners.
ToolD6providesdetailsofpotentiallocalleadersanddescribeswhattheirrolescouldbeintacklingoverweightandobesity.Thetoolalsoactsasachecklisttoassesslocalleadercommitmentandengagementintheprocess.ItisimportanttonotethattherolessetoutinToolD6willnotbeappropriateforeveryarea,butthetoolmayprovideahelpfulstartingpointforsomelocalareas.
Developingalocaloverweightandobesitystrategy 63
Choosinginterventions
Localareaswillneedtoplanspecificinterventionsaimedatachievingtheirlocaltargetstoreducelevelsofobesityandoverweightamongchildren.Ultimately,meetingthesetargetswillrequirechangingfamilies’attitudesandbehaviours.
Whenchoosinginterventionstochangeindividuals’behaviour,localareaswillneedtoknowwhatchangesinbehaviourwillhelptoachievetheirtargets,whatinterventionsshouldbechosentodeliverthedesiredbehaviourchange(usingNICEguidance),whatdifficultiesmayariseinachievingthedesiredbehaviour,andsohowtotailorinterventionstoensurethattheyareeffectivefordifferenttargetgroups.
Localareaswillthenneedtocommissionandprocureservicestodeliverbehaviourchange–forexample,weightmanagementservicesandsocialmarketingagencies.
Localareasshouldnotfeelconstrainedtoimplementonlyinterventionswithevidenceofeffectiveness.Theevidencebasetotacklethisseriousissuewillonlyimproveifareastrynewinterventionsandthenevaluatethem.
Whatsuccesslookslike
Beforechoosinginterventions,itisimportantforlocalareastoconsiderwhatchangesinindividualbehaviourtheywillneedtoachieveinordertodeliverthegoalsoftheirownobesitystrategies.InHealthy Weight, Healthy Lives: Guidance for local areas,2theDepartmentofHealthoutlinedwhatthekeysuccesseswouldlooklikeintermsofbehaviourchange,foreachofthefivethemes.Someexamplesareprovidedbelow:
• Children:healthygrowthandhealthyweight–forexample,asmanymothersaspossiblebreastfeedingupto6monthsandallschoolsarehealthyschools
• Promotinghealthierfoodchoices–forexample,lessconsumptionofhigh-fat,high-sugarandhigh-saltfoods
• Buildingphysicalactivityintoourlives–forexample,reducedcaruseandmoreoutdoorplay
• Creatingincentivesforbetterhealth–forexample,moreworkplacesthatpromotehealthyeatingandactivity
• Personalisedsupportforoverweightandobeseindividuals–forexample,everyoneabletoaccessappropriateadviceandinformationonhealthyweight.
RefertoNationalIndicatorsinToolD5.
ToolD7details‘whatsuccesslookslike’foreachofthefivekeythemesdetailedabove.
64 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Choosinginterventions
Choosingtherightinterventionsiscriticaltodeliveringbehaviourchange.Sobeforeinterventionsarechosen,localareasshouldconductafullservicereview,a‘gapanalysis’orauditoflocalservices,initiativesandinfrastructureincludingprotocols,procedures,pathwaysandpractice.Thiswillhelplocalareasfindoutwhatiscurrentlyhappening,wherethegapsare,whattheprioritiesareandwhattheopportunitiesfordevelopmentare.Thefollowingquestionsshouldbeaddressed:
• Whatactionisbeingdelivered?
• Istheactionfully/partially/notinplace?
• Whenistheactionbeingdelivered?
• Whoisdeliveringtheaction?
Key Point Each partner agency is usually best placed to undertake the mapping for its own sphere of influence and to feed its findings into the review.
Guidedbygood-qualitylocalintelligence,localareascanthencommissionarangeofinterventionsthatpreventandmanageexcessweight,focusedaroundthefivethemessetoutinHealthy Weight, Healthy Lives1whicharebasedontheevidenceprovidedbyForesight.Decisionsaboutspecificinterventionscanbeguidedby:
• evidenceofeffectiveness
• outcomesofpublichealthinterventions
• appropriatenessforthelocalcommunityorlocalgroups(egblackandminorityethniccommunities)andculturalissues
• cost-effectiveness
• nationalguidancesuchastheNICEguidelineonobesity6
• thebalancebetweenthepreventiveandmanagementstrandsoftheoverallstrategy
• thefeasibilityandprobabilityofsuccess
• availableresources
• timeframes,and
• organisationalandpoliticalpressures.
Estimating the potential cost-benefits of interventions Ideally,decisionsonwhichinterventionstochooseshouldtakeintoaccountcost-benefitanalyses,althoughtheseareextremelydifficulttocalculate.Theoretically,therearetwocomponentstoanalyse:
• thenumberofcasesofoverweightandobesitypreventedbylifestylechangesinthepopulation(andhencethecost-benefitsofprevention),and
• thenumberofcasesofcoronaryheartdisease,diabetes,strokes,andobesity-relatedcancerspreventedbyeffectiveidentificationandmanagementofoverweightandobesity(andhencethecost-benefitsofscreeningforobesity).
Inpractice,however,ithasproveddifficulttomodelsuchanalyseswithanydegreeofaccuracy.
Developingalocaloverweightandobesitystrategy 65
Estimating the cost of taking action NICEhasproducedacostingreportandcostingtemplatetoestimatethefinancialimpacttotheNHSofimplementingtheNICEclinicalguidelineonobesity.142 Thecostingtemplateprovideshealthcommunitieswiththeabilitytoassessthelikelylocalimpactoftheprincipalrecommendationsintheclinicalguidelinebasedonlocalpopulation,andothervariablescanbeamendedtoreflectlocalcircumstances.Thecostingreportfocusesonthefinancialimpactofimplementing,inEngland,therecommendationsthatrequirethebiggestchangesinresources.Gotowww.nice.org.uktodownloadthecostingreportandtemplate.
Notes:
ToolD8canhelplocalareaschooseinterventions.Itisbasedontheevidenceofeffectivenessandcost-effectivenessadaptedfromtheNICEguidelineonobesity.6Italsoactsasachecklistforlocalareastoassesswhetheraninterventionisalreadyinplace.
Healthy Weight, Healthy Lives: Guidance for local areas2alsoprovidesdetailedinformationregardingpotentialinterventions.Gotowww.dh.gov.uk
Quick reference guide 1 – For local authorities, schools and early years providers, workplaces and the public143providesexamplesofsuggestedactiontotackleoverweightandobesityinthesesettings.Theguidecanbedownloadedfromwww.nice.org.uk
Targetingbehaviours
QualitativeresearchconductedbytheDepartmentofHealthintothebehavioursoffamilieswithchildrenaged2-11years–bothmainstreamandblackandminorityethnic(BME)families(Pakistani,BangladeshiandBlackAfrican[GhanaianandNigerian])–canbeusedtoinformtheselectionofinterventions.Theresearchcanalsobeusedtoprovideasenseofthedifficultiesthatcanarisewhendeliveringinterventionswhichaimtoachievedesiredbehaviours.
Families with children aged 2-11 years Theresearchfoundthatthekeytodesigningeffectiveinterventionsistoengagethewholefamily,presentinghealthybehavioursasenjoyablefamilyexperiences,positioningchangeasapositivechoice,andfocusinginparticularonthebeneficialimpactofabetterdietandincreasedphysicalactivitylevelsatthesametimeasmakingitclearthatchildren’shappinessisthefirstpriority.
Basedontheresearch,theDepartmentofHealthsuggeststhatlocalareasshouldlooktodevelopinterventionsinthefollowingareas:
• structuredmealtimes–creatingawarenessamongparentsoftheimportanceoflimitingunhealthyandexcessivesnackingbetweenmeals
• shoppingandcooking–givingparentsandtheirchildrentheknowledgeandskillstheyneedtoshopforandpreparehealthymeals.Thiswillincludechallengingthebeliefthat‘kids’foods’and‘conveniencefoods’offerbettervaluethanfresh,healthyfoods
• portionsize–workinginpartnershipwiththeFoodStandardsAgencytohelpparentsunderstandhowmuchfoodtheirchildrenshouldbeeating
• improvingfoodliteracy–givingparentsabetterunderstandingofthecomponentsofahealthydiet
• sedentaryactivity–encouragingparentstolimittheirchildren’sscreentimeandreplaceitwithfamilyactivity
• outdoorplay–increasinglevelsoffamilyactivity,inparticularoutdoorplay,andreducinglevelsofsedentarybehaviour.Thiswillincludeprovidingsafe,family-friendlyenvironmentswherechildrencanplay,helpingfamiliesunderstandthevalueofstructuredexerciseandmakingexercisemoreinclusiveandaccessible;andactivetravel–encouragingfamiliestousetheircarslessforshort,walkablejourneys.
66 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Black and minority ethnic (BME) communities Whilethereisconsiderableoverlapbetweenattitudestodietandphysicalactivityacrossallpartsofthecommunity,therearealsosignificantdifferences.Asaresult,theresearchrecommendedthatthefollowingfactorsneedtobetakenintoaccount:
• Culturalappropriateness:Familiescouldbeencouragedtobemoreactivebyprovidingopportunitiestotakepartinculturallyappropriateandacceptableactivities,forexampledancing(fortheBlackAfricancommunityinparticular),walking,cricketandfootball.Adultsmayrespondpositivelytoopportunitiestotakepartinactivitieswithotherpeoplefromthesameethnicbackground.Linkingchildren’sphysicalactivitytoschool(forexample,bysettingupmoreafter-schoolclubs)couldhelpparents–whotendtoprioritisetheirchildren’seducationoverexercise–toseephysicalactivityasmoreculturallyacceptable.
• Adaptingexistingeatinghabits:Interventionsshouldfocusonwaysofmakingtraditionalethnicmealshealthier,forexamplebyusingslowcookersorpressurecookers(ratherthanfryingfood)andswappingghee,butterandpalmoilforalternativessuchasoliveoil.Guidelinesshouldalsobeprovidedon‘translating’currenthealthmessagesintospecificchangestotraditionalmeals,andonhealthiersnacksandtreatsforchildren.
• Engagingcommunityleadersandworkers:Gettingkeycommunityinfluencerstopromotethevalueofphysicalactivityforbothmaleandfemalechildrencouldhelpparentsfeeltheyhavebeengivenculturalandreligious‘licence’toencouragetheirchildrentobemoreactive.ForBangladeshiandPakistaniwomenbroughtupabroad,keyinfluencerssuchasGPs,healthvisitors,communityhealthpromotionworkersandpracticenursesarealsotrustedsourcesofinformation.
• Engagingtheextendedfamily:Extendedfamilymemberstendtohaveasignificantinfluenceoverchildren’sfoodintakeandfamilyeatinghabitsingeneral,especiallyinBangladeshiandPakistanifamilies.Interventionsmustthereforetargetextendedfamilymembers,inparticulargrandmothers.Engagingwiththeseoldermembersofthecommunitycouldalsobeasteptowardsbreakingdownthewidelyheldperceptionthatanoverweightchildisahealthychild.
• UsingchildrentoreachparentswithlimitedEnglish:ForBangladeshiandPakistaniwomenbroughtupabroad,childrenarethemostimportantsourceofinformationabouthealthissuesandguidelines.Childrenarealreadyfeedingbacktotheirparentsabouthealthissuescoveredduringlessonsandtheirschool’shealthyeatingpolicies.
• Usingone-to-one,community-basedinterventions:ThesearecrucialforthosewithlimitedEnglishandwhoseengagementwithmainstreammediachannelsisthereforelikelytoberestricted.Theseinterventionswillneedtobetargetedatspecificcommunitiesinordertoovercomeculturalandreligiousbarriers.
ToolD9providesdetailsofthekeybehaviouralinsightsfromthequalitativeresearchconductedamongfamilieswithchildrenaged2-11yearsinbothmainstreamfamiliesandBMEfamilies.
Forfurtherinformation,seeInsights into child obesity: A summary.AdraftofthisreportisavailabletoPCTsandLAsthroughtheirRegionalPublicHealthGroup.Afinalreportwillbepublishedinlate2008.
Communicatingwithtargetgroups–keymessages
Tohelpovercomethecomplexitiessetoutabove,andthuschangebehaviours,effectivecommunicationwiththetargetgroupisextremelyimportant.TheDepartmentofHealthcarriedoutnationalresearchwiththeclusterswiththegreatest‘at-risk’behaviours(clusters1,2and3)tofindoutwhatcommunicationswouldbeeffectiveinchangingbehaviour.(Seepage59formoreonclusters.)Thenationalresearchidentifiedthefollowingcommunicationsissuesthatshouldbeborneinmindwhenstructuringlocalprogrammes.
Developingalocaloverweightandobesitystrategy 67
• Conceptssuchas‘health’and‘healthylifestyles’canbealienatingtermstofamiliesmostatriskofproblems.
• Parentsneedtobeprovidedwithsimple,clearexpressionsofwhatriskandpositivebehaviourlooklike–outliningtherisksattachedto‘unhealthy’behaviourandthebenefitsattachedto‘healthybehaviour’.
• Anewlanguageneedstobeusedtotalkabouttheissues.Talkingdirectlyabout‘obesity’and‘weight’mayalienateparentsandcausethemtorejectordeselectthemselvesasthetargetaudience.
• Parentsexertapowerfulindirectinfluenceoverchildren’sbehaviourthroughrole-modellingandthus‘whole-family’solutionsneedtobefocusedupon.Parentsarefocusedontheirchild’shappinesssoitisimportanttoexpress‘success’intermswhicharerelevanttoparentalpriorities.
• Itisimportanttoacknowledgethevalueparentsplaceonchoiceforboththemselvesandtheirchildren.Thereforeadictatorialapproachshouldbeavoidedandwaystoencouragepositivechoicesshouldbefound.
Thebreadthoftheserecommendationsmeansthatcommissioningsuccessfulinterventionswillbeacomplextask,butanecessaryone.
ToolD10providesdetailsonhowlocalareascancommunicatewiththepriorityclusters.
Commissioningservices
WorldClassCommissioningsetsoutthebroadstepsforcommissioningservices(seepage55andToolD1).ThesearesupplementedbelowinthreespecificareasthatfeedbackfromPCTshassuggestedwouldbehelpful:
Procurement Whencommissioningservices,itisimportantthatlocalareasknowthekeyprocessesinvolvedinprocuringservicestoundertakethenecessarywork.Thus,theDepartmentofHealthhasproducedaguidetotheprocurementprocesswhichwillhelplocalareasdevelopplansthatwilleffectivelyandefficientlysecureservicestoundertakeinterventionwork.
ToolD11providesaguidetotheprocurementprocess.
Weight management services TheDepartmentofHealthhasproducedaframeworkforcommissioningweightmanagementservices.ItreflectstheprinciplesofWorldClassCommissioning(seeToolD1),focusingonhowcommissionersachievethegreatesthealthgainsandreductionininequalities,atbestvalue,through‘commissioningforimprovedoutcomes’.
ToolD12presentsaframeworkforcommissioningweightmanagementservicesforchildren,youngpeopleandfamilies.
Social marketing agencies Incommissioningsocialmarketingagencies,theNationalSocialMarketingCentre(NSMC)hasdevelopedanevaluationchecklistandsomesampleinterviewquestionsforassessingagencies.Itisimportantthatlocalareasputthecorrectprocurementprocedureinplacewhenapproachingsocialmarketingagencies.
ToolD13containstheevaluationchecklistandinterviewquestionsforcommissioningsocialmarketing.
68 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Monitoringandevaluation
Onceinterventionshavebeenchosen,localareasneedtodevelopamonitoringandevaluationframeworkinordertoassesstheeffectivenessandcost-effectivenessoftheinterventions.Itisimportantthatanevaluationofaninterventionisplannedandorganisedandthatithasclearobjectivesandmethodsforachievingthem.
Evaluationoflocalstrategiesandprogrammesforoverweightandobesityisessentialfor:
• clinicalgovernance
• auditandqualityimprovement
• providinginformationtothepublic
• strategyandperformancedevelopment
• assessingvalueformoney
• assessingsustainability,and
• increasingtheevidencebase.
Therearetwobasicrulesforsuccessfulevaluation:
• Theevaluationprocessmustbethoughtthroughfromthestart,atthesametimeasyoudevelopthestrategy’saims,objectivesandtargets.
• Adequatefundingshouldbesetasidefortheevaluation.Agoodguideis10%ofthetotalbudget.Evaluationofcommunityprojectsisnoteasyandnoteverythingcanbeevaluated.
Therationaleforevaluationcaninclude:
• toinformtheday-to-dayrunningoftheproject,totrytoimproveinterventionsandpossiblytodevelopnewones
• todemonstrateworthandvalueformoneytothecommissionerorfunder,inordertosupportrequestsforcontinuedoradditionalfunding
• todefineandexaminesuccessesandfailureswithallstakeholders,andtoknowhowandwhysomethingworks,aswellasattemptingtounderstandwhyitmaynot
• toassessbehaviouralchangeandenvironmentalimprovements
• todevelopmodelsofgoodpracticethatarethendisseminatedtoothers
• tocontributetothedebateonobesity,and
• toassistwithperformanceimprovement.
Thekeyareastoevaluatemustbeagreedamongthepartners,includingtheparticipants,toreflecttheirdifferentagendas.Evaluationwillinclude:
• measuringindicatorsofprogress,includingprogresstowardsanylocaltargets
• assessinghowwellvariousaspectsofthestrategywereperceivedtoworkfromtheviewpointofprofessionalsfromallsectorsandbycommunities,and
• assessingwhetherthechangeswerearesultoftheintervention.
Developingalocaloverweightandobesitystrategy 69
Itisessentialtoincludeinthesub-committeeorpartnershipboard(seeLocal leadershiponpage61)someonewithexpertiseintheevaluationofcommunityprojects.Thiscouldbesomeonefromthehealthorenvironmentdepartmentsofalocaluniversityorfurthereducationcollege,alocaldietitian,orsomeonefromthenutritiondepartmentofahospitalorthecommunity.
ToolD14providesaframeworkformonitoringandevaluation.
AuditcriteriaforNICEguidelineonobesity
NICEhasdevelopedauditcriteriafortheclinicalguidelineonobesity.Theaimoftheauditistohelphealthservicesandlocalauthoritiestodeterminewhethertheyareimplementingtheguidance.TheimplementationoftheauditwillhelporganisationsmeetdevelopmentalstandardD13ofStandards for better healthsetbytheDepartmentofHealth.StandardC5(d)statesthat“Healthcareorganisationsensurethatcliniciansparticipateinregularclinicalauditandreviewsofclinicalservices.”144TodownloadtheNICEauditcriteria,gotowww.nice.org.uk
70 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Buildinglocalcapabilities
Localareasneedtoensurethatallpartnersareawareoftheirrolesinpromotingthebenefitsofahealthyweight.Thereforeitisimportantthatbothhealthandnon-healthprofessionalsaretrainedinordertodealsensitivelywiththeissueofoverweightandobesity.
Awholesystemsapproachisnecessarysothatallthoseworkingatalocallevelinallorganisationsareawareoftheirroleinpromotingphysicalactivity,goodnutrition,andthebenefitsofahealthyweight.Inmanycases,localpartnerswillwanttocommissiontrainingtosupporttheirstaffinthisrole.Tomaximisecoverageofthetraining,asystemofcascadetraining(ortrainingtrainers)isaneffectivewayofcapturingthewholeworkforcequickly.2
Whencommissioningtraining,localareasshouldtakeintoaccountthedifferentneedsofhealthandnon-healthprofessionals.Forexample,healthprofessionalsmayneedadetailedunderstandingofnutritionandthepromotionofhealthylifestyles,whilenon-healthprofessionals,suchasteachers(especiallythosewithpastoraldutiesandthoseteachingPersonal,SocialandHealthEducation[PSHE]),mayneedtobeawareoftheroletheycanplay,andbeabletoprovidebasicadviceandsignpostingtoappropriatelocalservices.2
Inaddition,trainingwillneedtorecognisethesensitivityaroundtheissueofweightandbuildtheconfidenceofstafftobeabletoraisetheissueandknowhowtoinfluencebehaviourchange.Thiswillbeparticularlyimportantwhenroutinefeedbacktoparents,aspartoftheNCMP,isintroduced.Asmembersofthegeneralpublic,manystaffwillthemselveshaveweightissues:theymaybeoverweight,obeseorunderweight,andtheyarelikelytofeelparticularlyunconfidentinraisingissuesofweight.Trainingpackagesmusttakeaccountofthisandbuildintoolsforstafftoraisetheissue,takingintoaccountthestaff’sownweightstatus.2
Obesitytrainingdirectory
TheObesity training directory130producedbyDOMUKprovidesPCTswithinformationontrainingcoursesforobesitypreventionandmanagementavailableacrossthecountry.TheDirectorydoesnotrepresentalistofapprovedtrainingproviders;itismerelyalistofwhatisavailable.ItisintendedtoactasaguideforPCTswhoneedorwishtotakeamorestrategicapproachbycommissioningobesitytrainingfromawiderpoolbeyondthetrainingprogrammesthattheycanaccesslocally.PCTsmaywishtousethisresourceasastartingpointandseekfurtherguidancefromlocaltrainingofficersandexpertsinobesitymanagement,suchasphysicalactivityspecialistsandregistereddietitians.Toaccessthedirectory,gotowww.domuk.org.Thedirectoryiscurrentlybeingupdated.ThenewversionwillbeavailablebySpring2009.
TrainingtodeliverNICEguidance
NICEcommissionedBMJLearningtoproduceanonlinetrainingpackageforGPsandotherhealthprofessionals.Toaccessthislearningmodule,usersmustregisterwiththeBMJLearningwebsite,whichisfree,andthemoduleisthenfreetoaccess.Learnerswhosuccessfullycompletethemodule,whichtakesaboutanhour,willreceiveapersonalcertificateofcompletion.Themoduleincorporatestrainingon:
• BMIandothermeasuresofadiposity
• whatlevelofadviceorinterventiontousewithapatient,dependingontheirBMI,waistcircumferenceandco-morbidities
• howtoexploreapatient’sreadinesstochange
Developingalocaloverweightandobesitystrategy 71
• advicetopatientsondiet,physicalactivity,andcommunity-basedinterventions
• whentorefertoaspecialist.
ThistrainingmodulecomplementsthecarepathwaysanddocumentsreferencedinthetoolsforhealthcareprofessionalsfoundinsectionEofthistoolkit.Toaccessthemodule,gotolearning.bmj.com
TheExpertPatientsProgramme
TheExpertPatientsProgramme(EPP)isanationalNHS-basedself-managementtrainingprogrammewhichprovidesopportunitiesforpeoplewholivewithlong-termconditionstodevelopnewskillstomanagetheirconditionbetteronaday-to-daybasis.Forexample,intermsoftacklingoverweightandobesity,patientswithdiabetesorheartdiseasecanlearnhowtostartandmaintainanappropriateexerciseorphysicalactivityprogramme.Setupin2002,theExpertPatientsProgrammeisbasedonresearchfromtheUSandUKoverthelasttwodecadeswhichshowsthatpeoplelivingwithlong-termconditionsareofteninthebestpositiontoknowwhattheyneedtomanagetheirowncondition.Providedwiththenecessary‘self-management’skills,peoplewithlong-termconditionscanmakeatangibleimpactontheirownconditionandontheirqualityoflifemoregenerally.EPPcoursesarebeingrunbyprimarycaretruststhroughoutEngland.Tofindtrainingcourses,gotowww.expertpatients.co.uk
ToolD15Useful resourcesgivesfurthersourcesofinformationrelevanttobuildinglocalcapabilities.
72 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Toolsforhealthcareprofessionals
Localareaswillneedtoprovideappropriatesupporttohealthcareprofessionalssothatagreaternumberofindividuals,particularlychildrenandtheirfamilies,haveaccesstoweightmanagementservicesinordertomovetowardsahealthyweight.
TheNHSisperfectlyplacedtoidentifyoverweightandobesity,provideadviceonhealthylifestylesandreferindividualstoweightmanagementservices.Thisisasubstantialtask,sohealthcareprofessionalswillneedappropriatesupportfromPCTsandstrategichealthauthorities.TheninetoolsinsectionEhavebeenprovidedtohelpcommissionersofPCTsandlocalauthoritiesfurthersupporttheirlocalhealthcareprofessionals.Thereare:
• toolstohelphealthcareprofessionalsassessweightproblems
• toolstohelphealthcareprofessionalsraisetheissueofweightwiththeirpatients,and
• toolstohelpthemgainaccesstofurtherresources.
Assessmentofoverweightandobesity
AssessingwhetheranindividualisoverweightorobeseisundertakenprimarilybyprimarycarepractitionerssuchasGPs,practicenurses,healthvisitors,communitynurses,communitydietitians,midwivesandcommunitypharmacists.Theimportantaspectofassessmentisthatpeoplewithgreatestclinicalneedareprioritisedandofferedefficientweightmanagement.ThiscanbeinbothNHSandnon-NHSsettings.Toensurethatthereisasystematicapproachtotheassessmentandmanagementofoverweightandobesity,clinicalguidancehasbeenestablished.Withinthesesetsofguidanceareclinicalcarepathwaysthatdirecthealthcareprofessionalstoappropriatemeasuresforassessingandmanagingoverweightandobesity.
ExamplesofguidanceavailablearedetailedinsectionBonpage47.However,thetwomostimportantsetsofguidancethathealthprofessionalsshouldbereferredtoare:
• Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children,6 and
• Care pathway for the management of overweight and obesity.120
Moreinformationaboutthesesetsofguidance,theearlyidentificationofpatientswhoaremostatriskofbecomingobeselaterinlife,andmeasuringandassessingoverweightandobesityareprovidedinthefollowingtools.
ToolE1 Clinical care pathways
ToolE2Early identification of patients
ToolE3Measurement and assessment of overweight and obesity – ADULTS
ToolE4Measurement and assessment of overweight and obesity – CHILDREN
Developingalocaloverweightandobesitystrategy 73
Raisingtheissueofweightwithpatients–assessingreadinesstochange
Healthcareprofessionalshaveanextremelyimportantroletoplayintheprovisionofadviceonhealthierlifestyles,andcommissionerswillwanttobeassuredthatthisadviceisbeinggiven.ItisnotonlyGPswhocanprovideadvicetooverweightorobeseindividuals.Healthcareprofessionalsinarangeofsettingsplayanimportantrole.Examplesmayinclude:practicenurses;dentistswhoprovidesupportrelatingtooralhealth;healthtrainerswhoworkwithincommunitiespromotinghealthylifestyles;andpharmacistswhocomeintocontactwithpatientswhomaynotseekadvicefromtheirGP.TheRoyalPharmaceuticalSocietyofGreatBritain129hasproducedguidanceforcommunitypharmacistswhoprovideadviceonoverweightandobesity.Seewww.rpsgb.org.uk
TheGovernmentrecognisestheimportanceofdevelopingtheadvice-givingroleofhealthprofessionals,inordertoimprovelocalservicestopatients.However,researchundertakenfortheChoosing health 8consultationfoundthatsomehealthcareprofessionals,includingGPs,wereuncomfortableaboutraisingtheissueofweightwithpatients.Theylackedconfidencewhenitcametogivingpatientsadvice.Furthermore,anecdotalevidencerevealedthatsomeoverweighthealthprofessionalsfounditdifficulttogiveadviceonhealthyliving.Tosupporthealthcareprofessionalswiththeseissues,theDepartmentofHealthhasproducedguidanceonraisingtheissueofweightwithchildrenandadults,andcommissionedresearchintotheattitudesofoverweighthealthprofessionalsandpatients.
TheDepartmentofHealthguidanceandthemainfindingsfromtheresearchareprovidedinthefollowingtools:
ToolE5Raising the issue of weight – Department of Health advice
ToolE6Raising the issue of weight – perceptions of overweight healthcare professionals and overweight people
Resourcesforhealthcareprofessionals
Knowingwheretoaccessresourcesforpatients,supplyingusefulliteratureandprovidingcorrectinformationarecrucialforaneffectiveandefficientadviceservice.Tosupporthealthcareprofessionalsinaccessingthemostappropriateinformationandresources,thefollowingtoolsprovide:detailsofliteratureforpatientsonhealthylivingandlosingweightandmaintainingahealthyweight;suggestedresponsestofrequentlyaskedquestionsregardingobesity;andinformationontheNationalChildMeasurementProgramme(NCMP).
ToolE7Leaflets and booklets for patients
ToolE8FAQs on childhood obesity
ToolE9 The National Child Measurement Programme (NCMP)
SeealsotheNHSChoiceswebsiteatwww.nhs.uk
74 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
D Resources for commissioners
76 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
This section contains tools for commissioners in primary care trusts (PCTs) and local authorities developing local plans for tackling obesity, with a focus on children. It follows the framework for local action outlined in Healthy Weight, Healthy Lives: Guidance for local areas2, so it is divided into the five sub-sections:
Understanding the problem in your area and setting local goals
There are four tools in this sub-section that will help local areas understand the problem in their area and set local goals. Tools D2 and D3 will give areas a sense of the scale of the problem in terms of prevalence of obesity and cost to the NHS. Tool D4 will enable areas to identify priority groups using the national segmentation analysis undertaken by the Department of Health. Tool D5 gives the advice provided to PCTs and local authorities on how to use local data from the National Child Measurement Programme (NCMP) in setting child obesity goals to achieve an improvement on current prevalence of child obesity in each of the three years (2008/09 to 2010/11) as part of the Vital Signs and the National Indicator Set (NIS).
Local leadership
The Department of Health advises that a multi-agency approach is key to tackling obesity. Success looks like clearly identified responsibility for actions, with overall leadership and governance agreed by all partners. Tool D6 identifies key local leaders, the rationale for their involvement, their role in promoting a healthy weight, and ways to engage them.
Choosing interventions
This sub-section is about changing individual behaviour to reach the local goal of tackling obesity and promoting healthy weight. The seven tools in this sub-section will help local areas deliver behaviour change. Tool D7 gives areas an idea of what changes in behaviour are desired at the end of the process. These outcomes or successes were outlined in Healthy Weight, Healthy Lives: Guidance for local areas.2 Tool D8 provides details of how to deliver the desired behaviour change through various interventions, divided into the Department of Health’s five core themes set out in Healthy Weight, Healthy Lives.1 This tool is based on evidence of effectiveness and cost-effectiveness adapted from the NICE guideline on obesity.6 Tool D9 moves on to provide behavioural insight among families with children aged 2-11 years and minority
Resources for commissioners 77
ethnic communities. This tool gives a sense of the difficulties of achieving the desired behaviours but also can be useful in the initial design of interventions. Tool D10 gives details of how to reach the priority clusters 1, 2 and 3 (as detailed in Tool D4), by communicating using the right language and key messages. Tools D11, D12 and D13 all provide details on procuring outside services to deliver behaviour change. Tool D11 provides a guide to procurement, Tool D12 provides a guide to commissioning weight management services, and Tool D13 provides details of how to procure a social marketing agency.
Monitoring and evaluation
Evaluating the effectiveness of local initiatives is key to understanding which services to continue to commission in the future. Tool D14 provides a framework for monitoring and evaluating local interventions. It presents a 12-step guide on the key elements of monitoring and evaluation, an evaluation and monitoring checklist, and a glossary of terms.
Building local capabilities
Tool D15 provides a list of training programmes, publications, useful organisations and websites, and tools for healthcare professionals.
78 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Tools
Toolnumber
Title Page
ToolD1 Commissioningforhealthandwellbeing:achecklist 79
Understandingtheprobleminyourareaandsettinglocalgoals
ToolD2 Obesityprevalenceready-reckoner 91
ToolD3 Estimatingthelocalcostofobesity 95
ToolD4 Identifyingprioritygroups 101
ToolD5 Settinglocalgoals 105
Localleadership
ToolD6 Localleadership 109
Choosinginterventions
ToolD7 Whatsuccesslookslike–changingbehaviour 117
ToolD8 Choosinginterventions 119
ToolD9 Targetingbehaviours 133
ToolD10 Communicatingwithtargetgroups–keymessages 139
ToolD11 Guidetotheprocurementprocess 145
ToolD12 Commissioningweightmanagementservicesforchildren,youngpeopleandfamilies
151
ToolD13 Commissioningsocialmarketing 155
Monitoringandevaluation
ToolD14 Monitoringandevaluation:aframework 159
Buildinglocalcapabilities
ToolD15 Usefulresources 171
TOOLD1Commissioningforhealthandwellbeing:achecklist 79
TOOLD1Commissioningforhealthandwellbeing:achecklist
For: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities
About: ThistoolprovidesdetailsofWorldClassCommissioningincludinginformationontheorganisationalcompetencies.Italsoprovidesachecklistforcommissionerstoensurethattheirobesitystrategiesaredevelopedusingthebestavailableresources.
Purpose: ToprovideanunderstandingofhowWorldClassCommissioningcanhelplocalareasreachtheirgoalofreducingtheprevalenceofobesity.
Use: Canbeusedinthedevelopmentoflocalobesitystrategies.
Resource: WorldClassCommissioning:Competencies.145www.dh.gov.ukAvisionforWorldClassCommissioning:Addinglifetoyearsandyearstolife146www.primarycarecontracting.nhs.uk
WorldClassCommissioning:organisationalcompetenciesTheWorldClassCommissioningprogrammeisdesignedtoraiseambitionsforanewformofcommissioningthathasnotyetbeendevelopedorimplementedinacomprehensivewayanywhereintheworld.WorldClassCommissioningisaboutdeliveringbetterhealthandwellbeingforthepopulation,improvinghealthoutcomesandreducinghealthinequalities.Inpartnershipwithlocalgovernment,practice-basedcommissionersandothers,primarycaretrusts(PCTs),supportedbystrategichealthauthorities(SHAs),willleadtheNHSinturningtheworldclasscommissioningvisionintoareality.
WorldclasscommissioningPCTswillneedtodeveloptheknowledge,skills,behavioursandcharacteristicsthatunderpineffectivecommissioning.Theorganisationalcompetenciesaresetoutbelow.TheyhavebeendividedintofourofthefivethemesofHealthyWeight,HealthyLives1–understandingtheproblem,localleadership,choosinginterventions,andmonitoringandevaluation–inorderthatlocalareascanusethesecompetenciestodeveloptheirlocalobesitystrategies.
Understandingtheprobleminyourareaandsettinglocalgoals
Manageknowledgeandundertakerobustandregularlocalhealthneedsassessmentsthatestablishafullunderstandingofcurrentandfuturelocalhealthneedsandrequirements• Commissioningdecisionsshouldbebasedonsoundevidence.Theycapturehigh-qualityand
timelyinformationfromarangeofsources,andactivelyseekfeedbackfromtheirpopulationsaboutservices.Byidentifyingcurrentneedsandrecognisingfuturetrends,WorldClassCommissionerswillensurethattheservicescommissionedrespondtotheneedsofthewholepopulation,notonlynow,butalsointhefuture.
• Inparticular,WorldClassCommissioningwillensurethatthegreatestpriorityisplacedonthosewhoseneedsaregreatest.Toprioritiseeffectively,commissionerswillrequireahighlevelofknowledgemanagementwithassociatedactuarialandanalyticalskill.
TOOLD1
80 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
• ThePCTisabletoanticipateandaddresstheneedsofthewholepopulation,includingpeoplewithlong-termconditions.Ajointstrategicneedsassessment(JSNA)carriedoutbyPCTsandlocalauthorities,providesarichpictureofthecurrentandfutureneedsoftheirpopulations.Thisresultsincomprehensiveandbetter-managedcare.
Prioritiseinvestmentaccordingtolocalneeds,servicerequirementsandNHSvalues• Byhavingathoroughunderstandingoftheneedsofdifferentsectionsofthelocalpopulation,
WorldClassCommissioners,alongwiththeirpartners,willdevelopasetofclear,outcome-focused,strategicprioritiesandinvestmentplans.Thiswillrequiretakingalong-termviewofpopulationhealthandchangingrequirements.Theirprioritiesareformallyagreedthroughthelocalareaagreement(LAA).Strategicprioritiesshouldincludeinvestmentplanstoaddressareasofgreatesthealthinequality.
• PCTsmakeconfidentchoicesabouttheservicesthattheywanttobedelivered,andacknowledgetheimpactthatthesechoicesmayhaveoncurrentservicesandproviders.Theyhaveambitiousbutrealisticgoalsfortheshort,mediumandlongterm,linkedtoanoutcomesframework.Theyworkwithproviderstoensurethatservicespecificationsarefocusedonclinicalqualityandbasedontheoutcomestheywanttoachieve,andnotjustonprocessesandinputs.
Localleadership
Leadandsteerthelocalhealthagendainthecommunity• WorldClassCommissionerswillactivelysteerthelocalhealthagendaandwillbuildtheir
reputationwithinthecommunitysothattheyarerecognisedastheleaderofthelocalNHS.Theywillseekandstimulatediscussiononhealthandcaremattersandwillberespectedbycommunityandbusinesspartnersastheprimarysourceofcredibleandtimelyadviceonallmattersrelatingtohealthandcareservices.
Workcollaborativelywithcommunitypartnerstocommissionservicesthatoptimisehealthgainsandreductionsinhealthinequalities• WorldClassCommissionerswilltakeintoaccountthewiderdeterminantsofhealth,when
consideringhowtoimprovethehealthandwellbeingoftheirlocalcommunity.Todothiseffectively,theywillworkcloselyanddevelopasharedambitionwithkeypartnersincludinglocalgovernment,healthcareprovidersandthirdsectororganisations.Theserelationshipsarebuiltupovertime,reflectingthecommitmentofpartnerorganisationstodevelopinnovativesolutionsforthewholecommunity.Together,commissionersandtheirpartnerswillencourageinnovationandcontinuousimprovementinservicedesign,anddrivedramaticimprovementsinhealthandwellbeing.
Choosinginterventions
Engagewithpatientsandthepublictoshapeservicesandimprovehealth• Commissionersactonbehalfofthepublicandpatients.Theyareresponsibleforinvesting
fundsonbehalfoftheircommunities,andbuildinglocaltrustandlegitimacythroughtheprocessofengagementwiththeirlocalpopulation.Inordertomakecommissioningdecisionsthatreflecttheneeds,prioritiesandaspirationsofthelocalpopulation,WorldClassCommissionerswillengagewiththepublic,andactivelyseektheviewsofpatients,carersandthewidercommunity.Thisnewrelationshipwiththepublicislong-term,inclusiveandenduringandhasbeenforgedthroughasustainedeffortandcommitmentonthepartofcommissioners.Decisionsaremadewithastrongmandatefromthelocalpopulationandotherpartners.
TOOLD1Commissioningforhealthandwellbeing:achecklist 81
Engagewithclinicianstoinformstrategyanddrivequality,servicedesignandresourceutilisation• Clinicalleadershipandinvolvementisacriticalandintegralpartofthecommissioning
process.Worldclasscommissionerswillneedtoensuredemonstrableclinicalleadershipandengagementatallstagesofthecommissioningprocess.Cliniciansarebestplacedtoadviseandleadonissuesrelatingtoclinicalqualityandeffectiveness.Theyarethelocalcareexperts,whounderstandclinicalneedsandhaveclosecontactwiththelocalpopulation.Byencouragingclinicalinvolvementinstrategicplanningandservicedesign,WorldClassCommissionerswillensurethattheservicescommissionedreflecttheneedsofthepopulationandaredeliveredinthemostpersonalised,practicalandeffectivewaypossible.
• WorldclassPCTsneedworldclasspracticebasedcommissionerswithwhomtheyworkindemonstrablepartnershiptodriveimprovementsacrossthehighestpriorityservicesandmeetthemostchallengingneedsidentifiedbytheirstrategicplans.TosupportthisdrivetowardsWorldClassCommissioning,ProfessionalExecutiveCommittees(PECs)haveacrucialroletoplayinbuildingandstrengtheningclinicalleadershipinthestrategiccommissioningprocess.
Stimulatethemarkettomeetdemandandsecurerequiredclinical,andhealthandwellbeingoutcomes• Commissionerswillneedachoiceofresponsiveprovidersinplacetomeetthehealthandcare
needsofthelocalpopulation.
• Employingtheirknowledgeoffuturepriorities,needsandcommunityaspirations,commissionerswillusetheirinvestmentchoicestoinfluenceservicedesign,increasechoice,anddrivecontinuousimprovementandinnovation.
• WorldClassCommissionerswillhaveclearstrategiesfordealingwithsituationswherethereisalackofproviderchoice,inparticularinareaswherethereisrelativelypoorhealthandlimitedaccess.
Promoteimprovementinqualityandoutcomesthroughclinicalandproviderinnovationandconfiguration• WorldClassCommissionerswilldrivecontinuousimprovementintheNHS.Theirquestfor
knowledge,innovationandbestpracticewillresultinbetterqualitylocalservicesandsignificantlyimprovedhealthoutcomes.
• Byworkingwithpartnerstoclearlyspecifyrequiredqualityandoutcomes,andinfluencingprovisionaccordingly,WorldClassCommissionerswillfacilitatecontinuousimprovementinservicedesigntobettermeettheneedsofthelocalpopulation.Thiswillbesupportedbytransparentandfaircommissioninganddecommissioningprocesses.
Secureprocurementskillsthatensurerobustandviablecontracts• Procurementandcontractingprocesseswillensurethatagreementswithprovidersaresetout
clearlyandaccurately.Byputtinginplaceexcellentprocesses,commissionerscanfacilitategoodworkingrelationshipswiththeirproviders,offeringprotectiontoserviceusersandensuringvalueformoney.
Makesoundfinancialinvestmentstoensuresustainabledevelopmentandvalueformoney• WorldClassCommissionersensurethattheircommissioningdecisionsaresustainableand
thattheyareabletosecureimprovedhealthoutcomes,bothnowandinthefuture.Excellentfinancialskillsandresourcemanagementwillenablecommissionerstomanagethefinancialrisksinvolvedincommissioningandtakeaproactiveratherthanreactiveapproachtofinancial
82 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
management.Thefinancialstrategywillensurethatthecommissioningstrategyisaffordableandsetwithintheorganisation’soverallriskandassuranceframework.
Monitoringandevaluation
Managesystemsandworkinpartnershipwithproviderstoensurecontractcomplianceandcontinuousimprovementsinqualityandoutcomes• Commissionersmustensurethatprovidersaregiventhesupportneededtodeliverthe
highestpossiblequalityofserviceandvalueformoney.Thisinvolvesworkingcloselywithpartnerstosustainandimproveprovision,andengaginginconstructiveperformancediscussionstoensurecontinuousimprovement.
• Byhavingtimelyandcontinuouscontrolovercontracts,WorldClassCommissionersdeliverbettervaluetoserviceusersandtaxpayers.PCTsusearangeofapproaches,includingcollectingandcommunicatingperformancedataandserviceuserfeedback,workingcloselywithregulators,andinterveningwhennecessarytoensureservicecontinuityandaccess.PCTsensurethatthecommissioningprocessisequitableandtransparent,andopentoinfluencefromallstakeholdersviaanongoingdialoguewithpatients,serviceusersandproviders.
ChecklistInorderthatcommissionersdevelopasuccessfulobesitystrategyintermsoftheoutcomebeingareductioninobesity,particularlyinchildren,commissionersshouldgothroughthechecklistbelowandcheckwhethertheyareusingthebestavailableresourcesintheirareatoachievethisoutcome.
Understandingtheprobleminyourareaandsettinglocalgoals
Competency Yes No Action
Manageknowledgeandundertakerobustandregularlocalhealthneedsassessmentsthatestablishafullunderstandingofcurrentandfuturelocalhealthneedsandrequirements
Doyouhavestrategiestofurtherdevelopandenhancetheneedsassessmentdatasetsandanalysiswithyourpartners?
Areyouroutinelyacquiringknowledgeandintelligenceofthewholecommunitythroughwell-definedandrigorousmethodologies,includingdatacollectionwithlocalpartners,serviceprovidersandotheragencies?
Doyouidentifyandusetherelevantcoredatasetsrequiredforeffectivecommissioninganalysis?Areyoudemonstratingthisuse?
Areyouroutinelyseekingandreportingonresearchandbestpracticeevidence,includingclinicalevidencethatwillassistincommissioninganddecisionmaking?
Doyousharedatawithcurrentandpotentialprovidersandwithrelevantcommunitygroups?
Canyoudemonstratethatyouhavesoughtandusedallrelevantdatatoworkwithcommunitiesandclinicians,prioritisingstrategiccommissioningdecisionsandlonger-termworkforceplanning?
TOOLD1Commissioningforhealthandwellbeing:achecklist 83
Yes No Action
Prioritiseinvestmentaccordingtolocalneeds,servicerequirementsandNHSvalues
Doyouidentifyandcommissionagainstkeypriorityoutcomes,takingintoaccountpatientexperiences,localneedsandpreferences,riskassessments,nationalprioritiesandotherguidance,suchasNationalInstituteforHealthandClinicalExcellence(NICE)guidelines?
Aretheselectedclinical,healthandwellbeingoutcomesdesired,achievableandmeasurable?Dotheoutcomesalignwithpartners’commissioningstrategies?
Areyoudevelopingshort-,medium-andlong-termcommissioningstrategiesenablinglocalservicedesign,innovationanddevelopment?
Areyouidentifyingandtacklinginequalitiesofhealthstatus,accessandresourceallocation?
Areyouroutinelyusingprogrammebudgetingtounderstandinvestmentagainstoutcomes?
Canyoucompletecomprehensiveriskassessmentstofeedintothewiderdecision-makingprocessandallinvestmentplans?
Areyouusingfinancialresourcesinaplannedandsustainablemannerandinvestingforthefuture,includingthroughinnovativeservicedesignanddelivery?
Doyouseekandmakeavailablevalidbenchmarkingdata?
Doyousharedatawithpartnerorganisations,includingpractice-basedcommissionersandcurrentandpotentialproviders?
Areyoumonitoringtheperformanceofcommissionedstrategichealthoutcomes,usingpatient-reportedclinicaloutcomemeasuresandmeasuresrelatedtopatientexperienceandpublicengagement?
Localleadership
Competency Yes No Action
Leadandsteerthelocalhealthagendainthecommunity
Areyoutheprimarysourceofcredible,timelyandauthoritativeadviceonallmattersrelatingtotheNHS?
DoyouapplyNHSvalues(fair,personal,effectiveandsafe)tostrategicplanninganddecisionmaking?
DoyouworkcloselywithpartnerNHSorganisationsandotherproviders?
Doyouengagewithandinvolvethepublic,communityandpatients?
DoyoucommunicatelocalNHSprioritiestodiversegroupsofpeople?
DoyoudevelopthecompetencesandcapabilitiesoflocalNHSorganisations?
Doyoueffectivelymanagecontracts?
Doyouhaveaclearcommunicationspolicy?Canyourespondeffectivelytoindividual,organisationalandmediaenquiriesregardingtheNHS?
84 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Yes No Action
Workcollaborativelywithcommunitypartnerstocommissionservicesthatoptimisehealthgainsandreductionsinhealthinequalities
Doyouactivelyseekpartnershipwithappropriateagenciesbothwithinhealthandbeyondusingdefinedlegalagreementsandframeworks?
Doyoucreateinformalandformalpartneringarrangementsasappropriatetodifferentrelationships?
Doyouidentifykeylocalparticipantsandpotentialpartners(bothstatutoryandnon-statutory)tooptimiseimprovementsinoutcomes?
Doyouadviseanddeveloplocalpartnercommissioningcapabilitieswheretherewillbeadirectimpactonjointcommissioninggoals?
Doyousharewiththelocalcommunityitsambitionforhealthimprovement,innovation,andpreventivemeasurestoimprovewellbeingandtackleinequalities?
DoyouinfluencepartnercommissioningstrategiesreflectingNHScorevalues?
Doyouusetheskillsandknowledgeofpartners,includingclinicians,toinformcommissioningintentionsinallareasofactivity?
Doyouactivelysharerelevantinformationsothatinformeddecisionscanbemadeacrossthecommissioningcommunity?
Doyoumonitorandevaluatetheeffectivenessofpartnerships?
Choosinginterventions
Competency Yes No Action
Engagewithpatientsandthepublictoshapeservicesandimprovehealth
Canpatientsandthepublicsharetheirexperiencesofhealthandcareservices?Doyouusetheseexperiencestoinformcommissioning?
Doyouhaveanunderstandingofdifferentengagementoptions,includingtheopportunities,strengths,weaknessesandrisks?
Doyouinvitepatientsandthepublictorespondandcommentonissuesinordertoinfluencecommissioningdecisionsandtoensurethatservicesareconvenientandeffective?
Dopatientsandthepublicunderstandhowtheirviewswillbeused?Dotheyknowwhichdecisionstheywillbeinvolvedin,whendecisionswillbemade,andhowtheycaninfluencetheprocess?Doyoupublicisethewaysinwhichpublicinputhasinfluenceddecisions?
Doyouproactivelychallengeand,throughactivedialogue,raiselocalhealthaspirationstoaddresslocalhealthinequalitiesandpromotesocialinclusion?
Doyoucreateatrustingrelationshipwithpatientsandthepublic?Areyouseenasaneffectiveadvocateanddecisionmakeronhealthrequirements?
DoyoucommunicatethePCT’svision,keylocalprioritiesanddeliveryobjectivestopatientsandthepublic,clarifyingitsroleasthelocalleaderoftheNHS?
TOOLD1Commissioningforhealthandwellbeing:achecklist 85
Yes No Action
Doyourespondinanappropriateandtimelymannertoindividual,organisationalandmediaenquiries?
Doyouundertakeassessmentsandseekfeedbacktoensurethatthepublic’sexperienceofengagementhasbeenappropriateandnottokenistic?
Engagewithclinicianstoinformstrategyanddrivequality,servicedesignandresourceutilisation
Doyouencouragebroadclinicalengagementthroughdevolutionofcommissioningdecisions?Thisincludesmaximisingclinicalimpactthroughthedevelopmentofpractice-basedcommissioning(PBC).
Doyouengageandutilisetheskillsandknowledgeofclinicianstoinformcommissioningintentionsinallareasofactivity,includingsettingstrategicdirectionandformulatingcommissioningdecisions?
Doyoubuildandsupport:
broadclinicalnetworks,includingacrossproviderboundaries,to•facilitatemultidisciplinaryinputintopathwayandservicedesign?
informedclinicalreferencegroups,suchasProfessionalExecutive•Committees(PECs),ensuringthatcliniciansandpractice-basedcommissionershavefullandtimelyaccesstoinformation,enablinglocalcommissioningdecisionstobemade?
clinicalengagementinstrategicdecisionmakingandassureclinical•governancestructuresviaPECs?
DoyouoverseeandsupportPBCdecisionstoensureeffectiveresourceutilisation,reducinghealthinequalitiesandtransformingservicedelivery?
Doyouworkwithclinicalcolleagues,suchasPECs,alongcarepathwaystospreadbestpracticeandrigorousstandardstoholdclinicianstoaccount?
Doyouworkinpartnershipwithcliniciansalongcarepathwaysincommissionerandproviderorganisationstofacilitateandharnessfront-lineinnovationanddrivecontinuousqualityimprovement?
Stimulatethemarkettomeetdemandandsecurerequiredclinical,andhealthandwellbeingoutcomes
Doyoumapandunderstandthestrengthsandweaknessesofcurrentserviceconfigurationandprovision?
Doyouhaveanunderstandingandknowledgeofmethodsforfindingoutwhatmatterstopatients,thepublicandstaff?Areyouabletorespondtothiswhendefiningservicespecifications?
Canyoumodelandsimulatetheimpactofcommissioningdecisionsandstrategiesonthecurrentconfigurationofprovision?
Canyoupromoteservicesthatencourageearlyintervention,toavoidunnecessaryunplannedadmissions?
Doyouhaveaclearunderstandingandknowledgeoftheabilitiesandroleofthethirdsector,andofitsabilitytoprovideagainstservicespecifications?
Canyoutranslatestrategyintoshort-,medium-andlong-terminvestmentrequirements,allowingproviderstoaligntheirowninvestmentandplanningprocesseswithspecifiedrequirements?
86 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Yes No Action
Areyouawareofmarkettrendsandbehaviours?Canyoushowknowledgeofandactoncurrentgapsinthemarkettoprovidepatientswithachoiceoflocalproviders?
Canyoucreateincentiveswherenecessaryformarketentry,includingunderstandingtherequirementsoffullcostrecovery?
Canyoustimulateproviderdevelopmentmatchedtotherequirementsandexperiencesaccruedfromuserandcommunityfeedback(forexample,timelyandconvenientaccesstoservicesthatareclosertohome)?
Canyouspecifytherealistictimeschedulesthatareneededtoencourageanddeliverinnovationandchange,providingdirectsupportwhenrequired?
Canyoudeveloprelationshipswithpotentialfutureproviderswhoseservicesmaybeofinterestandmayberelevanttomeetingneedanddemand?
Doyoucommunicatewiththemarketasaninvestor,notafunder,usingandspecifyinganapproachbasedonqualityandoutcomes?
Promoteimprovementinqualityandoutcomesthroughclinicalandproviderinnovationandconfiguration
Doyoumapandunderstandthestrengthsandweaknessesofcurrentserviceinnovation,qualityandoutcomes?
Doyoumaintainanactivedatabaseofbestpractice,innovationandserviceimprovement?
Doyouanalyselocalandwiderclinicalandproviderqualityandcapacitytoinnovateandimprove?
Doyoushareresearch,clinicalandservicebestpracticelinkedtoclearspecificationsthatdriveinnovationandimprovement?
Doyoucommunicatewithcliniciansandproviderstochallengeestablishedpracticeanddriveservicesthatarebothconvenientandeffective?
Doyousetstretchtargets?Doyouchallengeproviderstocomeupwithinnovativewaystoachievethem?
Doyouunderstandthepotentialoflocalcommunityandthirdsectorproviderstodeliverinnovativeservicesandincreaselocalsocialcapital?
Doyoucatalysechangeandhelptoovercomebarriers,includingrecognisingandchallengingtraditionsandwaysofthinking(forexampleinservicedesignandworkforcedevelopment)thathaveoutlivedtheirusefulness?Doyousupportprovidersthatconstructivelybreakwiththese?
Doyoutranslateresearchandknowledgeintospecificclinicalandservicereconfiguration,improvingaccess,qualityandoutcomes?
Doyoudesignandnegotiatecontractsthatencourageprovidermodernisation,continuedefficiency,qualityandinnovation?
Areyoucreatingincentivestodriveinnovationandquality?
Doyousecureandmaintainrelationshipswithimprovementagenciesandsuppliers,brokeringlocalknowledgeandinformationnetworks?
TOOLD1Commissioningforhealthandwellbeing:achecklist 87
Yes No Action
Areyoudevelopingrelationshipswithcurrentandpotentialproviders,stimulatingwhole-systemsolutionsforthegreatesthealthandwellbeinggain?
Secureprocurementskillsthatensurerobustandviablecontracts
Areyouprocuringandcontractinginproportiontoriskandinlinewiththeclinicalprioritiesandwiderhealthandwellbeingoutcomesdescribedinthecommissioningstrategy?
AreyouprocuringandcontractinginlinewithrelevantDepartmentofHealthpolicies,suchaspatientchoice,competitionprinciplesandrules,careclosertohomeandNICEguidelines?
Doyouworkwithcommissioningpartnerstoensurethatyourprocurementplansareconsistentwithwiderlocalcommissioningpriorities?
Areyoucontinuouslydevelopingyourrangeofprocurementtechniquesandmakingeffectiveuseofthem?
Doyouhaveaworkingknowledgeofalllegal,competitionandregulatoryrequirementsrelevanttoyourrolewhentendering?
AreyoureflectingNHSvaluesthroughclearandaccurateservicespecifications?
Areyouassessingbusinesscasesaccordingtofinancialviability,risk,sustainabilityandalignmentwithcommissioningstrategies?
Doyoudesignandnegotiateopenandfaircontractsthatprovidevalueformoneyandareenforceable,withagreedperformancemeasuresandinterventionprotocols?
Docontractscoverreasonabletimeperiods,maximisingtheinvestmentofboththeproviderandthePCT?
Doyouunderstandandimplementstandardnationalcontractsasthesebecomeavailable?
Doyoucreatecontingencyplanstomitigateagainstproviderfailure?
Makesoundfinancialinvestmentstoensuresustainabledevelopmentandvalueformoney
Doyouhaveathoroughunderstandingofthefinancialregimeinwhichyouoperate?
Doyouprepareeffectivefinancialstrategiesthatidentifyandtakeaccountoftrends,keyrisksandpotentialhigh-impactchangesincostandactivitylevels?Thesestrategiesdrivetheannualbudgetingprocessandsupportthecommissioningstrategy.
Areyoudevelopingarisk-basedapproachtolong-termfinancialplanningandbudgetingthatsupportsrelevantandproportionateanalysisoffinancialandactivityflows?
Areyouroutinelyusingprogrammebudgetingtounderstandinvestmentagainstoutcomesandrelativepotentialshiftsininvestmentopportunitiesthatwilloptimiselocalhealthgainsandincreasequality?
Doyouusefinancialresourcesinaplannedandsustainablemannerandinvestforthefuture?
88 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Yes No Action
Doyouanalysecosts,suchasprescribing,andidentifyareasforimprovement?
Doyouhaveaclearunderstandingofthelinksbetweenthefinancialandnon-financialelementsofthecommissioningstrategies?
Areyoudevelopingarisk-basedapproachtoannualfinancialmanagementandbudgeting?Thisissupportedbytheongoinganalysisoffinancialandactivityflowsandincludescashmanagementplanstoensureanefficientuseofallocatedresources.
Doyoubudgetproactivelyratherthanreactively,withlarge,high-riskorvolatileelementsbeingidentifiedandcross-referencedtooperationalactivity?
DoestheBoardhavecleargovernancestructuresinplacethatfacilitateandensureactivemanagementofallaspectsofthePCT’sbusinessandplanningfunctions?Arethesetransparent,easilyunderstoodandpublic-facing?
Doyouanalysetheactivityoftheproviders,PBCleads,andotherbudgetholdersthroughdetailedcomparisonsofexpectedandactualcostsandactivity?
Doyouprovideuseful,conciseandcompletefinancialandactivityinformationtotheBoardtoaiddecisionmaking,highlightingsignificantvarianceswheretheseareoccurring?
Doyouhaveclearandunderstoodprocessesfordealingwithanyareaswhichbegintoshowsignificantvariancefrombudgetduringthefinancialyear?AretheseimplementedeffectivelybyallrelevantstaffandreportedtotheBoardwherenecessary?
Areyoucalculating,allocatingandreviewingPBCbudgetsinafairandtransparentmannerwitheffectiveincentivesystems?AreyouenablingPBCleadstofullyunderstandandmanagetheirdevolvedbudgets?
Areyoudevelopingshort-,medium-andlong-termstrategicfinancialplans,highlightingareassuitableforlocalserviceredesign,innovationanddevelopment?
Areyouworkingeffectivelywithallserviceprovidersbyprovidingfinancialsupportandinformationtoachievethemostclinicallyeffectiveandcost-effectiveapproaches?
Doyouhaveawell-developedsystemofgovernancethatensuresfinancialrisksarereportedandmanagedattheappropriatelevel?
Doyouhavestrongfinancialandethicalvaluesandprinciplesthatarepubliclyexpressedandunderpintheworkofallstaffandboardmembers,includingthoseworkingundercontract?ThesevalueswillalsobeexpressedinallcontractsenteredintobythePCT.
Doallstaffhaveaclearunderstandingoftheirdelegatedcommissioningbudgets?Doallstaffresponsibleforthemanagementofbudgetshaveaccesstorelevantandtimelyactivityandperformancedatathatenablethemtooperatethesebudgetseffectively?
TOOLD1Commissioningforhealthandwellbeing:achecklist 89
Monitoringandevaluation
Competency Yes No Action
Managesystemsandworkinpartnershipwithproviderstoensurecontractcomplianceandcontinuousimprovementsinqualityandoutcomes
Doyoumonitorproviderfinancialperformance,activityandsustainabilityinaccordancewithitscontractualagreements?
Areyoutransparentaboutyourrelationshipswithotherorganisationsthatcollect,publish,assessandregulateproviders?
Doyouevaluateindividualproviderperformanceaccordingtoagreedprovisionmeasurements?
Doyouusebenchmarkingtocompareperformancebetweenproviders?Areyoucommunicatingperformanceevaluationfindingswithproviders?
Doyouuseperformanceevaluationfindingstoleadregularandconstructiveperformanceconversationswithproviders,workingwiththemtoresolveissues?
Doyouuseagreeddisputeprocessesforunresolvedissues?
Doyourecogniseanadvocacyandexpertroleinservicedevelopmentforproviders?Doyouinvitethemtocontributeinthatrole?
Doyoudisseminaterelevantinformationtoallowcurrentproviderstoinnovateanddeveloptomeetchangingcommissioningrequirements?
Doyouunderstandthemotivationsofcurrentproviders?Areyoufosteringanenvironmentofsharedresponsibilityanddevelopment?
Doyouterminatecontractswhennecessary?
90 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLD2Obesityprevalenceready-reckoner 91
TOOLD2Obesityprevalenceready-reckonerTOOLD2For: Commissionersinprimarycaretrusts(PCTs)
About: Thistoolisaready-reckonerwhichcanbeusedtoestimatethenumberofadults(aged16andabove)orthenumberofchildrenaged1-15yearswithinaprimarycaretrustwhoareobeseoroverweight.
Purpose: ToprovideanunderstandingofthescaleoftheobesityprobleminyourPCT.
Use: CanbeusedforunderstandingtheprobleminyourPCT–casefor•funding.
Canbeusedforevaluationandmonitoringpurposes.Thedatacanbe•usedasabaselinewhencalculatingthesuccessofinterventionsusingperformanceindicators.
Resource: AnelectronicversionoftheObesityprevalenceready-reckoner,whichcanbecompletedonline,canbefoundatwww.heartforum.org.ukorwww.fph.org.uk
EstimatingtheprevalenceofobesityandcentralobesityTheready-reckonercanbeusedtoestimate:
• thenumberofadultsaged16andoverwhoareobese–measuredbyBodyMassIndex(BMI)ofmorethan30kg/m2.
• thenumberofadultsaged16andoverwithcentralobesityasmeasuredbyaraisedwaistcircumference.Araisedwaistcircumferencehasbeentakentobe102cm(40inches)ormoreinmenand88cm(35inches)ormoreinwomen.Theselevelshavebeenusedtoidentifypeopleatriskofthemetabolicsyndrome,adisordercharacterisedbyincreasedriskofdevelopingdiabetesandcardiovasculardisease.Centralobesity,asmeasuredbywaistcircumference,isreportedtobemorehighlycorrelatedwithmetabolicriskfactors(highlevelsoftriglyceridesandlowHDLcholesterol)thaniselevatedBMI.12
• thenumberofchildrenaged1-15yearswhoareobeseusingtheUKNationalBMIPercentileClassificationasrecommendedbytheNationalInstituteforHealthandClinicalExcellence(NICE)andtheDepartmentofHealth.
Howtousetheready-reckoner
1 IncellsA1toA7andB1toB7,entertheactualnumbersofresidentsineachagegroup,basedonlatestpopulationestimatesforyourarea.
2 Calculatetheothercellvaluesaccordingtotheformulae.
Note:Theready-reckonerusesnationaldataanddoesnottakeintoaccountlocalfactorssuchasethnicity,deprivationorotherfactorsthatmightaffectoverweightandobesityprevalence.
92 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Obesityprevalenceready-reckoner:adultsaged16andover
A B C D E FPCTpopulation Estimateofnumberof Estimateofnumberof(Enteractualnumbers) peoplewhoareobese peoplewhohavea
(BMIgreaterthan30kg/m2)
raisedwaistcircumference(Male102cmorabove.Female88cmorabove)
Age Male Female Male Female Male Female1 16-24 Enteractual
numberEnteractual
numberA1x0.09 B1x0.12 A1x0.10 B1x0.17
2 25-34 Enteractualnumber
Enteractualnumber
A2x0.21 B2x0.18 A2x0.21 B2x0.30
3 35-44 Enteractualnumber
Enteractualnumber
A3x0.25 B3x0.24 A3x0.30 B3x0.36
4 45-54 Enteractualnumber
Enteractualnumber
A4x0.28 B4x0.27 A4x0.38 B4x0.45
5 55-64 Enteractualnumber
Enteractualnumber
A5x0.33 B5x0.30 A5x0.46 B5x0.50
6 65-74 Enteractualnumber
Enteractualnumber
A6x0.31 B6x0.35 A6x0.51 B6x0.60
7 75+ Enteractualnumber
Enteractualnumber
A7x0.18 B7x0.27 A7x0.41 B7x0.57
8 Sub-total Sumof Sumof Sumof Sumof Sumof SumofA1-A7 B1-B7 C1-C7 D1-D7 E1-E7 F1-F7
9 Total SumofA8andB8 SumofC8andD8 SumofE8-F8
Source:TheformulaeforbothobesityandwaistcircumferencearebasedontheHealthSurveyforEngland2006.10
Example–SouthwarkPrimaryCareTrust:adultsaged16andover
Thefollowingisanexampleofhowtousetheready-reckoner,basedon2001censusfiguresforSouthwarkPrimaryCareTrust,London.
A B C D E F
SouthwarkPCT Estimateofnumberof Estimateofnumberofpopulation peoplewhoareobese
(BMIgreaterthan30kg/m2)
peoplewhohavearaisedwaistcircumference(Male102cmorabove.Female88cmorabove)
Age Male Female Male Female Male Female
1 16-24 17,812 18,011 1,603 2,161 1,781 3,062
2 25-34 25,894 26,865 5,438 4,836 5,438 8,060
3 35-44 21,501 20,998 5,375 5,040 6,450 7,559
4 45-54 11,960 12,478 3,349 3,369 4,545 5,615
5 55-64 8,137 8,831 2,685 2,649 3,743 4,416
6 65-74 6,421 7,213 1,991 2,525 3,275 4,328
7 75+ 4,286 7,434 771 2,007 1,757 4,237
8 Sub-total 96,011 101,830 21,212 22,587 26,989 37,277
9 Total 197,841 43,799 64,266
TOOLD2Obesityprevalenceready-reckoner 93
Obesityprevalenceready-reckoner:childrenaged1-15years
A B C D
PCTpopulation(Enteractualnumbers)
Estimateofnumberofchildrenwhoareobese(UKNationalBMIPercentileClassification*)
Age Male Female Male Female
1 1 Enteractualnumber Enteractualnumber A1x0.173 B1x0.160
2 2 Enteractualnumber Enteractualnumber A2x0.174 B2x0.170
3 3 Enteractualnumber Enteractualnumber A3x0.171 B3x0.166
4 4 Enteractualnumber Enteractualnumber A4x0.165 B4x0.162
5 5 Enteractualnumber Enteractualnumber A5x0.166 B5x0.166
6 6 Enteractualnumber Enteractualnumber A6x0.166 B6x0.163
7 7 Enteractualnumber Enteractualnumber A7x0.163 B7x0.169
8 8 Enteractualnumber Enteractualnumber A8x0.171 B8x0.176
9 9 Enteractualnumber Enteractualnumber A9x0.180 B9x0.181
10 10 Enteractualnumber Enteractualnumber A10x0.183 B10x0.187
11 11 Enteractualnumber Enteractualnumber A11x0.193 B11x0.195
12 12 Enteractualnumber Enteractualnumber A12x0.192 B12x0.205
13 13 Enteractualnumber Enteractualnumber A13x0.208 B13x0.211
14 14 Enteractualnumber Enteractualnumber A14x0.206 B14x0.220
15 15 Enteractualnumber Enteractualnumber A15x0.216 B15x0.225
16 Sub-total SumofA1-A15 SumofB1-B15 SumofC1-C15 SumofD1-D15
17 Total SumofA16andB16 SumofC16andD16
Source:TheformulaeforobesityarebasedontheHealthSurveyforEngland2006.11
*TheUKNationalBMIPercentileClassificationdefinesobesityasaBMIofmorethanthe95thcentile,andoverweightasaBMIofmorethanthe85thcentileoftheUK1990referencechartforageandsex.(SeeToolE4insectionE.)
94 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
EstimatingtheprevalenceofobesityandcentralobesityamongadultsinethnicgroupsTomodelforethnicity,usingtheresultsfromtheready-reckonerasabase,applytheethnicitybreakdownforeachage/gendergroup,andforeachcellapplythefollowingadjustmentfactors(derivedfromTable1onpage12)tocalculatetheprevalenceofobesityandcentralobesitybyage/gender/ethnicity.Theresultingprevalenceestimatescanbesummedwhicheverwayyouchoose.Theseadjustmentfactorsrepresentthenationalprevalenceofobesityandcentralobesityinadults(aged16andover)byethnicgroupcomparedtothegeneralpopulation(=1.0).
Ethnicgroup Obesity Centralobesity
Men Women Men Women
BlackCaribbean 1.11 1.38 0.71 1.15
BlackAfrican 0.75 1.66 0.61 1.29
Indian 0.61 0.87 0.65 0.93
Pakistani 0.67 1.21 0.97 1.17
Bangladeshi 0.26 0.74 0.39 1.05
Chinese 0.26 0.33 0.26 0.39
Estimatingtheprevalenceofoverweightamongadults
Amodifiedversionoftheready-reckonercanbeusedtoestimatethenumberofoverweightpeople–thosewithaBMImorethan25kg/m2–usingthedataonprevalenceofoverweightindifferentagegroupsfromtheHealthSurveyforEngland2006.Toestimatetheprevalenceofoverweightforethnicgroups,followthesameprocedureasdescribedabove.UseTable1onpage12tocalculatetheadjustmentfactors.
Primarycareorganisation(PCO)levelmodel-basedestimateofadultobesityAnotherwayofassessinglocalprevalenceofadult(aged16andover)obesityisusingmodel-basedestimatesproducedbytheNHSInformationCentreforHealthandSocialCare.Theseestimatesarecalculatedusingpooled2003-05HealthSurveyforEngland(HSE)data.However,becausestatisticalmodellingwasused,prevalencedatashouldbeappliedwithcaution.147
Note:StatisticalmodellingwasusedtoproducethePCO-levelmodel-basedestimatesbecausethesamplesizeofnationalsurveysistoosmallatlocalarealeveltoprovidereliabledirectestimates.Themodel-basedestimateforaparticularlocalareaistheexpectedprevalenceforthatareabasedonitspopulationcharacteristics(asmeasuredbythecensus/administrativedata)andassuchdoesnotrepresentanestimateoftheactualprevalenceforthelocalarea.Confidenceintervalsareprovidedinordertomakethemarginoferroraroundtheestimatesclear.
ToviewthePCO-levelmodel-basedestimatesforadultobesity,gotowww.ic.nhs.uk
TOOLD3Estimatingthelocalcostofobesity 95
TOOLD3EstimatingthelocalcostofobesityTOOLD3For: Commissionersinprimarycaretrusts(PCTs)
About: ThistoolprovidesestimatesoftheannualcoststotheNHSofdiseasesrelatedtooverweightandobesityandobesityalone,brokendowntoPCTlevel.EstimatedcostshavebeenbasedonadisaggregationofthenationalestimatescalculatedbyForesight(forselectedyears2007-2015).SeeSettinglocalgoalsinSectionC.
Purpose: TogiveanunderstandingofthescaleoftheproblemtotheNHSinPCTsifcurrenttrendscontinue.
Use: CanbeusedforunderstandingtheprobleminyourPCT–casefor•funding.
Canbeusedforevaluationandmonitoringpurposes.Thedatacanbe•usedasabaselineandformonitoringinterventionsrelatingtoreducingcoststoNHS.
Resource: Modellingfuturetrendsinobesityandtheimpactonhealth.Foresighttacklingobesities:Futurechoices.16www.foresight.gov.uk
TheestimatedannualcoststotheNHSofdiseasesrelatedtooverweightandobesity(BMI25kgm2
ormore)andobesityalone(BMI30kg/m2ormore),byPCT,areprovidedbelow.
ThecostshavebeenestimatedusingthenationalestimatescalculatedbyForesight.AmicrosimulationmodelwasusedtoforecastcoststotheNHSoftheconsequencesofoverweightandobesity.Noinflationcosts,eitherofpricesgenerallyorhealthcarecostsinparticular,wereincorporatedwithinthecosts,sothisallowsfordirectcomparisontocurrentprices.FutureBMI-relatedcostswereapproximatedbysubtractingestimatesofcurrentNHScostsofobesityfromprojectedcostsderivedfromthemodel.Furtherinformationaboutthemicrosimulationmodelcanbefoundatwww.foresight.gov.uk
EstimatedannualcoststoNHSofdiseasesrelatedtooverweightandobesity(BMI25kg/m2ormore)andobesityalone(BMI30kg/m2ormore),byPCT
EstimatedannualcoststoNHSofdiseasesrelatedtooverweightandobesity
£million
EstimatedannualcoststoNHSofdiseasesrelatedtoobesity
£million
2007 2010 2015 2007 2010 2015
GovernmentOfficefortheNorthEast
CountyDurhamPCT 156.7 162.7 173.9 81.3 88.1 101.1
DarlingtonPCT 27.6 28.6 30.6 14.3 15.5 17.8
GatesheadPCT 61.9 64.3 68.7 32.1 34.8 39.9
HartlepoolPCT 29.3 30.4 32.5 15.2 16.5 18.9
MiddlesbroughPCT 45.8 47.5 50.8 23.7 25.7 29.5
NewcastlePCT 81.1 84.1 90 42.1 45.6 52.3
NorthTeesPCT 51.9 53.9 57.6 26.9 29.2 33.5
NorthTynesidePCT 58.9 61.2 65.4 30.6 33.1 38
NorthumberlandCareTrust 85.7 88.9 95.1 44.4 48.1 55.3
96 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
EstimatedannualcoststoNHSofdiseasesrelatedtooverweightandobesity
£million
EstimatedannualcoststoNHSofdiseasesrelatedtoobesity
£million
2007 2010 2015 2007 2010 2015
RedcarandClevelandPCT 41 42.5 45.5 21.3 23 26.4
SouthTynesidePCT 48.8 50.7 54.2 25.3 27.4 31.5
SunderlandTeachingPCT 88.4 91.7 98.1 45.9 49.7 57
GovernmentOfficefortheNorthWest
Ashton,LeighandWiganPCT 90.8 94.3 100.8 47.1 51 58.6
BlackburnwithDarwenPCT 46.4 48.1 51.4 24.1 26 29.9
BlackpoolPCT 45.8 47.5 50.8 23.8 25.7 29.6
BoltonPCT 78.3 81.3 86.9 40.6 44 50.5
BuryPCT 50 51.9 55.5 26 28.1 32.3
CentralandEasternCheshirePCT 111.4 115.6 123.6 57.8 62.6 71.9
CentralLancashirePCT 119.2 123.7 132.3 61.8 67 76.9
CumbriaPCT 136.8 141.9 151.8 71 76.9 88.2
EastLancashirePCT 110.1 114.2 122.2 57.1 61.9 71
HaltonandStHelensPCT 95.3 98.9 105.8 49.5 53.6 61.5
Heywood,MiddletonandRochdalePCT
63.4 65.8 70.4 32.9 35.6 40.9
KnowsleyPCT 55 57.1 61 28.5 30.9 35.5
LiverpoolPCT 163.6 169.8 181.5 84.9 91.9 105.5
ManchesterPCT 166.8 173.1 185.1 86.6 93.7 107.6
NorthLancashirePCT 90.5 93.9 100.4 47 50.9 58.4
OldhamPCT 67.5 70.1 74.9 35 37.9 43.6
SalfordPCT 73.3 76.1 81.3 38 41.2 47.3
SeftonPCT 82.1 85.2 91.1 42.6 46.1 52.9
StockportPCT 74.4 77.2 82.6 38.6 41.8 48
TamesideandGlossopPCT 66.8 69.3 74.1 34.6 37.5 43.1
TraffordPCT 57.5 59.7 63.8 29.8 32.3 37.1
WarringtonPCT 51.2 53.1 56.8 26.6 28.8 33
WesternCheshirePCT 65.6 68.1 72.8 34 36.8 42.3
WirralPCT 98.5 102.2 109.3 51.1 55.3 63.6
GovernmentOfficeforYorkshireandTheHumber
BarnsleyPCT 72.3 75.1 80.3 37.5 40.6 46.7
BradfordandAiredalePCT 142.6 148 158.3 74 80.1 92
CalderdalePCT 53 55 58.8 27.5 29.8 34.2
DoncasterPCT 88.4 91.7 98.1 45.9 49.7 57
EastRidingofYorkshirePCT 76.4 79.3 84.8 39.7 43 49.3
HullPCT 78.8 81.8 87.4 40.9 44.3 50.8
KirkleesPCT 103.4 107.3 114.8 53.7 58.1 66.7
TOOLD3Estimatingthelocalcostofobesity 97
EstimatedannualcoststoNHSofdiseasesrelatedtooverweightandobesity
£million
EstimatedannualcoststoNHSofdiseasesrelatedtoobesity
£million
2007 2010 2015 2007 2010 2015
LeedsPCT 197.4 204.9 219.1 102.4 110.9 127.4
NorthEastLincolnshirePCT 45.2 46.9 50.1 23.4 25.4 29.1
NorthLincolnshirePCT 42 43.6 46.6 21.8 23.6 27.1
NorthYorkshireandYorkPCT 186.6 193.6 207.1 96.8 104.8 120.4
RotherhamPCT 72.2 74.9 80.1 37.4 40.6 46.6
SheffieldPCT 148.7 154.3 165 77.1 83.6 95.9
WakefieldDistrictPCT 98.5 102.3 109.3 51.1 55.4 63.6
GovernmentOfficefortheEastMidlands
BassetlawPCT 29.6 30.8 32.9 15.4 16.7 19.1
DerbyCityPCT 73.4 76.2 81.5 38.1 41.3 47.4
DerbyshireCountyPCT 184.3 191.3 204.5 95.6 103.5 118.9
LeicesterCityPCT 86.6 89.9 96.1 45 48.7 55.9
LeicestershireCountyandRutlandPCT
147.6 153.2 163.8 76.6 83 95.3
LincolnshirePCT 187.9 195 208.6 97.5 105.6 121.3
NorthamptonshirePCT 167.6 173.9 186 86.9 94.2 108.1
NottinghamCityPCT 85.1 88.3 94.4 44.1 47.8 54.9
NottinghamshireCountyPCT 166.8 173.1 185.1 86.5 93.7 107.6
GovernmentOfficefortheWestMidlands
BirminghamEastandNorthPCT 122.5 127.2 136 63.6 68.9 79.1
CoventryTeachingPCT 96.1 99.7 106.6 49.8 54 62
DudleyPCT 80.9 84 89.8 42 45.5 52.2
HeartofBirminghamTeachingPCT 92.9 96.5 103.1 48.2 52.2 60
HerefordshirePCT 46.3 48.1 51.4 24 26 29.9
NorthStaffordshirePCT 54.7 56.8 60.7 28.4 30.7 35.3
SandwellPCT 94.1 97.6 104.4 48.8 52.9 60.7
ShropshireCountyPCT 72.4 75.1 80.3 37.5 40.7 46.7
SolihullCareTrust 51.4 53.4 57.1 26.7 28.9 33.2
SouthBirminghamPCT 100.9 104.8 112 52.4 56.7 65.1
SouthStaffordshirePCT 143.7 149.2 159.5 74.6 80.8 92.7
StokeonTrentPCT 77.9 80.8 86.4 40.4 43.8 50.3
TelfordandWrekinPCT 42.8 44.4 47.5 22.2 24.1 27.6
WalsallTeachingPCT 74.4 77.2 82.5 38.6 41.8 48
WarwickshirePCT 131.6 136.5 146 68.3 73.9 84.9
WolverhamptonCityPCT 73.8 76.6 81.9 38.3 41.5 47.6
WorcestershirePCT 136.6 141.8 151.6 70.9 76.8 88.1
98 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
EstimatedannualcoststoNHSofdiseasesrelatedtooverweightandobesity
£million
EstimatedannualcoststoNHSofdiseasesrelatedtoobesity
£million
2007 2010 2015 2007 2010 2015
GovernmentOfficefortheEastofEngland
BedfordshirePCT 98.8 102.6 109.7 51.3 55.5 63.8
CambridgeshirePCT 138.3 143.5 153.5 71.7 77.7 89.2
EastandNorthHertfordshirePCT 134.4 139.4 149.1 69.7 75.5 86.7
GreatYarmouthandWaveneyPCT 65.4 67.9 72.6 33.9 36.8 42.2
LutonPCT 50.7 52.6 56.2 26.3 28.5 32.7
MidEssexPCT 82 85.1 91 42.5 46.1 52.9
NorfolkPCT 188.7 195.8 209.4 97.9 106 121.7
NorthEastEssexPCT 86.3 89.6 95.8 44.8 48.5 55.7
PeterboroughPCT 42.7 44.4 47.4 22.2 24 27.6
SouthEastEssexPCT 88 91.3 97.6 45.6 49.4 56.8
SouthWestEssexPCT 106.3 110.3 117.9 55.1 59.7 68.6
SuffolkPCT 146.4 152 162.5 76 82.3 94.5
WestEssexPCT 66.7 69.2 74 34.6 37.5 43
WestHertfordshirePCT 130.8 135.8 145.2 67.9 73.5 84.4
GovernmentOfficeforLondon
BarkingandDagenhamPCT 54.6 56.7 60.6 28.3 30.7 35.2
BarnetPCT 85.1 88.3 94.4 44.1 47.8 54.9
BexleyCareTrust 55.5 57.6 61.6 28.8 31.2 35.8
BrentTeachingPCT 83 86.2 92.2 43.1 46.7 53.6
BromleyPCT 77.2 80.1 85.7 40.1 43.4 49.8
CamdenPCT 74.6 77.4 82.8 38.7 41.9 48.1
CityandHackneyTeachingPCT 85.3 88.5 94.6 44.2 47.9 55
CroydonPCT 88.9 92.2 98.6 46.1 49.9 57.3
EalingPCT 89 92.4 98.8 46.2 50 57.4
EnfieldPCT 75.7 78.6 84.1 39.3 42.6 48.9
GreenwichTeachingPCT 73 75.8 81 37.9 41 47.1
HammersmithandFulhamPCT 53.4 55.4 59.2 27.7 30 34.4
HaringeyTeachingPCT 73.7 76.5 81.8 38.2 41.4 47.6
HarrowPCT 50.9 52.8 56.4 26.4 28.6 32.8
HaveringPCT 65.2 67.7 72.4 33.9 36.7 42.1
HillingdonPCT 63.6 66 70.6 33 35.8 41.1
HounslowPCT 60.8 63.1 67.5 31.6 34.2 39.3
IslingtonPCT 66.3 68.8 73.6 34.4 37.3 42.8
KensingtonandChelseaPCT 56 58.1 62.1 29.1 31.5 36.1
KingstonPCT 39.7 41.1 44 20.6 22.3 25.6
LambethPCT 88.6 91.9 98.3 46 49.8 57.1
TOOLD3Estimatingthelocalcostofobesity 99
EstimatedannualcoststoNHSofdiseasesrelatedtooverweightandobesity
£million
EstimatedannualcoststoNHSofdiseasesrelatedtoobesity
£million
2007 2010 2015 2007 2010 2015
LewishamPCT 76.2 79.1 84.5 39.5 42.8 49.1
NewhamPCT 92.6 96.1 102.8 48.1 52.1 59.8
RedbridgePCT 62.3 64.7 69.1 32.3 35 40.2
RichmondandTwickenhamPCT 42.4 44 47.1 22 23.8 27.4
SouthwarkPCT 83 86.1 92.1 43.1 46.6 53.5
SuttonandMertonPCT 93.8 97.4 104.1 48.7 52.7 60.5
TowerHamletsPCT 80.9 84 89.8 42 45.5 52.2
WalthamForestPCT 68 70.6 75.5 35.3 38.2 43.9
WandsworthPCT 74.1 76.9 82.2 38.4 41.6 47.8
WestminsterPCT 70.2 72.9 77.9 36.4 39.4 45.3
GovernmentOfficefortheSouthEast
BrightonandHoveCityPCT 75.3 78.1 83.5 39.1 42.3 48.6
EastSussexDownsandWealdPCT 88.2 91.5 97.9 45.8 49.6 56.9
EasternandCoastalKentPCT 201.8 209.5 224 104.7 113.4 130.2
HastingsandRotherPCT 52.2 54.2 58 27.1 29.4 33.7
MedwayPCT 69.7 72.3 77.4 36.2 39.2 45
SurreyPCT 251.3 260.8 278.8 130.4 141.2 162.1
WestKentPCT 160 166.1 177.6 83 89.9 103.3
WestSussexPCT 199.5 207 221.4 103.5 112.1 128.7
BerkshireEastPCT 91 94.5 101 47.2 51.2 58.7
BerkshireWestPCT 103.5 107.4 114.8 53.7 58.1 66.7
BuckinghamshirePCT 113.6 117.9 126.1 59 63.8 73.3
HampshirePCT 300.8 312.2 333.8 156.1 169 194.1
IsleofWightNHSPCT 41.9 43.5 46.5 21.8 23.6 27.1
MiltonKeynesPCT 56.9 59 63.1 29.5 31.9 36.7
OxfordshirePCT 143.4 148.8 159.1 74.4 80.6 92.5
PortsmouthCityTeachingPCT 50.1 52 55.6 26 28.2 32.3
SouthamptonCityPCT 65.2 67.6 72.3 33.8 36.6 42.1
GovernmentOfficefortheSouthWest
BathandNorthEastSomersetPCT 44.1 45.8 49 22.9 24.8 28.5
BournemouthandPoolePCT 89.5 92.8 99.3 46.4 50.3 57.7
BristolPCT 111.6 115.8 123.9 57.9 62.7 72
CornwallandIslesofScillyPCT 145.1 150.6 161 75.3 81.5 93.6
DevonPCT 190.5 197.7 211.4 98.8 107 122.9
DorsetPCT 102.4 106.2 113.6 53.1 57.5 66
GloucestershirePCT 143.7 149.1 159.5 74.6 80.7 92.7
NorthSomersetPCT 51.4 53.4 57.1 26.7 28.9 33.2
100 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
EstimatedannualcoststoNHSofdiseasesrelatedtooverweightandobesity
£million
EstimatedannualcoststoNHSofdiseasesrelatedtoobesity
£million
2007 2010 2015 2007 2010 2015
PlymouthTeachingPCT 68.5 71 76 35.5 38.5 44.2
SomersetPCT 133.8 138.8 148.4 69.4 75.2 86.3
SouthGloucestershirePCT 54.8 56.9 60.8 28.4 30.8 35.3
SwindonPCT 48 49.8 53.3 24.9 27 31
TorbayCareTrust 42.4 44 47.1 22 23.8 27.4
WiltshirePCT 106.6 110.6 118.3 55.3 59.9 68.8
ElevatedBMI(£million) Obesity(£million)
FORESIGHTestimateofnationalannualcoststoNHS
2007 2010 2015 2007 2010 2015
13,891 14,416 15,415 7207 7,805 8,962
Notes:Costsarecalculatedat2004prices.ItisassumedtheBMIdistributionforEnglandchangesinlinewithcurrenttrends.
Note:NICEhasproducedareportwhichattemptstoestimatethecostofimplementingtheNICEguidelinesonobesity.142Thisreportestimatesthecostof:treatmentofobese/overweightchildrenwithco-morbidities(referraltoaspecialist,drugtreatmentforsomechildren);bariatricsurgeryforveryobeseadults;andstafftraininginpreventionandmanagementofobesity.Toviewthereport,visitwww.nice.org.uk
TOOLD4Identifyingprioritygroups 101
TOOLD4IdentifyingprioritygroupsTOOLD4For: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities
About: ThistooldescribeshowlocalareascanaccessandusethenationalsegmentationanalysisproducedbytheDepartmentofHealththroughastep-by-stepguide.
Purpose: Toprovidelocalareaswithanunderstandingofwhythethreepriority•groupswereselectedfornationalintervention.
Toexplainhowthesegmentationanalysiscanbeusedatalocallevel.•
Use: Canbeusedtoidentifyprioritygroupsinlocalareas.•
Thesegmentationanalysiscanbeusedtofurtherdefineparticular•clustersinlocalareas.
Resource: Insightsintochildobesity:Asummary.AdraftofthisreportisavailabletoPCTsandLAsthroughtheirRegionalPublicHealthGroup.Afinalreportwillbepublishedinlate2008.
Nationalsegmentationoffamilieswithchildrenaged2-11Aquantitativesegmentationofthepopulationaged2-11yearswascarriedoutbytheDepartmentofHealthtohelpbetterunderstandthebehavioursthatleadtoindividualsbecomingoverweightandobese,andtounderstandwhichbehavioursarecommonwithindifferentclustersinsociety.Segmentingindividualsandfamiliesintoclustersallowsinterventionstohelpsupportbehaviourchange–forinstancetheNationalMarketingPlan–tobeprioritisedtothegroupswiththegreatestneed,andtotailortheinterventionstothoseneeds,increasingtheireffectiveness.
Analysisshowedthatchildrenaged2-11yearsandtheirfamiliescouldbedividedintosixbroadgroupsorclustersaccordingtotheirattitudesandbehavioursrelatingtodietandphysicalactivity,inadditiontotheirdemographicmake-up,levelsoffoodconsumption,socioeconomicgrouping,educationandemployment.Theclusterswerefurtherdevelopedusingqualitativeresearchwiththeaimofgaininginsightfromwhichtodesignbehaviour-changeinterventionsamongparentsandchildren.Ofthesixclusters,threedemonstratedcommonbehavioursthatputthemmost‘atrisk’ofdevelopingobesity–andindeedtheseclustershadthehighestratesofadultandchildobesity.ThesethreeclustersarethepriorityclusterswithintheNationalMarketingPlan.
Thethreepriorityclusterscanalsobeusedbylocalareastobettertargetinterventionstopromotehealthyweight,leadingtomoreeffectiveinterventionsanduseofpublicresources.LocalauthoritiesandPCTscanaccessadraftreportthatdescribesthesixclustersindetailviatheobesityleadintheirRegionalPublicHealthGroup,orbyemailinghealthyweight@dh.gsi.gov.uk.Afinalversionofthereportwillbepublishedinlate2008,informedbycontinuingresearch.Inthemeantime,theCross-GovernmentObesityUnitwelcomesfeedbackonthedraftreport.
102 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Usingthesegmentationanalysisatalocallevel–astep-by-stepguideStep1–Prioritiseclusters1,2and3askeyinterventiongroups,inlinewithnationalpolicy.
Fordetailsofhowtoaccessinformationonthepriorityclusters,seepage101.
Step2–Usesocioeconomicdatatoidentifythemostlikelyareaswiththetargetclusters.
Anumberoforganisationscanassistwithmappinghigh-riskgroupsandidentifyingdeprivationlevels:
• PublicHealthObservatories–www.apho.org.uk/apho
• TheNorthEastPublicHealthObservatoryhasanon-linemappingfacilitywhichcanidentifyobesityratesatPCTandwardlevel(NorthEastregiondataonly)www.nepho.org.uk
• UniversityofSheffieldPublicHealthGISUnit–gis.sheffield.ac.uk
• CommunitiesandLocalGovernment–IndicesofDeprivation–www.communities.gov.uk
• Localacademicdepartments–www.hero.ac.uk
Commercialorganisationscanalsohelpwithmapping.
KeypointTofurthersupporttheidentificationoftheclustersatalocallevel,theDepartmentofHealthisundertakingamappingexercisetoprovidePCTswithinformationonwheretheymightfindclusterswithintheirlocalpopulationandinwhatproportion(currentpercentagesizesgivenarebasedonthenationalsample).ThisworkwillbeundertakenwithCACIusingtheirHealthAcornproductandtheoutputswillbecomparablewithMOSAICcodes.Mapsanddatatableswillbeavailableatwww.dh.gov.ukinlate2008.
Step3–Bringtogetherlocalfocusgroupsoftargetclusters1,2and3.
Tofurtherinformtheselectionoftargetinterventiongroups,localareasmaywanttoconductindependentqualitativeresearch.Focusgroupscanbeusedtoidentifythosefamilieswhomostneedhelpandsupporttochangebehaviours,butalsotohelpalignlocalresearchprogrammeswithnationalresearch.
Step4–Tailoryourinterventionstofittheattitudes,behavioursandbarrierselicitedbyeachclusterfocusgroup.
SeeToolsD8,D9andD10formoreinformationonchoosinginterventions,targetingbehavioursandcommunicatingtokeytargetgroups.
TOOLD4Identifyingprioritygroups 103
CASESTUDY–ThePeople’sMovement,Sheffield
SheffieldCityCouncilandSheffieldFirstforHealthandWell-beinghavesetupaphysicalactivitycampaign,‘ThePeople’sMovement’,whichencouragespeopletomakepositivechoicesaroundincreasingtheamountofphysicalactivitytheydo.Furtherdetailsareprovidedinthetablebelow.
Aim–Behaviouralgoal
Toencourageandsupportpeopletobemorephysicallyactiveandtopromote30minutes’exerciseonasmanydaysaspossible,brokendownintobite-sizechunksof10minutes.
Marketresearch Healthprofessionalswereconsultedwhendesigningthecampaign.Nofocusgroupsorresearchwereconductedwiththetargetaudience.
Segmentation Thetargetaudiencewassegmentedbycurrentbehaviour:
1Thosealreadyactive–thecampaignaimedtokeepthemactive(behaviouralreinforcement).
2Thenearlyactive–thosedoingsomeactivitybutnotreachingminimumrecommendedlevels.Thecampaignencouragedthemtodomore(positivebehaviouralpromotion).
3Theinactive–thecampaignaimedtoencouragethemtotryactivitiesandbegintobuildactivityintotheirlives(behaviouralchange).
Intervention Differentinterventionsfordifferentsegmentsofthetargetaudienceweredesigned:
Behaviouralreinforcement
Celebratingacommunitychampion•
Ayoungpeople’sphysicalactivitycampaignpromotedthrough•competitions.
Positivebehaviouralpromotion
Awebsitewithinformationandapersonalisedactivitydiary•
Eventssuchaswalkingfestivals,bellydancingandsalsanights.•
Behaviouralchange
DVDstoenablebeginnerstotraintoparticipateina3krun•
Leafletsandlargestreet-basedposterscarryingpowerfulmessages•aboutthebenefitsofexercising
Promotinglocalparksandleisurefacilities.•
Participantscouldalsoregistertobesentpersonaliseddetailsofeventshappeningintheircommunitythatmayappealtothem.
Evaluation Noevaluationhasyetbeenconducted.However,thereareplanstodoanevaluationwhichwilllookatawareness.
Furtherinformation
www.thepeoplesmovement.co.uk
104 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLD5Settinglocalgoals 105
TOOLD5SettinglocalgoalsTOOLD5For: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities
About: ThistoolprovidesadvicefromtheDepartmentofHealthonsettinglocalgoalsusingNationalChildMeasurementProgramme(NCMP)prevalenceestimates.148Italsoprovidesadviceonestablishinginterventionobjectives–alistofNationalIndicatorsofsuccessrelevanttoobesityisprovided.RefertoToolD14Monitoringandevaluation:aframework.
Purpose: Togivelocalareasanunderstandingofhowtoestablishlocalplansthatarebasedonachievingachangeinobesityprevalence.
Use: Shouldbeusedtosetlocalgoals.•
Canbeusedtoestablishobjectives.•
Canbeusedforevaluationandmonitoringpurposes.Datacanbeused•asperformanceindicators.
Resource: Howtosetandmonitorgoalsforprevalenceofchildobesity:Guidanceforprimarycaretrusts(PCTs)andlocalauthorities.141www.dh.gov.uk
SettinglocalgoalsAlllocalareashavealreadysettheirgoalsfortacklingobesityovertheperiod2008/09to2010/11,eitherthroughPCTplans,oradditionallyinlocalareaagreements.However,thistoolsummarisestheDepartmentofHealth’sguidanceonsettinglocalgoals149asitisusefultorememberwhatunderpinsthosetargets.
Currently,basedonHealthSurveyforEnglanddata,theestimatedprevalenceofobesityinchildreninbothReceptionandYear6isrisingatayearlyrateofaround0.5%points.TheDepartmentofHealthsuggeststhatlocalauthoritiesandPCTsshouldestablishlocalplansthatarebasedonachievingachangeinprevalenceineachofthethreeyearsthatbettersthecurrentnationaltrend–thatis,anincreaseoflessthan0.5%points,ornoincreaseatall,orareductioninobesity.InorderthatlocalauthoritiesandPCTscanachievethischangeinprevalence,theDepartmentofHealthhascalculatedwhatpercentagechangesinobesityprevalenceinReceptionandYear6wouldbeneededby2010/11toachieveastatisticallysignificantimprovementonthecurrenttrend.Thesedataareavailableatwww.dh.gov.ukandarebasedonNCMP2006/07prevalenceestimates.148BecausenumbersmeasuredandprevalencewillbedifferentforfutureyearsoftheNCMP,thefiguresareindicative,buttheygiveareasonableapproximationofthechangethatneedstoberecordedtobestatisticallysignificantlylessthanthenationaltrend.
Note:Thesefiguresprovideboth95%and75%confidencelevels.Useofahigherconfidencelevelreducestheriskofincorrectlyconcludingthatasignificantimprovementinprevalenceofchildobesityhasbeenachieved.(At95%,theriskis1in20;at75%,theriskis1in4.)However,useofahigherconfidencelevelmeansthatagreaterchangeinprevalenceisneededforittobedeemedasignificantchange.Insomeareas,itmaybenecessarytosacrificeconfidencetosomeextentinordertosetagoalthatisachievable.Therequiredchangesassociatedwiththe95%and75%confidencelevelscouldbeusedasupperandlowerlimitstoinformlocalnegotiationsongoalsetting.
106 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Step-by-stepguideBarkingandDagenhamlocalauthorityhasbeenusedhereasaworkedexampletoshowwhatstepslocalauthoritiesandPCTsneedtotaketosetagoaltoachieveastatisticallysignificantimprovementonthecurrentnationaltrend(ofannualrisesinlevelsofchildobesityof0.5%points)by2010/11.
Step1–LocalauthoritieschoosewhethertosetagoalforReceptionYear,orYear6,orboth.PCTshavetousebothfortheirplans,asrequiredbytheOperatingFramework.
Localauthoritydecisionsshouldbebasedoncurrentlevelsofprevalenceforeachyear,thecoherenceofanygoalwithothersbeingset(egonschoolfood),andwhethertheyarejointlysettinggoalswiththelocalPCT.GovernmentofficesandstrategichealthauthoritieswillofcoursediscussthesedecisionswithlocalauthoritiesandPCTs.Forthebasisofthisworkedexample,itisassumedthatBarkingandDagenhamlocalauthoritychoosebothyears.
Step2–Determinewhatconfidenceleveltouse,andlookuptherequiredchangeby2010/11atthatconfidencelevel.(Gotowww.dh.gov.ukfordata.)
Theconfidencelevelchosenisinpartareflectionofhowambitiouslocalareasfeelthattheycanbe.TheDepartmentofHealthwouldurgeasmanyareasaspossibletochoosethe95%levelofconfidence.
Whateverlevelischosen,forsomeareasthiswillmeanthattheyneedtorecordareductionintheirprevalenceofchildobesityiftheyaretobeconfidentofachievingastatisticallysignificantreductioningrowthversusthenationalaveragegrowthof0.5%points.Forotherareas,thisrequirementcanbemetbyrecordingareduced,butstillincreasing,levelofgrowthinprevalence.
ForBarkingandDagenham,usingNCMP(2006/07)data,148thefigureswouldbeasfollows:
Receptionyear:
• Currentprevalenceis14.4%.
• Requiredchangeby2010/11tobe95%confidentofreducinggrowthinprevalencebelowthenationaltrendis-1.1%points,ie13.3%.
Year6:
• Currentprevalenceis20.8%.
• Requiredchangeby2010/11tobe95%confidentofreducinggrowthinprevalencebelowthenationaltrendis-1.9%points,ie18.9%.
Step3–Settrajectory
Oncethefinalgoalfor2010/11hasbeenset,atrajectoryforthechangeinprevalenceto2010/11mustbechosen.IfareasareusingthelatestNCMPdata,for2006/07,asabaselinefortheirgoal,thetrajectorywillalsoneedtoinclude2007/08,aswellas2008/09to2010/11.Areasthatalreadyhaveestablishedinitiativestotacklechildobesitymayfeelthatastraightlinetrajectorywouldbemoreappropriateforthem.However,areaswhereinitiativesareintheirinfancymaywanttosetacurvedtrajectory,whereagreaterproportionofthechangeisachievedinthelateryearsoftheperiodto2010/11.
TOOLD5Settinglocalgoals 107
ForBarkingandDagenham,thetrajectory,whetherstraightorcurved,wouldlookasfollows:
TargetobesitylevelsforReceptionandYear6children,BarkingandDagenham,2006-07to2010-11
Receptionchildren
14.5
Perc
enta
ge o
besi
ty
14
13.5
13
Change –1.1% points
2006/07 2007/08 2008/09 2009/10 2010/11
Straight trajectory Curved trajectory
Year6children
21
20.5
Change –1.9% points
Perc
enta
ge o
besi
ty
20
19.5
19
18.5 2006/07 2007/08 2008/09 2009/10 2010/11
Straight trajectory Curved trajectory
SettingobjectivesOncethelocalgoalhasbeenset(egtoreduceprevalenceby1.9%),localareascanestablishinterventionobjectivesinordertoreachthatgoal.ToolD7setsoutwhatsuccesslookslikeagainstarangeofbehavioursandthesecanbeusedtosetlocalobjectives.AwiderangeofdatacanbeusedtomeasuresuccessagainstlocalobjectivesandthefollowingtableprovidesalistoftheNationalIndicatorsofsuccessrelevanttoobesity.137
108 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
NationalIndicatorsofsuccessrelevanttotheDepartmentofHealth’skeythemes
Children:healthygrowthandhealthyweight
NI50 Emotionalhealthofchildren
NI52 Take-upofschoollunches
NI53 Prevalenceofbreastfeedingat6-8weeksfrombirth
NI55 ObesityamongprimaryschoolagechildreninReception
NI56 ObesityamongprimaryschoolagechildreninYear6
NI57 Childrenandyoungpeople’sparticipationinhigh-qualityPEandsport
NI69 Childrenwhohaveexperiencedbullying
NI198 Childrentravellingtoschool–modeoftravelusuallyused
Promotinghealthierfoodchoices
NI119 Self-reportedmeasuresofpeople’soverallhealthandwellbeing
NI120 All-age,all-causemortalityrate
NI121 Mortalityratefromallcirculatorydiseasesatagesunder75
NI122 Mortalityratefromallcancersatagesunder75
NI137 Healthylifeexpectancyatage65
Buildingphysicalactivityintoourlives
NI8 Adultparticipationinsport
NI17 Individuals’perceptionsofcrimeandanti-socialbehaviour
NI47and48 Reductioninroadtrafficaccidents
NI175 Accesstoservicesbypublictransport,walkingandcycling
NI186 PercapitaCO2emissionsinthelocalauthorityarea
NI188 Adaptingtoclimatechange
NI198 Childrentravellingtoschool–modeoftravelusuallyused
Creatingincentivesforbetterhealth
NI8 Adultparticipationinsport
NI119 Self-reportedmeasureofpeople’soverallhealthandwellbeing
NI120 All-age,all-causemortalityrate
NI121 Mortalityratefromallcirculatorydiseasesatagesunder75
NI122 Mortalityratefromallcancersatagesunder75
NI137 Healthylifeexpectancyatage65
NI152and153 Working-agepeopleclaimingout-of-workbenefits
NI173 Peoplefallingoutofworkandontoincapacitybenefits
Personalisedsupportforoverweightandobeseindividuals
NI120 All-age,all-causemortalityrate
NI121 Mortalityratefromallcirculatorydiseasesatagesunder75
NI122 Mortalityratefromallcancersatagesunder75
NI137 Healthylifeexpectancyatage65
RefertoToolD14Monitoringandevaluation:aframeworkforadviceonusingtheindicatorsforevaluationpurposes.
TOOLD6Localleadership 109
TOOLD6LocalleadershipFor: Commissionersinprimarycaretrustsandlocalauthorities
About: Thistoolprovidesalistofkeylocalleaders(actors)indeliveringtheobesitystrategy.Itdetailstherationalefortheirinvolvement,theirroleinpromotingahealthyweight,andhowtoengagethem.
Purpose: Toshowwhichactorscouldbeengagedinlocalobesitystrategies.Pleasenotethattherolessetoutinthistoolwillnotbeappropriateforeveryarea,buttheymayprovideahelpfulstartingpoint.
Use: Shouldbeusedasaguideforrecruitingactors.
Resource: HealthyWeight,HealthyLives:Guidanceforlocalareas.2www.dh.gov.uk
TOOLD6
Outlineofrolesandresponsibilitiesofkeyactorswithintheobesitydeliverychain
Actor Rationaleforinvolvement Outlineroleinpromotinghealthyweight Howtoengagethem
Wholestrategy
Strategicleadershipintheprimarycaretrust(PCT)actingwithpartnersintheLocalStrategicPartnership(LSP)andChildren’sTrust
NHSOperatingFramework• 149
Howtosetandmonitor•goalsforprevalenceofchildobesity:guidanceforprimarycaretrusts(PCTs)andlocalauthorities141
TheEveryChildMatters•(ECM)agendaspecificallyincludespromotingchildren’shealthStatutorydutiesand•guidanceforPCTs,localauthorities,strategichealthauthorities(SHAs)andkeypartnerstopromoteEveryChildMatters(ECM)outcomesandreduceinequalitiesintheoutcomesof0-5yearoldsGuidanceonJointStrategic•NeedsAssessment
LocalStrategicPartnership(LSP):
settingthevisionforthelocalarea•carryingoutstrategicneedsassessment•discussingandagreeinglocalprioritiesandtargetsfortheLocalArea•Agreements(LAAs)developingtheSustainableCommunityStrategy.•
WithintheLSP‘umbrella’,Children’sTrustpartnershiparrangements:
workinpartnershiptopromotethefiveEveryChildMattersoutcomesfor•childrenandyoungpeoplereduceinequalitiesinECMoutcomesfor0-5s•agreetheChildren’sandYoungPeople’sPlan•
ComplementarywithHealthyWeight,HealthyLives
ThefiveECMoutcomesincludeHealthyWeight,HealthyLives,1andare:
beinghealthy• –physical,mental,emotionalwellbeing–livingahealthylifestylestayingsafe• –protectionfromharmandneglect–growingupabletolookafterthemselvesenjoyingandachieving• –education,trainingandrecreation–gettingthemostoutoflifeanddevelopingbroadskillsforadulthoodmakingapositivecontribution• –tocommunityandsociety–notengaginginanti-socialbehavioursocialandeconomicwellbeing• –overcomingsocioeconomicdisadvantagestoachievefullpotentialinlife
Ensureobesityishighonlocalagenda,•withkeystrategicleaderswithinPCT,localauthority(LA)andpartnerorganisationsinformedabout(usingNationalChildMeasurementProgramme(NCMP)andotherdata)andpreparedtopromoteobesityissues,makingthelinksacrossprojectsandprogrammesegtransportandsustainabilityplanningPCTs,LAsandotherpartnersdevelopand•agreeevidence-drivenobesityplansusingNCMPdataandotherdata
Outcomes:
HealthyWeight,HealthyLives• 1isaclearlydefinedelementwithinstrategicplansRobustandrealisticVitalSignsobesity•deliveryplansaremirroredinLAAdeliveryplanswhereobesityand/orrelatedindicatorsarechosenasLAApriority(fromtheNationalIndicatorSet)
Children:Healthygrowthandhealthyweight
PCT/LAservicecommissioners
JointPlanningand•CommissioningFrameworkforChildren,YoungPeopleandMaternityServices150
LocalpartnershipsusetheJointCommissioningFrameworktocreateaunified•systemforpoolingbudgetsandprovidingchildren’sservicestomeettheneedsidentifiedinthestrategicneedsassessment–withinwhichHealthyWeight,HealthyLives1 shouldbeclearlydefined
Ensurelocalcommissionersareinformed•andpreparedtocommissionandfundservicessothatHealthyWeight,HealthyLives1 andtherevisedChildHealthPromotionProgramme151arefirmlyembeddedinsustainableservicecommissioningLocalTrustshavelocalprotocolsto•supportthemanagementofobesepregnantwomenthattakeaccountoftheneedsofthesewomen,andthefacilitiesandservicesavailabletothem.Arrangementsthroughmaternityandneonatalnetworkssupportthesemothersandtheirbabies
110H
ealthyW
eigh
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olkitfo
rdevelo
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TOO
LD6Lo
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ip
111Actor Rationaleforinvolvement Outlineroleinpromotinghealthyweight Howtoengagethem
FamilyInformationServices(FIS)
(formerlyChildren’sInformationServices)
StatutorydutiesonLAsand•guidance
LAsstrategicallyleadingandprovidinganintegratedserviceofferingtheinformationparentsneedtosupporttheirchildrenuptotheir20thbirthday:
comprehensive,accurate,easilyaccessibleinformationtosupportallparents,•includingfathersaswellasmothersandallwithcareofachildoryoungpersoneggrandparentslocalservicesandreferencestonationalservices/informationavailablethrough•websitesandhelplinesmustreachouttodisadvantagedfamilieswhomaybenefitmostfrom•services,andprovideinformationinwaysthatwillovercomebarrierstoaccess
LAEarlyYearsLead•
Midwives Professionalexpertiseand•codesofconductTheNationalInstitutefor•HealthandClinicalExcellence(NICE)guidance6
DeliveringtherevisedChild•HealthPromotionProgramme(CHPP)151
Supportingobesewomentoloseweightbeforeandafterpregnancythrough•astructuredandtailoredprogrammethatcombinesadviceonhealthyeatingandphysicalexercisewithongoingsupporttoallowforsustainedlifestylechangesDuringpregnancypromotinghealthandlifestyleadvicetoincludedietand•weightcontrol.Encouragingregularphysicalactivity,atanappropriatelevel,aspartoftheantenatalcareprogrammePromotionofbenefitsofbreastfeeding•FollowingtheCHPPscheduletoidentifyfamilieswithchildrenatriskof•becomingobeseReferralofat-riskfamiliestootherservices(egGP)whereappropriate•Encouragingregularphysicalactivity,atanappropriatelevel,during•pregnancyandaspartoftheantenatalcareprogramme
PCTEarlyYearsLead(andLAEarlyYears•Lead)
Healthvisitors CHPP• 151
Otherguidance(egNICE•obesityguidance6)
LeadingteamsimplementingCHPP–focusingontheearlyidentificationand•preventionofobesitythroughpromotingbreastfeeding,healthyweaningandeating,andhealthyactivitytoallfamilieswithbabiesandyoungchildren–inhealthsettingsincludingChildren’sCentres,generalpracticeandinhomesFollowingtheCHPPscheduletoidentifyfamilieswithchildrenatriskof•becomingobese,providingthemwithmoreintensivesupportandreferringtootherserviceswhereappropriate
PCTEarlyYearsLead•LAEarlyYearsLead,particularlytolink•withlocalSureStart
SureStartChildren’sCentremanagersandstaff
SureStartChildren’sCentre•guidance152
CHPP• 151
Integratedmulti-agencyservicesforfamilieswithyoungchildrenaged0–5•years,focusedonmostdisadvantagedareasKeydeliveryvehicleforhealthprioritiesandtargets,includingencouraging•take-upofbreastfeedingandreducingobesityratesforparentsandyoungchildrenDeliveringtherevisedCHPP(ledbyhealthvisitors)•
LAEarlyYearsLeadandotherLA•colleaguesresponsibleforsupplyandqualityofEarlyYearsprovisionandschoolstandardsPCTEarlyYearsLead–promotinghealth•activitiesinChildren’sCentressuchasmidwivesprovidingantenatalandpostnatalcare
EarlyYearsworkforceprovidingintegratedcareandlearningfor0-5yearolds,includingchildmindersandstaffinschoolsandprivatenurseries
EarlyYearsproviders•governedbystatutoryduties,regulationandinspectionbyOfsted,andrequirementtodelivertheEarlyYearsFoundationStage(EYFS)101
TheEYFSrequiresyoungchildren’sphysicalwellbeingandhealthtobe•promotedaspartoflearningthroughplay,withopportunitiesforphysicalactivity(includingoutdoorplaywhereverpossible)Allmeals,snacksanddrinksprovidedarehealthy,balancedandnutritious•Parentsandcarersareinvolvedaspartnersinthelearninganddevelopment•oftheirchildren
PCTEarlyYearsLead•LAEarlyYearsLeadandotherLA•colleaguesresponsibleforsupplyandqualityofEarlyYearsprovisionandschoolstandards
NominatedHealthProfessionalsinmulti-agencyFamilyInterventionProjects(FIPs)
ResourceManualfor•NominatedHealthProfessionalsworkingwithFIPs
Multi-agencyteams,includinghealth,workingtosupportchallenging,•vulnerableandmarginalisedfamilies.EvidencefromFIPstudiessuggeststhatpoornutritionisacommonfeatureinmanyofthefamiliesinvolved,withover50%ofFIPchildrenalreadybeingobese
PCTandLAEarlyYearsLeads•WhereFIPSarebeingdelivered,support•NominatedHealthProfessionalstotackleHealthyWeight,HealthyLives1 nutritionandactivityissues
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FamilyNursePartnerships(FNPs)
CHPPandotherplansand•guidanceIntegralpartofdetailed•programmemanuals
Evidence-basedintensivehomevisitingpreventiveprogrammeforthemost•at-riskyoung,firsttimemothersDeliveredbyskillednurses(healthvisitors,midwives,schoolnurses)to•improvetheoutcomesofthemostat-riskchildrenandfamiliesThestrength-based,licensedprogrammebeginsinearlypregnancyand•continuesuntilthechildistwoyearsoldFocusonhealthylifestyleandnutritioninpregnancy•Supportingparentsinbreastfeeding,healthyweaningandeatingandhealthy•activityforallthefamilyDeliveryofCHPP•
PCTandLAEarlyYearsLeads•WhereFNPsarebeingdelivered,support•FamilyNursestotackleHealthyWeight,HealthyLives,1 nutritionandactivityissues
Schoolnurses CHPP• 151 Adviceonhealthynutritionandregularphysicalactivity•Signpostingtoprogrammesinextendedschoolservicesandcommunity-•basedprogrammesCollectionofheightandweightdatafortheNCMP•
PCTEarlyYearsLead•LAleadcontactforschoolsthrough•Children’sTrustarrangements
Schools:Governors Newdutyongovernorsof•maintainedschoolstopromotefiveECMoutcomesoftheirpupils(s.38EducationandInspectionsAct2006)153
Guidanceforgovernorsonthenewdutywaspublishedforconsultationin•July2008
LAleadcontactforschoolsthrough•Children’sTrustarrangementsanddirectcontactwithschoolsthroughschoolnurses
Schools:Headteachersandschoolstaff
Linkedtothenewdutyon•governorsofmaintainedschoolstopromotefiveECMoutcomesoftheirpupils(s.38EducationandInspectionsAct2006)153
Implementingplansfulfillingthedutyonschoolgovernorstopromotethe•fiveECMoutcomesEnsuringHealthySchoolstatusisacquiredandmaintainedwhereappropriate•Encouragingextendedservicestopromote• HealthyWeight,HealthyLives1
Ensuringwhole-schoolapproachtoschoolfood:•schoollunchesthatmeetnutritionalstandards–novendingmachines–waterfreelyavailable–agreedpolicieswithparentsonpackedlunches–on-sitelunchtimes–
Providingcookinglessonsinlinewiththenewkeystage3designand•technologycurriculumEnsuring2hoursofPE/sportaweekavailableforallduringtheschoolday•andencouraging100%participationPromotingprovisionandparticipationinafurther3hoursofsporting•activitiesthroughextendedservicesImplementingtheschoolactivetravelplan•
LAleadcontactforschoolsthrough•Children’sTrustarrangementsanddirectcontactwithschoolsthroughschoolnursesWorkwithLocalHealthySchoolsteamto•accesssupport,possiblepartnersandpracticaladviceonachievingNationalHealthySchoolStatus
Promotinghealthierfoodchoices
Healthtrainers HealthInequalities:Progress•andNextSteps156
NICEbehaviourchange•guidance154
Ifaclientidentifieshealthyeating/physicalactivityasoneoftheirgoals:
helpingthemreflectontheircurrentbehaviourandhowtheymightchangeit•forthebetterhelpingthemtounderstandthelinkbetweenobesityandhealth-related•problemshelpingthemtosetrealisticgoalsforchange,helpingtomonitortheseand•keepclientmotivatedincreasingclientconfidenceinbeingabletosustainlifestylechange•signpostingtheclienttoappropriateservices•
PCThealthtrainercoordinator•Healthtrainersareaccessiblewithintheir•communities/groupsandpeoplecanself-referorbereferredbyothers
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Dietitians NICEobesityguidance• 6
Dietitiansareresponsiblefor•assessing,diagnosingandtreatingdietandnutritionproblemsatanindividualandwiderpublichealthlevel
Provisionofcommunity-basedweightmanagementservices•Ensuringconsistentadviceonhealthyeatingandphysicalactivityisavailable•Involvementinresearchintowhichinterventionsaremosteffectivein•encouragingindividualsandfamiliestochangetheirbehaviourProvisionoftrainingforotherhealthworkersonmotivationalinterviewing•andbehaviourchangeProvisionofpersonalisedhealthadviceandlifestylemanagementprogrammes•
Dieteticsdepartmentmanager•
Buildingphysicalactivityintoourlives
Midwives CHPP• 151 Encouragingregularphysicalactivity,atanappropriatelevel,during•pregnancyandaspartoftheantenatalcareprogramme
Primarycaretrust(PCT)EarlyYearsLead•
Healthvisitors CHPP• 151 Encouragingnewmumstobeactiveandsuggestwaystheycoulddothis•Encouragingregularactivityforallthefamily•Signpostingtoapprovedserviceproviders,egleisureservices,commercial•weightmanagementorganisations,primarycareweightmanagementclinics,healthwalkleaders
PCTEarlyYearsLead•
Schoolnurses CHPP• 151 Opportunisticadviceonregularphysicalactivity•Signpostingtoprogrammesinplacewithinschool,extendedschoolservices•andcommunity-basedprogrammesCollectionofheightandweightdatafortheNCMP•
PCTEarlyYearsLead•
Earlyyearsworkers(egnurserynurses,playworkers,familysupportworkers)
Earlyyearsproviders•governedbystatutoryduties,regulationandinspectionbyOfsted,andrequirementtodelivertheEYFS101
CHPP• 151
Encouragingactiveplayforallchildrenaspartofdailyroutine•Discussingactivitywithyoungchildren•
PCTEarlyYearsLead•ChildrenandYoungPeople’sStrategic•Partnership
Children’sCentres(includingSureStart)
CHPP• 151
SureStartChildren’sCentre•guidance152
Provisionofphysicalactivityprogrammesforyoungfamilies•Educationalsessionsforyoungfamilies–forexample,howtomakehealthy•foodchoices,healthycookingonabudget,waystobeactivewithyoungchildrenActiveplayfacilitiesonsite•Provisionofsafeandsecurecyclestoragefacilitiestoencourageactive•transporttofacilitiesSignpostingtootherserviceproviders•
PCTEarlyYearsLead•Children’sCentrecoordinators•
Dietitians NICEobesityguidance• 6 Provisionofcommunity-basedweightmanagementservices•Ensuringconsistentadviceonhealthyeatingandphysicalactivityisavailable•Encouragingregularphysicalactivityaspartofconsultations•
DieteticsDepartmentManager•
NationalHealthySchoolsProgramme
CHPP• 151
NationalHealthySchools•Status(NHSS)
Workingwithschoolstoachievephysicalactivityandhealthyeatingcore•criteriaEncouragingschoolstolookatotherwaystomaximisephysicalactivity•opportunitiesforpupilsandtheirfamilies,especiallyforthoseschoolswhodrawfromcommunitieswithhigherlevelsofoverweightandobesity,identifiedfromNCMPdata
ALocalHealthySchoolsteamwillbe•basedineithertheLAorPCTandwillprovidethisfunction.DetailsofeachLocalHealthySchoolsteamisonwww.healthyschools.gov.ukSchoolSportsPartnershipscanbe•contactedthroughyourLocalHealthySchoolsteamorbycontactingYouthSportTrust
Schooltraveladvisers
NICEphysicalactivityand•environmentguidance117
Supportingthedevelopmentofschooltravelplans•Encouragingschoolstolookatnewwaystoincreasethenumberofpupils•walkingandcyclingtoschool
Localauthority•
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Leisureproviders •
•
NICEphysicalactivityguidance128
NationalQualityAssuranceFramework(NQAF)ExerciseReferralSystems131
•
••
ProvisionoffacilitiesandappropriatelytrainedstafftoworkwithpatientsreferredthroughthelocalexercisereferralsystemProvisionofapprovedweightmanagementinformationwithinfacilitiesProvisionofweightmanagementsupportforclients
• JointLA/PCTstrategicpartnerships
Youthworkers • NICEphysicalactivityguidance128
• Signpostingyoungpeopletocommunity-basedphysicalactivityprogrammes • ChildrenandYoungPeople’sStrategicPartnerships
Occupationalhealth •
•
NICEphysicalactivityandworkplaceguidance155
NICEobesityguidance6
•
•
OpportunisticphysicalactivityadviceforstaffaccessingoccupationalhealthservicesProvisionofdrop-inweightmanagementservicesforallstaff
• PCTWorkforceDevelopmentLead
Primarycareteams(GPs,practicenurses,districtnurses)
••
NICEobesityguidance6
NICEphysicalactivityguidance128
•••
•
ProvisionofopportunisticadviceonphysicalactivityandhealthyweightAssessmentofheightandweightofpracticepopulationSignpostingtophysicalactivityopportunitiesandweightmanagementservicesProvisionofweightmanagementandphysicalactivityclinicsinpractices
••
Practice-basedcommissioninggroupsPCTLeadNurse
Pharmacists ••
NICEobesityguidance6
Choosinghealththroughpharmacy(2005)136
•••
ProvisionofphysicalactivityleafletsandinformationissuedwithprescriptionsOpportunisticadviceonphysicalactivitySignpostingtolocalphysicalactivityopportunities
• PCTMedicinesManagement/PharmacyLead
Planners • NICEphysicalactivityandthebuiltenvironmentguidance117
•
•
Promotingahealthyweightthroughtheirroleinshapinghowcities,townsandvillagesaredevelopedandbuiltConsideringtheimpactofallplanningrequestsonlevelsofphysicalactivityandaccesstohealthyfoodchoices
• LA
Transportplanners • NICEphysicalactivityandthebuiltenvironmentguidance117
••
PromotingahealthyweightDevelopingandmanagingtheimpactofroad,railandairtransportinthelocalarea
• LA
Localauthoritycyclingandwalkingofficers
• LocalAreaAgreements(LAAs)
••
EnsuringlocalopportunitiesforwalkingandcyclingLiaisonwithplannerstoensurewalkingandcyclingopportunitiesareconsidered
• LA
Parksmanagement •
•
NICEphysicalactivityandthebuiltenvironmentguidance117
FairPlay(DCSF):Encouragingchildrenandfamiliestoengageinphysicalactivity
•
•
Roleinthemanagement,maintenanceanddevelopmentofopen/greenspacefacilitatingandencouragingphysicalactivitybythelocalandwidercommunityWorkingwithotherLAareastofacilitatewalkingandcyclingroutesin,andto,open/greenspaces
• LA
Healthtrainers •
•
HealthInequalities:ProgressandNextSteps156
NICEbehaviourchangeguidance154
•
••
AttendingtrainingtobeabletodiscussphysicalactivityandhealthyweightappropriatelywithclientsProvisionofphysicalactivityadvicetoclientsSignpostingclientstophysicalactivityopportunities
•
•
ByworkingwiththehealthtrainercoordinatorsatPCTlevelHealthtrainersareaccessiblewithintheircommunities/groupsandpeoplecanself-referorbereferredbyothers
Healthwalkleaders ••
LegacyActionPlan116
CMOReportAtleastfiveaweek113
• LeadinghealthwalksforpeopleofallagesacrosscommunitiesandensuringlinkstolocalGPpracticesandChildren’sCentres
•
•
RegionalWalkingtheWaytoHealth(WHI)coordinatorsandvolunteersPCT
Commercialweightmanagementorganisations
• NICEobesityguidance6 •
•
ProvisionofweightmanagementservicesineasilyaccessiblecommunityvenuesProvisionofappropriatephysicalactivityadviceaspartofweightmanagementsupport
•
•
HealthImprovementProgramme(HImP)andpublichealthNutritionanddieteticsservices
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Creatingincentivesforbetterhealth
LAandPCTcommissioners
Responsiblefor•commissioningservices
Commissioningprevention,interventionandtreatmentservices,andmeeting•workforcerequirementsCommissioningtrainingforstaffwhodeliverservicesandstaffwhocomein•tocontactwiththoseatriskManagementof/influenceonresourcesallocatedlocallyforobesityand•makingprioritisationdecisionsSupportinglocalflexibilitiesandrewardsinfundingflows•
LA•PCT•
Occupationalhealth NICEphysicalactivityand•workplaceguidance155
NICEobesityguidance• 6
Opportunisticphysicalactivityadviceforstaffaccessingoccupationalhealth•servicesProvisionofdrop-inweightmanagementservicesforallstaff•
PCTWorkforceDevelopmentLead•
Personalisedadviceandsupport
GP QualityandOutcomes•Framework(QOF)(adults)134,
135
ConsideringhowtomakeuseofexistingBMIregisterforadults•Raisingissueofweightwithadults/parentsproactively•Revisitingissueinfutureifpatientnotreadytochange•Deliveryofbriefinterventions•Identificationofandreferraltolocalorin-houseprovisionofweight•managementservicesandwiderhealthylivingservicesorprogrammesProvidingpre-conceptionadviceforwomen•
Engageindevelopmentand•implementationoflocalcarepathwaysPCT/GPforums•
Practicenurses NICEobesityguidance• 6 Raisingissueofweightproactively•Referraltolocalorin-houseprovisionofweightmanagementservices•Deliveryofbriefinterventions•
Engageindevelopmentand•implementationoflocalcarepathwaysPCT/GPforums•
Dietitians NICEobesityguidance• 6
Dietitiansareresponsiblefor•assessing,diagnosingandtreatingdietandnutritionproblemsatanindividualandwiderpublichealthlevel
Referraltolocalorin-houseprovisionofweightmanagementservices•Ensuringconsistentadviceonhealthyeatingandphysicalactivityisavailable•Involvementinresearchintowhichinterventionsaremosteffectivein•encouragingindividualsandfamiliestochangetheirbehaviourProvisionoftrainingforotherhealthworkersonmotivationalinterviewing•andbehaviourchangeProvisionofpersonalisedhealthadviceandlifestylemanagementprogrammes•
DieteticsDepartmentManager•Engageindevelopmentand•implementationoflocalcarepathwaysDirectcommissioning/servicelevel•agreement(SLA)
Pharmacists Choosinghealththrough•pharmacy(2005)136
Provisionofhealthylivingadvice•Referraltolocalweightmanagementservices•Deliveryofweightmanagementservicesorbriefinterventionswhere•appropriate
PCTMedicinesManagement/Pharmacy•LeadEngageindevelopmentand•implementationoflocalcarepathways
Partnersdeliveringcommunity-basedweightmanagementservices,egleisureservices,voluntaryandcommunitysectorgroups,commercialsector,training/programmeproviders
SLAwithPCTorLA• Reinforcingconsistentnationalmessagesintermsofhealthyeatingand•physicalactivityUseofsocialmarketinginformationtopromoteservicesandengagepotential•clientsFeedingbackinformation/progresstoreferringclinicians(inlinewithdata•protectionrequirements)Referralto/awareness-raisingofwidersuiteofhealthylivingandpreventative•servicesavailablelocally–forchildrenandadults
SLAwithPCTorLA•
116 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLD7Whatsuccesslookslike–changingbehaviour 117
TOOLD7Whatsuccesslookslike–changingbehaviour
For: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities
About: ThistoolshowsthebehaviourchangeoutcomesthattheDepartmentofHealthhighlightedinlocalobesityguidance.
Purpose: Toshowwhatbehaviourchangesarerequiredtoachievelocalgoals.
Use: Canbeusedforevaluationandmonitoringpurposes–asperformanceindicators.
Resource: HealthyWeight,HealthyLives:Guidanceforlocalareas.2www.dh.gov.uk
TOOLD7
Children: Healthy growth and
healthy weight
As many mothers breastfeeding up to 6 months as possible, with families knowledgeable about healthy weaning and feeding of their young children
All children growing up with a healthy weight by eating well, for example by eating at least 5 portions of fruit and vegetables a day
All children growing up with a healthy weight by enjoying being active, for example by doing at least one hour of moderately intensive physical activity each day
Parents have the knowledge and confidence to ensure that their children eat healthily and are active and fit
All schools are Healthy Schools, and parents who need extra help are supported through Children’s Centres, health services and their local community
More eligible families signing up to the Healthy Start scheme
Less consumption of high fat, sugar, salt (HFSS) foods, especially by children
More consumption of fruit and vegetables and more people eating 5 A DAY, especially children
More healthy options in convenience stores, school canteens, vending machines, at supermarket tills and at non-food retailers
Promoting healthier food choices
Building physical activity into our lives
Creating incentives for better health
Personalised advice and support
More people, more active, more often, particularly those individuals and families who are currently the most inactive
Reduced car use, especially for trips under a mile in distance
More outdoor play by children
More workplaces that promote healthy eating and activity, with the public sector acting as an exemplar, both through the location and design of the buildings on the government estate and through staff engagement programmes
Everyone able to access appropriate advice and information on healthy weight
Increasing numbers of overweight and obese individuals able to access appropriate support and services
Local staff/practitioners understanding their role and empowered to fulfil it
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TOOLD8ChoosinginterventionsTOOLD8For: Allcommissionersinlocalareasdevelopinganobesitystrategy
About: Thistoolprovidesinformationoninterventions,dividedintotheDepartmentofHealth’sfivecorethemes,assetoutinHealthyWeight,HealthyLives.1Itisbasedonevidenceofeffectivenessandcost-effectivenessadaptedfromtheNICEguidelineonobesity.6InterventionshavebeenrankedaccordingtothelevelofevidenceofeffectivenessasassignedbyNICE.
Purpose: Togivelocalareasanunderstandingofwhatinterventionsareeffectiveandcost-effective.However,localareasshouldnotfeelconstrainedtoimplementonlyinterventionswithevidenceofeffectiveness.Itisimportantthatareastrynewinterventions,providedtheyareevaluatedandsoaddtotheevidencebase.SeeToolD14Monitoringandevaluation:aframework.
Use: Shouldbeusedasaguidetoselectinginterventions.•
Canbeusedasachecklistofinterventions.•
Resource: Obesity:Theprevention,identification,assessmentandmanagementofoverweightandobesityinadultsandchildren.6www.nice.org.uk
Keytogradingevidence
Levelsofevidenceforinterventionstudies
Levelofevidence
Typeofevidence
1++ High-qualitymeta-analyses,systematicreviewsofRCTs,orRCTswithaverylowriskofbias
1+ Wellconductedmeta-analyses,systematicreviewsofRCTs,orRCTswithalowriskofbias
1- Meta-analyses,systematicreviewsofRCTs,orRCTswithahighriskofbias*
2++ Highqualitysystematicreviewsofnon-RCT,case-control,cohort,CBAorITSstudies
Highqualitynon-RCT,case-control,cohort,CBAorITSstudieswithaverylowriskofconfounding,biasorchanceandahighprobabilitythattherelationiscausal
2+ Wellconducted,non-RCT,case-control,cohort,CBAorITSstudieswithaverylowriskofconfounding,biasorchanceandamoderateprobabilitythattherelationiscausal
2- Non-RCT,case-control,cohort,CBAorITSstudieswithahighriskofconfounding,biasorchanceandasignificantriskthattherelationshipisnotcausal
3 Non-analyticstudies(egcasereports,caseseries)
4 Expertopinion,formalconsensus
Notes:*Studieswithalevelofevidence(-)shouldnotbeusedasabasisformakingrecommendations.RCT:Randomisedcontrolledtrial.CBA:Controlledbeforeandafter.ITS:Interruptedtimeseries.
Source:NationalInstituteforHealthandClinicalExcellence(2006)6
EvidencetablesChildren:healthygrowthandhealthyweight
Desiredbehaviour
Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost-effectiveness
EARLYYEARS
Morehealthyoptionsandhealthyeating
Improvementinfoodservicetopre-schoolchildren
Reductionsindietaryintakesoffatandimprovedweightoutcomes(1+)
AUS-basedstudyreportedthataparenteducationprogrammefocusingonnutrition-relatedbehaviourresultedintheinterventiongroupconsumingsignificantlymorefruits,vitamin-C-richfruits,greenvegetables,breads,rice/pastaandorangevegetablesthanthecontrolgroup.157Anotherstudyreportedthatattendingeducationalsessionssignificantlyimprovedthefrequencyofparentsofferingtheirchildwater.158Furthermore,asystematicreviewreportedbeneficialeffectsonthenutritionalcontentofday-caremenus.66
–
Educationthroughvideosandinteractivedemonstrations
Changingfoodprovisionatnursery
Smallbutimportantbeneficialeffectaslongasinterventionsnotsolelyfocusedonnutritioneducation(2+)
–
Provisionofregularmealsinsupportiveenvironmentfreefromdistractions
OpinionofGuidelineDevelopmentGroup(GDG)(4)
–
Morephysicalactivity
Encourageparentstoengageinasignificantwayinactiveplay,andreducesedentarybehaviour
Particularlyeffective(2+) Onestudyreportedthatattendingeducationalsessionssignificantlyimprovedthefrequencyofparentsengaginginactiveplaywiththeirchild.158
AUK-basedstudywassuccessfulinsignificantlyreducingtelevision-viewing(theprimaryaimofthestudy)butdidnotshowsignificantimprovementsinsnackingorwatchingtelevisionduringdinner.159
TheUK-basedMAGIC(MovementandActivityGlasgowInterventioninChildren)pilotstudyreportedthatanursery-basedstructuredphysicalactivityprogrammeresultedinasignificantimprovementinchildren’sphysicalactivitylevels.6
–
Structuredphysicalactivityprogrammeswithinnurseries
Limitedevidenceofeffectiveness(gradepending)
–
Keypoints
Interventionsshouldbetailoredasappropriateforlower-incomegroups.• (1+)2-5yearsisakeyageatwhichtoestablishgoodnutritionalhabits,especiallywhenparentsareinvolved.• (1+)Interventionsrequiresomeinvolvementofparentsorcarers.• (1+)
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placeintervention
Effectiveness Evidence Cost-effectiveness
SCHOOLS
More Reduce Limitedevidencethat Threelarge-scaleinterventionsaimedtomodifyschoollunchprovision: Thereissomehealthy consumptionof interventionswere onesignificantlyreducedchildren’stotalenergyandfatintake;160one evidencethateating carbonateddrinks effectiveinreducing reducedchildren’sfatintakebutnottotalenergyintakeinschoollunch school-based
overweightandobesity observations;161andthelastshowednodifferenceinfatintake.162One interventionscan(1++) additionalstudywithinthefruitandvegetableinterventionreview
showedthatreducingrelativepricesoflow-fatsnackswaseffectiveinpromotinglower-fatsnackpurchasesfromvendingmachinesinadolescentsoveroneyear.163
AnalysisoftheUKNationalSchoolFruitScheme(nowknownastheSchoolFruitandVegetableSchemeorSFVS)showedthat4-6yearoldchildrenreceivingschoolfruithadasignificantlyhigherdailyintakethancontrols(117g/daycomparedto67g/day,respectively)butthisdifferencewasnotmaintainedtwoyearsaftertheinterventionwhenfreefruitwasnolongeravailable.164
resultincost-effectivehealthgains.Bothinterventionsidentifiedresultedinweightlossatacceptablecosts.(Wangetal,2003165 (1+);Wangetal,2004166 (2+))
Increasefruitand(toalesserextent)vegetableintake
Improveschoolmeals
Promotewaterconsumption
Effectiveinimprovingdietaryintake(1+)
Keypoint
Schoolchildrenwiththelowestfruitandvegetableintakesatbaselinemaybenefitmorefromtheschool-basedinterventionsthantheirpeers(2+)
More Promotionofless Mayhelpchildrenlose Activeplay:A12-week,US-basedinterventionpromotingactiveplayphysical sedentarybehaviour weight(nograde) supplementarytousualPEamong9yearoldsshowedsignificantactivity (televisionwatching) improvementsintheinterventionchildrencomparedwiththecontrols,
Multi-componentinterventions
Effectivewhileinterventioninplay(1+)
particularlyamonggirls.167Anotherstudyreportedthatasmallinterventionover14monthsresultedin5-7yearoldchildrenintheinterventiongroupbeingmoreactiveintheplaygroundthanthecontrolgroupchildren.168
PEclasses:Onestudyreportedsignificantincreasesinmoderatephysicalactivityamongfemaleadolescents,particularly‘lifestyle’activity,atfour-monthfollow-up,followingthepromotionof60-minutePEclassesfivedaysaweekandassociatededucationclasses.169
ThereisgoodcorroborativeevidencefromtheUKthat‘saferroutestoschool’schemescanbeeffective.170Aseriesofstudiesfoundthat,whenbothschooltravelplansandsaferroutestoschoolprogrammeswereinplace,therewasa3%increaseinwalking,a4%reductioninsingle-occupancycaruseanda1.5%increaseincarsharing.Busandcycleuseremainedlargelystatic.171Conversely,aseriesofselectedcasestudiesfoundanoverallincreaseincycleuseandadecreaseincartravelwhereastheeffectsonwalkingandbustravelwerevariable.172
Anotherschemealsofoundaconsiderableincreaseinwalkingandcyclingtoandfromschoolthreeyearsaftertheintervention.173
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Desiredbehaviour
Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost-effectiveness
Morehealthyschools
Multi-componentaddressingvariousaspectsincludingschoolenvironment
Equivocaltopreventobesity(2+)
Effectiveinimprovingphysicalactivityanddietarybehaviourduringintervention.UK-basedevidenceislimited(1+)
Onestudyreportedthat7-11yearoldchildreninschoolsadoptingawhole-schoolapproachwereconsumingsignificantlymorevegetablesatone-yearfollow-up.174Anothermulticomponentinterventionstudyreportedthat5-7yearoldchildrenintheinterventiongroupconsumedsignificantlymorevegetablesandfruit(girlsonly).168Thetwo-yearPlanetHealthprogrammeamongUS12yearolds–promotingphysicalactivity,improveddietandreductionofsedentarybehaviours(withastrongemphasisonreducingtelevision-viewing)–resultedinareductionintheprevalenceofobesityininterventiongirls(butnotboys)comparedwithcontrols.175,176
AreviewoffiveUKschool-basedinterventionsconcludedthatallfiveinterventionsconsidered(fruittuckshops,CD-ROM,art/playtherapy,whole-schoolapproachandafamily-centredschool-basedactivity)havethepotentialtobeincorporatedintoahealth-promotingschoolapproachandcouldbemoreeffectivethanstand-aloneinterventions.Theauthorshighlightedtheimportanceofactivelyengagingschoolsforthesuccessoftheintervention.177
Thereissomeevidencethatschool-basedinterventionscanresultincost-effectivehealthgains.Bothinterventionsidentifiedresultedinweightlossatacceptablecosts.(Wangetal,2003165 (1+);Wangetal,2004166 (2+))
Keypoints
Thereisabodyofevidencetosuggestthatyoungpeople’sviewsofbarriersandfacilitatorstohealthyeatingindicatedthateffectiveinterventionswould(i)makehealthyfoodchoices•accessible,convenientandcheapinschools,(ii)involvefamilyandpeers,and(iii)addresspersonalbarrierstohealthyeating,suchaspreferencesforfastfoodintermsoftaste,andperceivedlackofwill-power.(1++)Thereisabodyofevidencetosuggestthatyoungpeople’sviewsonbarriersandfacilitatorstophysicalactivitysuggestthatinterventionsshould(i)modifyphysicaleducationlessonstosuit•theirpreferences,(ii)involvefamilyandpeers,andmakephysicalactivityasocialactivity,(iii)increaseyoungpeople’sconfidence,knowledgeandmotivationrelatingtophysicalactivity,and(iv)makephysicalactivitiesmoreaccessible,affordableandappealingtoyoungpeople.(1++)ThereislimitedUKevidencetoindicatethatintermsofengagingschoolsitisimportanttoenlistthesupportofkeyschoolstaff.• (2+)
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123Promotinghealthierfoodchoices
Desiredbehaviour
Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost–effectiveness
RAISINGAWARENESS
Morehealthyeating
Educationalpromotionalcampaign
Unclearforweightmanagement(1+)
Evidencethatcampaigncanincreaseawarenessofhealthydietandsubsequentlyimprovedietaryintake(2+)
Interventionscanresultinimprovementsinvariousdietaryoutcomes,includingadecreaseinfatconsumption,anincreaseinfruitandvegetableintake,andadecreaseinfriedfoodsandsnacking.Forexample:
TheBBC’sFightingFat,FightingFitcampaigndemonstrated•statisticallysignificantimprovementsindietfivemonthsafterthecampaigninarandomsurveyofpeoplewhoregisteredformoreinformation.Significantimprovementswerereportedinfruitandvegetableintake,witha13%increaseinrespondentseatingtherecommended5portionsaday.Therewasalsoa16%increaseinparticipantseatingfriedfoodlessthanonceaweek.Significantimprovementswerealsoobservedinconsumptionoffatspreads,consumptionoflower-fatmilk,removaloffatfrommeat,snackingandconsumptionofstarch-basedmeals.178,179
One-yearfollow-upoftheDepartmentofHealth’scommunity-based•5ADAYpilotprojectsdemonstratedthattheinterventionhadstemmedafallinfruitandvegetableintakeagainstthenationaltrend.Overalltheinterventionhadapositiveeffectonpeoplewiththelowestintakes.Thosewhoatefewerthan5portionsadayatbaselineincreasedtheirintakeby1portionoverthecourseofthestudy.Incontrast,thosewhoate5ormoreportionsadayatbaselinedecreasedintakesbyabout1portionperday.180
AreviewbytheFoodSafetyPromotionBoard• inIrelandreportedthatsocialmarketinginterventionswerestronglyandequallyeffectiveatinfluencingbehaviour,knowledgeandpsychosocialvariablessuchasself-efficacy,attitudesandperceptionsofthebenefitsofeatingmorehealthily.Socialmarketinginterventionsappearedtobemoderatelyeffectiveatinfluencingstageofchangeinrelationtodiet,andtohaveamorelimitedeffectondiet-relatedphysiologicaloutcomessuchasbloodpressure,BodyMassIndexandcholesterol.181
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Foodpromotion Someevidencethatitcanhaveaneffectonchildren’sfoodpreferences,purchasebehaviourandconsumption.Themajorityoffoodpromotionfocusesonfoodshighinfat,sugarandsaltandthereforetendstohaveanegativeeffect.However,foodpromotionhasthepotentialtoinfluencechildreninapositiveway(2+)
–
Publichealthmediacampaign
Limitedevidencethatitcanhavebeneficialeffectonweightmanagement,particularlyamongindividualsofhighersocialstatus(2+)
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Keypoints
Parentsareimportantrolemodelsforchildrenandyoungpeopleintermsofbehavioursassociatedwiththemaintenanceofahealthyweight.• (3)Books,magazinesandtelevisionprogrammesareanimportantsourceofinformation,andactivelyinvolvingmediaprovidersmayimprovetheeffectivenessofinterventions.• (3)Asignificantproportionofparentsmaynotrecognisethattheirchildisoverweightandmayhaveapoorunderstandingofhowtotranslategeneraladviceintospecificfoodchoices.• (3)
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Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost–effectiveness
COMMUNITYINTERVENTIONSLEDBYHEALTHCAREPROFESSIONALS
Morehealthyeating
Supportandadviceonphysicalactivityanddiet(notalone)
Effectiveforweightmanagement(1+)
– –
Moderateorhighintensitydietaryinterventions–reducefatintakeandincreasefruitandvegetableconsumption
Clinicallysignificantreductionsinfatintakeandincreasesfruitandvegetableconsumption(1++)
– –
Briefcounselling,ordietaryadvicebyGPsorotherhealthprofessionals
Effectiveinimprovingdietaryintakebuttendtoresultinsmallerchangesthanintensiveinterventions(1++)
– –
Keypoints
Interventionswithagreaternumberofcomponentsaremorelikelytobeeffective.• (1++)Althoughthemajorityofstudiesincludedpredominantlywhite,highersocialstatusandreasonablymotivatedindividuals,thereissomeevidencethatinterventionscanalsobeeffective•amonglowersocialgroupsandeffectivenessdoesnotvarybyageorgender.(1+)Tailoringdietaryadvicetoaddresspotentialbarriers(taste,cost,availability,viewsoffamilymembers,time)iskeytotheeffectivenessofinterventionsandmaybemoreimportantthanthe•setting.(3)Thetypeofhealthprofessionalwhoprovidestheadviceisnotcriticalaslongastheyhavetheappropriatetrainingandexperience,areenthusiasticandabletomotivate,andareableto•providelong-termsupport.(3)Thereissomeevidencethatprimarycarestaffmayholdnegativeviewsontheabilityofpatientstochangebehaviours,andontheirownabilitytoencouragechange.• (3)ThereisabodyofevidencefromUK-basedqualitativeresearchthattime,space,training,costsandconcernsaboutdamagingrelationshipswithpatientsmaybebarrierstoactionbyhealth•professionals(GPsandpharmacists).(3)ThereissomeevidencefromtheUKthatpatientsarelikelytowelcometheprovisionofadvice,despiteconcernsbyhealthprofessionalsaboutinterferenceordamagingtherelationship•withpatients.(3)Itremainsunclearwhetherinterventionsaremoreeffectivewhendeliveredbymultidisciplinaryteams.• (N/A)
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Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost–effectiveness
BROADERCOMMUNITY
Morehealthyeating
Point-of-purchaseschemesinshops,supermarkets,restaurantsandcafés–supportedbyeducation,informationandpromotion
Effectiveinshortterm.Longer-term,multi-componentinterventionsmayshowgreatereffects(2++)
Strategiestominimisebarrierstohealthyeatingbyimprovingavailabilityandaccess:
Studiesthatlookedattheeffectoftheopeningofasupermarketinadeprived,poor-retail-accesscommunityinLeedsfoundthatparticipantswhoswitchedtothenewstoreincreasedtheirconsumptionoffruitandvegetablesby0.23portionsperday.Thefindingssuggestthatfundamentalissuesaroundcost,availabilityandtastearekeyconsiderationsforfutureinterventions.Twenty-eightpercentofthosewhodidnotswitchtothenewstorewereconcernedabouttheexpense.Thiswasbackedupbyqualitativeworkwhichfoundthat,althoughthestoresimprovedphysicalaccess,thisdidnotfundamentallyaltereconomicaccess.182,183
Thereissomeevidencethatadietandphysicalactivityinterventionincorporatinginteractiveeducationalsessionsiscost-effectivewhencomparedwithasimilarinterventionusingonlymailshotadviceforcoupleslivingtogetherforthefirsttime.(Dzatoretal,2004184 (1+),Rouxetal,2004185 (1+))
Noveleducationalandpromotionalmethodssuchasvideosandcomputergames
Maybeeffectiveinimprovingdietaryintake(1++)
Keypoints
Interventionsmaybeineffectiveunlessfundamentalissuesareaddressed,suchas:individualconfidencetochangebehaviour;costandavailability;pre-existingconcernssuchaspoorer•tasteofhealthierfoodsandconfusionovermixedmessages;andtheperceived‘irrelevance’ofhealthiereatingtoyoungpeople.(3)Auditingtheneedsofalllocaluserscanhelpengageallpotentiallocalpartnersandestablishlocalownership.• (3)
Buildingphysicalactivityintoourlives
Desiredbehaviour
Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost–effectiveness
RAISINGAWARENESS
Morephysicalactivity
Promotionalcampaigns
Unclearonweightmaintenance(1+)
Canimproveknowledge,attitudesandawarenessofphysicalactivity.Levelsofawarenessarelikelytovaryaccordingtotypeofmediumusedandthescaleofthecampaign(2++)
Physicalactivityandfitnesscampaigns:
TheBBC’sFightingFat,FightingFitcampaignshowedsignificant•improvementsinphysicalactivity:overall39%ofthefullsampleand74%ofcompletersincreasedtheiractivitylevelsandtheproportionundertakingregularmoderateexerciseincreasedfrom29%to45%(andfrom29%to60%forcompletersonly).179
TheUS-basedVERBcampaignwhichaimstoincreaseawarenessof•physicalactivityamong9-13yearolds,foundthatlevelsofactivityincreasedinlinewithawarenessofthecampaign.Those9-10yearoldswhowereawareofthecampaignengagedin34%morefree-timephysicalactivitysessionsperweekthanthosewhowereunaware.However,nooveralleffectonfree-timephysicalactivitysessionswasdetectedatthepopulationlevel.Furthermore,90%ofchildrenwhowereawareofVERBalsodemonstratedunderstandingofthemessages.AsignificantpositiverelationwasdetectedbetweenthelevelofawarenessofVERBandweeklyaveragesessionsoffree-timephysicalactivity.186
TheAustralianWalkSafelytoSchoolDayattributedarelative,•short-termincreaseof31%ofchildrenwalkingtoschooltothecampaign.Onapopulationlevelthisequatestoa6.8%increaseinwalkingtoschool.187,188
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Publichealthmediacampaign
Limitedevidenceofbeneficialeffectonweightmanagement,particularlyamongindividualsofhighersocialstatus(2+)
Unclearoninfluencingparticipationinphysicalactivity.Evidencethatcampaignsshouldtargetmotivatedsub-groups(2++)
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Keypoints
Books,magazinesandtelevisionprogrammesareanimportantsourceofinformation,andactivelyinvolvingmediaprovidersmayimprovetheeffectivenessofinterventions.• (3)
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Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost–effectiveness
COMMUNITYINTERVENTIONSLEDBYHEALTHCAREPROFESSIONALS
Morephysicalactivity
Supportandadviceonphysicalactivityanddiet(notalone)
Effectiveforweightmanagement(1+)
– –
Behavioural/educationalinterventions
Moderatelyeffectiveforwalkingandnon-facility-basedactivities(1++)
– –
Freeaccesstoleisurefacilities
Limitedevidence–increaseinactivitylevels(1+)
– –
Keypoints
Interventionswithagreaternumberofcomponentsaremorelikelytobeeffective.• (1++)Althoughthemajorityofstudiesincludedpredominantlywhite,highersocialstatusandreasonablymotivatedindividuals,thereissomeevidencethatinterventionscanalsobeeffective•amonglowersocialgroupsandeffectivenessdoesnotvarybyageorgender.(1+)Tailoringphysicalactivityadvicetoaddresspotentialbarriers(suchaslackoftime,accesstoleisurefacilities,needforsocialsupportandlackofself-belief)iskeytotheeffectivenessof•interventions.(1++)Thetypeofhealthprofessionalwhoprovidestheadviceisnotcriticalaslongastheyhavetheappropriatetrainingandexperience,areenthusiasticandabletomotivate,andareableto•providelong-termsupport.(3)Thereissomeevidencethatprimarycarestaffmayholdnegativeviewsontheabilityofpatientstochangebehaviours,andontheirownabilitytoencouragechange.• (3)ThereisabodyofevidencefromUK-basedqualitativeresearchthattime,space,training,costsandconcernsaboutdamagingrelationshipswithpatientsmaybebarrierstoactionbyhealth•professionals(GPsandpharmacists).(3)ThereissomeevidencefromtheUKthatpatientsarelikelytowelcometheprovisionofadvicedespiteconcernsbyhealthprofessionalsaboutinterferenceordamagingtherelationshipwith•patients.(3)Itremainsunclearwhetherinterventionsaremoreeffectivewhendeliveredbymultidisciplinaryteams.• (N/A)
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Effectiveness Evidence Cost–effectiveness
BROADERCOMMUNITY
Morephysicalactivity
Promotionofactivetravel(egpublicitycampaigns)
Noteffective(1++) Asystematicreviewofactivetravelversuscartravelconcludedthattargetedbehaviouralchangeprogrammeswithtailoredadvicecanimprovethetravelbehaviourofmotivatedsubgroups(thelargeststudyshowinga5%shifttoactivetravel).189
Thereissomeevidencethatadietandphysicalactivityinterventionincorporatinginteractiveeducationalsessionsiscost-effectivewhencomparedwithasimilarinterventionusingonlymail-shotadviceforcoupleslivingtogetherforthefirsttime.(Dzatoretal,2004184
(1+),Rouxetal,2004185(1+))
Targetedbehaviouralchangeprogrammeswithtailoredadvice.
Subsidiesforcommuters
Effectiveinchangingtravelbehaviourofmotivatedgroups
Maybeeffective(1++)
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Creationof,orenhancedaccesstospaceforphysicalactivity(suchaswalkingorcyclingroutes),combinedwithsupportiveinformation/promotion
Effective(2++) Asystematicreview(ofallUS-basedstudiesofvaryingdesigns)foundstrongevidencethatthecreationofspaceorenhancedaccesstoplacesforphysicalactivitycombinedwithinformationaloutreachactivitiesiseffectiveinincreasingphysicalactivitylevels.Interventionsincreasedthefrequencyofactivitybybetween21%and84%.Interventionsincludedaccesstofitnessequipment,accesstocommunitycentresandcreationofwalkingtrails.190
Point-of-decisionpromptsoreducationalmaterialssuchaspostersandbanners
Weakpositiveeffectonstairwalking(2+)
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Changestocity-widetransport,whichmakeiteasierandsafertowalk,cycleandusepublictransport–suchasthecongestionchargingschemeintheCityofLondonandSafeRoutetoSchoolschemes
Maybeeffectiveinmakingactivetransportappealingtolocalusers(3)
–
Keypoints
Addressingsafetyconcernsinrelationtowalkingandcyclingmaybeparticularlyimportantforfemales,andforchildrenandyoungpeopleandtheirparents.• (3)Interventionsmaybeineffectiveunlessfundamentalissuesareaddressed,suchasindividualconfidencetochangebehaviour;costandavailability;andthepotentialrisks(including•perceptionofrisk)associatedwithwalkingandcycling.(3)Auditingtheneedsofalllocaluserscanhelpengageallpotentiallocalpartnersandestablishlocalownership.• (3)
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Desired Interventions Evidencebase Intervention Selectbehaviour alreadyin
placeintervention
Effectiveness Evidence Cost-effectiveness
Morehealthyeating
Informationstrategiessuchaslabelling
Increasedprovisionofhealthierfood
Reductionincostoflow-fatsnacks
Effectivenessonweightoutcomesisunclear(2++)
Encouragesconsumptionofahealthydiet(2++)
Healthierfoodprovision–Onesystematicreviewconcludedthatworksiteinterventionstudiestargetinghealthierfoodprovisionbyinformationstrategiessuchaslabellingand/orchangesinfoodavailabilityorcostcanencouragehealthiereating.191
Incentives–Onestudyconcludedthat,whenpricesoflow-fatsnacksin55vendingmachineswerereducedby10%,25%and50%,thetotalnumberofitemssoldincreasedby9%,39%and93%,respectively.192
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Provisionofwater Nostudiesidentified(N/A)
– –
Behaviour Short-termweightloss. Evidencefrom10randomisedcontrolledtrialsandonecontrolled –modification Weightlossmaybe non-randomisedtrialsuggeststhatworksitebehaviourmodificationprogrammessuchas regainedpost programmes,suchasa‘healthcheck’followedbycounselling,canhealthscreening intervention(1+) resultinshort-termweightorbodyfatloss,althoughtherewasawithcounselling/ tendencyforweightregainaftertheintervention.6
education
Behaviour Improvementsin Asystematicreviewfoundthatworksitebehaviourmodification –modification nutritionwhile programmescanshowapositiveeffectondietaryfatintake(upto3%programmessuchas interventioninplace decreaseinpercentageofenergyfromfat).193
healthscreeningfollowedbycounsellingandsometimesenvironmentalchanges
(1+) Programmescanalsoincreaseconsumptionoffruitandvegetablesfrom0.09to0.5portionsperday.Successfulprogrammesincludedawiderangeofeducationalinterventions(suchasahealthcheckfollowedbycounselling)sometimesaccompaniedbyenvironmentalchanges.Informationaboutlong-termeffectswaslimited.6
Morephysicalactivity
Useofeducationalsessionsandinformativematerials
Inconclusiveevidenceonweightoutcomes(N/A)
Encouragingincreasedphysicalactivity–Asystematicreviewconcludedthattheuseofworkplace-basededucationalsessionsandinformativematerialshadsignificanteffectsonlevelsofphysicalactivity.193Resultsfromasystematicreviewsupporttheimplementationofworksitephysicalactivityprogrammes.194Theoverallconclusionofthereviewwasthattherewasstrongevidenceforapositiveeffectofphysicalactivityprogrammesonlevelsofphysicalactivity.
Evidencesuggeststhatphysicalactivitycounsellingdoesnotresultinanycost-effectivegainsinhealthoutcomes,andstudiesonthebenefitsintermsoflostproductivityareequivocal.(Properetal,2004195 (1+),Aldanaetal,2005196 (2-))
Activetravel Nostudiesidentified Activetravelplans(egCycletoWorkscheme) –schemes (N/A) ThereisevidencefromaUK-basedstudy197andaFinnish-basedstudy198
thatworkplacepromotionalstrategiescanincreasethenumberofpeopletravellingactivelytowork.
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Effectiveness Evidence Cost-effectiveness
More Payrollincentive Eitheronlyeffectivein – –physical schemes(egfree theshortterm(duringactivity gymmembership) theperiodofthe(continued) intervention)or
ineffectiveforweightcontrol(1+)
Usingthestairs Nostudiesidentified(N/A)
– –
Behaviour Short-termweightloss. Evidencefrom10randomisedcontrolledtrialsandonecontrolled –modification Weightlossmaybe non-randomisedtrialsuggeststhatworksitebehaviourmodificationprogrammessuchas regainedpost programmes,suchasa‘healthcheck’followedbycounsellingcanhealthscreening intervention(1+) resultinshort-termweightorbodyfatlossalthoughtherewasawithcounselling/ tendencyforweightregainaftertheintervention.6
education
Behaviour Improvementsin – –modification physicalactivitywhileprogrammessuchas interventioninplacehealthscreening (1+)followedbycounsellingandsometimesenvironmentalchanges
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Desiredbehaviour
Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost-effectiveness
NON-CLINICALSETTINGSTARGETEDATADULTS
Morehealthyeatingandphysicalactivity
Multi-componentcommercialgroupprogrammes
Multi-componentprogrammemoreeffectivethanstandardself-helpprogramme.Itremainsunclearwhetherthebrandedcommercialgroupprogrammeforwhichthereisevidenceofeffectiveness(WeightWatchers)ismoreorlesseffectivethanotherbrandedcommercialprogrammes(1++)
– –
Computer/email/internet-basedprogrammesaccompaniedbygreaterongoingsupport–inperson,bypostoremail
Programmesmoreeffectivewiththanwithoutongoingsupport(1+)
– –
Peer-ledprogrammeandagroup-basedandindividual-basedweightlossprogrammeinareligious-basedsetting,ahome-basedexerciseprogramme(accompaniedbyregulargroupsessions)andaprogrammeprovidinginformationthroughinteractivetelevision
Maybeeffectiveinthemanagementofobesity(1+)
– –
Mealreplacementproducts
Nostrongevidence(N/A) – –
Commercialandcomputer-basedweightlossprogrammesinmen
Unclear(N/A) – –
Keypoints
Thereislimitedevidencethatinterventionstomanageobesitybasedinworkplacesettingscanbeeffective,althoughweightlossmaybesmallinthelongterm.• (1-)Thereislimitedevidenceontheeffectivenessofinterventionsbasedinnon-clinicalsettingstomanageobesityinadults(particularlymen).• (N/A)
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Interventions Evidencebase Interventionalreadyinplace
Selectintervention
Effectiveness Evidence Cost-effectiveness
NON-CLINICALSETTINGSTARGETEDATCHILDREN
Morehealthyeatingandphysicalactivity
Home-basedinterventionsaccompaniedbybehaviourmodificationmaterialandongoingsupport
Effectivebutreplicabilityonwiderscaleremainsunclear(1+)
– –
Keypoints
Thereislimitedevidencethatinterventionsprovidedbyschoolstaffcanaidthemanagementofobesityinchildrenandyoungpeople,atleastintheshortterm,butthismaybelesseffectivethana•moreintensiveinterventiondeliveredinaclinicalsetting.(2-)Thereisapaucityofevidenceontheeffectivenessofinterventionstomanageobesityinchildrenbasedinnon-clinicalsettings.Theevidencethatwasidentifiedwasgenerallyforchildrenaged8-12•yearsandattheextremeendofobesity.(N/A)ThereisnoUK-basedevidenceavailableontheeffectivenessofinterventionstomanageobesityinchildrenandyoungpeopleinnon-clinicalsettings.• (N/A)Thereisinsufficientevidencetocomparetheeffectivenessofinterventionswithorwithoutfamilyinvolvementinnon-clinicalsettings.• (N/A)Noevidencewasidentifiedwhichconsideredtheeffectivenessofexercisereferralprogrammestomanageoverweightorobesityinchildrenandyoungpeople.• (N/A)Amongbothchildrenandadults,interventionsinnon-clinicalsettingsthatareshowntobeeffectiveintermsofweightmanagement,arelikelytodemonstratesignificantimprovementsin•participants’dietaryintakes(mostcommonlyfatandcalorieintake)orphysicalactivitylevels.(1+)Theimpactofparticipantjoiningfeesandparticipantcostsonthelong-termeffectivenessin‘reallife’commercialprogrammesremainsunclear.• (N/A)Thereisinsufficientevidencetoidentifystrategiesinnon-clinicalsettingsthatareassociatedwiththelong-termmaintenanceofweightandcontinuationofimprovedbehavioursamongoverweight•andobeseadultsandchildren.(N/A)Itremainsunclearwhetherthesourceofdelivery(boththemaininterventionandongoingsupport)hasaninfluenceoneffectiveness.• (N/A)Thereisinsufficientevidencetoassesstheimportanceofthesourceofdelivery(forexample,healthprofessionalversusvolunteerworker)ontheeffectivenessofprogrammesforchildrenoradults.•(N/A)Noneoftheidentifiedstudiesconsideredinter-agencyorinter-professionalpartnerships.• (N/A)
TOOLD9Targetingbehaviours 133
TOOLD9TargetingbehavioursTOOLD9For: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities
About: ThistooldetailsthekeybehaviouralinsightsfromthenationalsocialmarketingresearchconductedbytheDepartmentofHealth.
Purpose: Togivelocalareasanunderstandingofhowfamilieswithchildrenaged•2-11yearsandminorityethniccommunitiesperceivehealthandweightanddietandphysicalactivity(seebelow).
Togivelocalareasasenseofthedifficultiesofachievingthedesired•behaviours.
Use: Canbeusedtohelpinformtheinitialdesignofinterventionswhichcanthenbetailoredtotakeaccountofthelocalenvironmentbytestingthedesignwiththetargetgroups.
Resource: Insightsintochildobesity:Asummary.AdraftofthisreportisavailabletoPCTsandLAsthroughtheirRegionalPublicHealthGroup.Afinalreportwillbepublishedinlate2008.
Whenstructuringlocalobesitystrategies,itisimportanttounderstandthebehavioursofthetargetgroupsothatinterventionscanbedesignedaccordingly.Atanationallevel,theDepartmentofHealthconductedqualitativeresearchamongfamilieswithchildrenaged2-11years,includingbothgeneralpopulationfamiliesandfamiliesinblackandminorityethnic(BME)communities(Pakistani,BangladeshiandBlackAfrican[GhanaianandNigerian]),togainanunderstandingoftheirdietandphysicalactivitybehaviours.Researchersobservedfamiliesoveranumberofdaystoobtainknowledgeofwhatfamilieswere‘actually’doingratherthanwhatthefamilies‘perceived’themselvesor‘claimed’tobedoing.Belowaredetailsofthekeybehaviouralinsightsfromthisresearch.
InsightsonhealthandweightGeneralpopulation
Parentshaveaninaccuratepictureoftheirownandtheirchildren’sweightWhilechildhoodobesityisacknowledgedasaproblem,parentsoftendonotrecognisethatitisrelevanttotheirownfamily.Only11.5%ofparentswithobeseandoverweightchildrenidentifiedtheirchildrenasbeingobeseoroverweight.
ParentsdisassociatetheirfamiliesfromtheissueofobesityParentsoftenrefusetoacknowledgethattheirchildrenareoverweight,evenwhentoldsobyahealthprofessional.Thisisasensitiveissueforparentsaschildhoodobesityisoftenconnectedinparents’mindswithcasesofsevereneglectandabuse.Thisisrepeatedlyreinforcedbymediastoriesofextremeobesity.Also,parentsarealienatedbyacademicandmedicallanguage:phraseslike‘clinical’or‘morbid’obesityencouragemanyfamiliesinthepriorityclusterstodisassociatethemselvesfromtheissue.
134 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
ParentsareunawareoftherisksassociatedwithbehaviourssuchassedentaryactivityorconstantsnackingManyparentsseriouslymisperceivetherisksassociatedwiththeirdietandlevelsofphysicalactivity.High-riskbehaviourslikeeatingalotofconveniencefoods,highlevelsofsnackingandsedentarybehaviourareprevalent,yetperceptionofriskislow.‘At-risk’familiesarealsolargelyunawareoftheirownriskbehaviours,underestimatinghowmuchunhealthyfoodandconveniencefoodtheybuyandoverestimatingtheamountofactivitytheirchildrendo.
AwarenessofhealthrisksassociatedwithbeingoverweightorobeseislimitedTherelativelylowimportanceattachedtoconcernsaboutdietandactivitycouldbepartlyexplainedbylackofawarenessofthehealthrisksassociatedwithpoordietandinactivity.DatafromCancerResearchUKshowthatonly38%ofadultsrecognisethatobesityisariskfactorforheartdiseaseandjust6%areawareofthelinktocancer.Awarenessofthehealthrisksforchildrenisparticularlylow.
ParentsbelievetheirchildrenarehealthyifthechildrenarehappyManyparentsassumetheirchildrenare‘healthy’aslongastheyseemhappyandprovidedtheyhavenoobvioushealthproblems.Manyfamiliesinthepriorityclustersthereforeseehealthasrelatedtoemotionalandpsychologicalwellbeingratherthanphysicalwellbeing.Prioritisingchildren’shappinessinthiswaycanleadparentstoencourage‘unhealthy’activitiessuchassnackingandexcessivesedentarybehaviourbecauseitmakestheirchildrenhappy.
Itcanbehardtoengagewiththeconceptof‘healthyliving’Adoptinga‘healthylifestyle’isseenashardwork,stressfulandunrealistic.Itisalsostronglylinkedto‘middleclass’valuesandactivitiessuchasyogaclasses,gymmembershipandbuyingorganicfood.Manyfamiliesinthepriorityclustersseehealthylivingastheprovinceofstay-at-homemumswhocanaffordnottoworkandinsteadspendtheirtimeexercisingandshoppingforandcookinghealthymeals.Atthesametime,theyidentifystronglywiththosecommercialbrandsthatseemtoalignthemselveswiththeirprioritiesandpromiserewarding,positiveexperiences.
Blackandminorityethnic(BME)families
Parents’attitudetowardshealthisreactiveandtendstobemorerationalandphysicalthanemotionalParentstookareactiveapproachtotheirchild’shealth,seeingitasanabsenceofillness.Theydefinedhealthasthechild’sabilitytofunctionintermsoftheiroverallpriorities,especiallyaroundeducationandfaith,suchasdoinghomework,goingtoschoolandobservingreligiousobligations.
ChildhoodobesityisnotanovertissueThemediagaveyoungerparentssomelow-levelawarenessofchildhoodobesitybeingagovernmentconcern.However,olderparentstendedtobelessengagedwiththemediaandthuswerelessaware.Parentswereunlikelytopersonalisetheissue,eveniftheywereawareofit.Thiswasbecausetheywereunawareofthelong-termhealthrisksortherisksattachedtopoordietandlowactivitylevels,andtheymisjudgedtheweightoftheirchildren,eitherassumingthatitwaspuppyfatorthattheirchildwasanappropriateweight.Importantly,itwaspossibletotalktoparentsdirectlyaboutobesity.Directandrationalmessagesthatdealwithobesityandhealthwereverymotivatingtominorityethnicparents,andobesitydidnotcarrythesameemotiveconnotationsthatitdidformainstreamparents.
TOOLD9Targetingbehaviours 135
‘Bigisbeautiful’isapowerfulculturalinfluenceManyparentsweremoreconcernedabouttheirchildrenbeingunderweightratherthanoverweightandoftencitedfamilypressurestohave‘chubby’children.Therewasasensethatbeing‘big’wasconsideredtobemoreappealinganddesirableandasignofhealthandwealth.
InsightsonfamilydietGeneralpopulation
ParentshavesurrenderedfoodchoicestotheirchildrenInmanyofthefamiliesinthepriorityclusters,parentsplacedgreatvalueongivingchoicetochildren,particularlyoverfood.Giventhechoice,childrenwillmoreoftenthannotoptforunhealthyfoodswhichcanleadtoproblembehavioursuchashyperactivity,lethargyortantrums.
SnackingisawayoflifeformanyfamiliesinthepriorityclustersFamiliesinthepriorityclustersusesnacksinanumberofcomplexways:forexample,asrewardsforgoodbehaviour,as‘fillers’duringperiodsofboredom,ortoappeaseconflict.Parentsareoftenunawareofhowmuchsnackingtheyaredoingthemselvesandhowmuchtheirchildrenaredoing.Theyhaveafalsepictureofwhatkindsofsnackstheirchildrenareconsuming,andtheyhaveamisplacedsenseof‘control’–theysaytheyonlyallowsnackswhentheirchildrenaskbutinrealitytheyneversay‘no’.
Parentsfocuson‘fillingup’theirchildrenParentsaremorelikelytobeconcernedaboutnotgivingtheirchildrenenoughfoodthanaboutgivingthemtoomuch.Inyoungchildrenthereareconcernsoverafailuretogrowanddeveloprapidly.Byschoolage,parentsareoftenconcernedthattheirchildrenhaveenoughenergyforthemultitudeofactivitiesthattheyhavetodo.Inolderchildrenthereisaperceivedriskofeatingdisorderssuchasanorexianervosaorbulimianervosa,despitetheabsenceofevidencethatparentalbehaviourcanaffecttheriskofdevelopingtheseconditions.Parents’shoppingchoicesarethereforefocusedonbuyingthefoodstheyknowtheirchildrenwilleat.
Parentslackknowledge,skillsandconfidenceinthekitchenWhileparentswilloftencite‘timeandconvenience’ortheirown‘laziness’asthereasonswhytheydon’tcookfromscratch,inrealitythemainbarrierstocookingmealsarelackofknowledge,skillsandconfidence.Anecdotally,motherstalkedaboutexperiencingfeelingsofrejectioninthepastwhenchildrenhadrefusedmealsthattheyhadprepared.Manythereforesticktoalimitedrepertoireof‘triedandtested’mealswhichhastheeffectofmakingtheirchildrenmorefussyaboutfood.
Blackandminorityethnic(BME)families
FoodisacriticalpartofcommunitylifeFoodplaysanimportantroleandthereisconsiderableemotioninvestedincooking,sharingandconsumptionof‘good’food.Forwomenitfulfilledanumberoffunctions–demonstratinglovefortheirfamily(bytakingtimeandefforttocook‘proper’familymeals);asignofstatus–beingabletoprovidefoodinabundancetofamiliesandfriends;andasignofgoodupbringing–forwomenintraditionalfamilies,beingabletocookethnicmealsfromscratchdemonstratedtheyhadbeenwellbroughtupbytheirmothers.
136 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
CookingfromscratchiswidespreadandknowledgeandskillsarehighCookingtraditionalfoodsfromscratchwithfreshingredientswaswidespreadandoccurredonadailybasis,soparentsbelievedthattheirdietswerehealthy.Traditionalcookingmethodswereobservedandcookingpracticeshadbeenpassedonfrommothertodaughter.However,unhealthyelements,particularlyintheuseofcookingoilsandghee(clarifiedbutter),werefoundtobecommonplace.Whilesomemothersbelievedtheyhadcutdownontheuseofcookingoils,othersfelttheycouldnotbecauseoffamilymembers’preferences.
FamilydietsarewellplannedandorganisedbutthereisanemphasisonabundanceTheculturalsignificanceoffoodandtheprevalenceofmoreauthoritarianparentingstylesmeantthatfamilymealswerewellplannedandorganised.However,itwasclearthatevenwithinthistherewereunhealthypractices,suchaslargeportionsizesatmealtimesbecauseofthevalueplacedontheprovisionofabundantfood,frequentmeals(sometimestwiceinanevening)andchildrenbeingencouragedtocleartheirplates.
Consumptionofunhealthy‘Westernfoods’isunregulatedbyparentsChildrenwerebeingallowedtoconsumelargequantitiesofWesternconveniencefoodsinadditiontotheirtraditionalfamilymeals.ParentsacknowledgedthatWesternfoodscouldbeunhealthybutbecausechildrenwerealsoeatingtraditionalfoodswhichmaintainedtheirculturalvalues,parentsbelievedthatoveralltheirchildren’sdietwasacceptable.
InsightsonphysicalactivityGeneralpopulation
ParentsbelievetheirchildrenarealreadysufficientlyactiveManyparentsbelievetheirchildrenaregettingenoughexerciseduringtheschooldaytojustifysedentarybehaviourathome.Inmostcases,researchersbelievedthatparentswereconfusinghighenergylevelswithhighlevelsofactivity.
ChildrenareallowedandencouragedtobesedentaryHighlevelsofsedentarybehaviourwereobservedamongchildreninfamiliesinthepriorityclusters.Itwasapparentthatcurrentlyparentstendtoencouragethis,bothasawayofcontrollingchildrenandstoppingthemfrombehavingboisterously,andasawayofbondingwiththembygettingthemtojoininthesedentaryactivitiestheythemselvesprefer.
SedentarybehaviourisastatussymbolSedentarybehaviourisoftenlinkedtoexpensiveandaspirationalentertainmentproductssuchasgamesconsolesandtelevisions.Thisispartlywhyasedentarylifestyleisseenasastatussymbol–assomethingthefamilyhasearned,andascompensationforworkinghardtherestofthetime.HavingpaidforexpensivetoyssuchasPlayStations,parentswillalsoputpressureonchildrentoget‘valueformoney’byusingthemregularly.
PlayingoutsideisperceivedtobetoodangerousParentswereoftenreluctanttolettheirchildrenplayoutside,whetherornottheywereaccompaniedbyanadult,becauseofconcernsaboutsafetyandthenatureofthelocalenvironment.Theyalsowantedtokeeptheirownchildrenawayfromolderchildren,whomightbeanegativeinfluence.
TOOLD9Targetingbehaviours 137
CaruseishabitualandregardedasastatussymbolFamiliesinthepriorityclustersseecarsasstatussymbolsandameansofexercisingpowerandcontrolovertheirownlives.Thusmanyareusingthemforshort,walkablejourneys,forexampletoschoolorthelocalshops.Manyparentsreportedthattheirchildrenstronglyresistedtheideaofwalkingtoschoolandcitedthesimplicity,speedandconvenienceofthecar.However,itseemslikelythattheirownreluctancetowalkisamajorreasonfortheircar-dependency,andapowerfulinfluenceontheirchildren’sattitudesandbehaviour.
Blackandminorityethnic(BME)families
ChildrenwanttobemorephysicallyactiveParentsbelievethatenoughphysicalactivityisbeingdoneinschoolandthatthechildrenarethereforealreadysufficientlyactive.However,childrenthemselveswanttobemoreactivetorelieveboredom.
Physicalactivityisnotakeypartofanyofthethreecultures(Pakistani,Bangladeshi,andBlackAfrican[NigerianandGhanaian])Physicalactivitywasnotaculturalnorminanyofthethreecultures,particularlytakingpartinorganisedactivity.Theparents’priorityfortheirchildrenwasthechildren’seducation,andinMuslimfamiliesthisincludedreligiousinstructionafterschool.Thefocusoutsideschoolhourswasthereforehomework,extratuitionandattendanceatMosqueschools.Inaddition,motherswereexpectedtocarefortheirfamilyandextendedfamilies,andsoitwashardtojustifytimeawayfromhomebeingphysicallyactive.
Keybarrierscitedare‘tiredness’,‘time’,‘weather’and‘safety’Lowactivitylevelswereobservedacrossmothers.Healthreasonswerenotareasonforbeingphysicallyactiveandthereisabelief,especiallyamongolderBlackAfricanwomen,that‘bigisbeautiful’.Forothermothers,tirednessandtimeassociatedwithworkandfamilypressureswereoftencited.TheUKweathermadewalkinglessattractiveandnotapracticaloption.Safetywasakeyissueforchildrenbeingphysicallyactive.
Somedifferencesamongyounger,lesstraditionalfathersYoungerfathers,particularlythosebornandbroughtupintheUK,aremorelikelytobeinvolvedinplayingsportsattheweekend,particularlycricketandfootball.Thesewereactivitiesthattheyofteninvolvedtheirmalechildrenin,butfemalechildrenwereoftennotperceivedtobetheirresponsibility.
138 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLD10Communicatingwithtargetgroups–keymessages 139
TOOLD10Communicatingwithtargetgroups–keymessages
For: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities
About: Thistoolprovidesthekeymessagesforcommunicatingtomainstreamandminorityethnicfamiliesaboutdietandphysicalactivity.ItalsoprovidesdetailsontheNationalMarketingPlan.
Purpose: Togivelocalareasanunderstandingofhowtheycanreachthepriorityclustergroups(1,2and3)usingkeymessagesderivedfromnationalqualitativeresearch.
Use: Thekeymessagesshouldbeusedtoreachappropriateclustergroups.•
DetailsoftheNationalMarketingPlancanhelplocalareassynchronise•theirmarketingstrategywithnationalpolicy.
Resource: Insightsintochildobesity:Asummary.AdraftofthisreportisavailabletoPCTsandLAsthroughtheirRegionalPublicHealthGroup.Afinalreportwillbepublishedinlate2008.
CommunicatingtofamiliesThefindingsofthenationalqualitativeresearchcommissionedbytheDepartmentofHealth(seepage59andToolD9)suggestthatparentsoverallneedtobemoreengagedwiththechildobesityissueinordertotakeproactivestepstopreventobesityintheirchildren.Todothis,itwillbeimportanttoraisetheirawarenessofwhathealthybehaviourisandtherisksandbenefitsassociatedwithit,throughtargetedinterventions.Toengagefamilieswithmessagesaboutdietandphysicalactivity,itisessentialthatthenationalresearchfindingsaretakenintoaccount.Forexample,thequalitativeresearchfoundthateffectivecommunicationsshouldfocusoneitherdietorphysicalactivity,butnotboth:
• Whenmessagesarecombined,dietmessagesdominateandtheactivitycomponentisignored,regardlessoftheorderinwhichmessagesarepresented.
• Parentsarelikelytoacknowledgetheneedfordietarychangebutarenotlikelytorecognisetheneedforachangeinactivitylevels.Thisisbecausefordiet,parents’awarenessoftheproblemishighsotheyarealreadyactivelyengagedinriskbehaviours.However,forphysicalactivity,parentstendtobelievetheirchildrenarealreadyactiveenoughandtheyarelessinclinedtoseetheirchildren’sactivitylevelsastheirresponsibilitythantheyarewiththeirchildren’sdiet.
• Inaddition,someparentsfinditdifficulttomakethelinkbetweendietandactivity,andwillrejectcommunicationsthattrytomakethatconnectionclear.
• Combiningdietandphysicalactivityincommunicationscanalsoperpetuateunhealthydietsasparentsbelievethataslongaschildrenareactive,itdoesnotmatterwhattheyeat.
Theresearchconcludedthat,tobesufficientlymotivating,dietandactivitymessagesneedtooccupyverydifferentemotionalterritories:
• Messagesondietthatoutweighthenegative,short-termconsequencesofintroducinghealthydiets(egresistancefromfussychildren)by‘shocking’parentswiththelong-termnegativeconsequencesoffailingtochangebehaviourcanbeverymotivating,butcarefultestingwithrepresentativefocusgroupsisneededontheexactwordingbeforesuchmessagesareused.
TOOLD10
140 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
• Successfulmessagesaboutactivityfocuson‘disarming’parentsbyshowingthepositivebenefits(non-health-related)ofbeingactivewithchildren,suchascreatingtreasuredfamilymemories.
Inadditiontocommunicationwhichmotivatesfamiliestoaddresstheirchildren’sdietandactivitylevels,theresearchrecommendedthat:
• Parentswouldrequirespecific,supportivemessagesthatempowerthemtomakechanges.
• Messageswillneedtofeelrelevantandactionableandshouldbeeasilyadaptabletonormalfamilylife,andpresentedinadown-to-earthway.
• Thelanguageusedwhencommunicatingtofamiliesneedstobeclear,simpleandnon-judgemental,andthetoneofvoiceneedstobeempatheticandpositive.Thiswillhelpsecureparticipationfromthetargetaudience.Furtherdetailsaboutwhatworks(languageandimagery)areprovidedbelow.
Whatworksforthepriorityclusters–Language
• Languageshouldbeempathetic.Use‘we’and‘us’,ratherthan‘you’.
• Don’ttellparentswhattodo.Thisalienatesand‘de-skills’them.
• Use‘couldhappen’ratherthan‘willhappen’whentalkingaboutnegativeconsequences.Parentsneedtofeelthatthereishope.
• Usethekindofcolloquialphrasesthatparentsusethemselves,like‘bagsofenergy’.
• Acknowledgetheirconcernsandreflectthemback,byusingphraseslike‘It’shardtosaynotoyourkids’and‘Youdon’thavetoturnintoahealthfanatictodosomethingaboutit.’
• Don’tbejudgmental.Avoidtalkingaboutthe‘right’foodsor‘good’and‘bad’energy.
• Directreferencesto‘obesity’and‘weight’alienateparentsandmaymeantheyfailtorecognisethemselvesaspartoftheaudienceforacampaignorintervention.
• Ifyoumusttalkaboutweight,useclear,simplelanguage.Explainjargonanddefinetermslike‘overweight’and‘obese’.
• Focusingonfuturedangers,whichmostparentsarewillingtoacknowledge,willreducetheriskofparents‘optingout’ofacommunicationbecausetheydon’tbelievetheirchildrenarecurrentlyoverweightorinactive.
Whatworksforthepriorityclusters–Imagery
• Imagesofhappy,healthychildrendrawparentsinandencouragethemtoidentifywithasharedgoal.
• Imagesofadultsmakeparentsmorelikelytothink“They’renotlikeme,sothisdoesn’tapply.”Imagesofchildrenarelikelytoappealtoadults,regardlessoftheirbackground.
• However,imagesofveryoverweightorobesechildrenalsoencouragede-selectionsincethemajorityofparentswithoverweightandobesechildrenmaybeunawareoforsensitiveabouttheirchildren’sweightstatus.
• Settingsshouldbefamiliarandeveryday,forexamplelocalparks,gardensorthekitchen.
• Avoidanythingtooaspirationalor‘middle-class’–forexample,toys,environmentsorclothes.
• Focusonimagesofchildrenplayingasopposedtotakingpartinspecificsportsortypesofexercise,assportsandexercisemayleadparentstoturnoff.
• Forthesamereason,avoidimagesofchildreneatingspecificfoods.
• Imageryshouldreflectthefactthatfamilies,particularlythoseinthe‘at-risk’clusters,oftendon’tfitthestereotypeoftwoparentsand2.4children.
TOOLD10Communicatingwithtargetgroups–keymessages 141
Cluster-specificmessagesResearchhasestablishedthatmotivatingpropositions(re-framingdietintermsofnegativelong-termconsequences,andactivityintermsofpositivefamilyexperiences)workedtostimulateadesiretochangebehaviouracrossalloftheat-riskclustergroups.However,whencreatingtargetedmessagesitmaybenecessarytocreateamixoftailoredmessages.
ToolD8andtheoverviewofresearchgivenonpages139–140provideinsightintohowfamiliesthinkandfeelaboutissuesandareausefulstartingpointformessagedevelopment,aswillanylocallycommissionedresearch.Thefollowingtablesuggestskeyissuesthatshouldbeconsideredwhendevelopingmessagestotargetoneofthepriorityclusters.
Cluster Mindset Messagingconsiderations
1 Cluster1familiesarefatalisticabouttheirabilitytomakechangesandbelievethebarrierstodoinganythingaretoosubstantial.Theyareparticularlysensitivetojudgementoftheirparentingskills.
Emphasisehowthebarriers–time,costandconvenience–canbeovercome.
Demonstratethatchangeisachievable–possiblybyshowingthatotherslikethemareachievingit.
Avoidanyimplicitjudgementofparentingskills.
2 Cluster2parentshavelowlevelsofunderstandingoftheissuesbutarekeentobe‘goodparents’.
Encouragepersonalisationbytalkingaboutthekindsofissuestheyarestrugglingwith,suchaschildfussiness.
Messagesshouldaimtoincreasetheirawarenessofdiet-andactivity-relatedissuesbutwillneedtofocuson‘skills’forimplementingsolutionsaswellasthesolution,eghowtoencouragefruitandvegetableconsumption,andnotjustwhyitisimportant.
Asthisclustertendstobeinalowersocioeconomicgroup,solutionsshouldbelow-cost.
3 Cluster3parentsbelievetheyknowalotaboutdietandphysicalactivityandbelievetheirfamilyarealreadyhealthy.
Asparentsinthisclusterareleastlikelytorecognisetheissueasbelongingtothem,messagingwillneedtopersonalisetheissuebydemonstratinglikelygapsbetweenperceivedandactualbehaviour.Therewillbelessneedtoovertlytacklebarrierssuchas‘time’and‘cost’.
Communicatingtoblackandminorityethnic(BME)familiesResearchwithBMEcommunitiesshowsthatdirectmessagesregardinghealth,childhoodobesityandassociatedhealthrisksweremostsuccessful.Aswithmainstreamcommunities,messagesaboutdiettendedtohavemoreimpactthanmessagesaboutphysicalactivity,andcommunicationswillhavetoworkhardtoencouragetake-upofmessagesaboutphysicalactivity.
Hard-hittingmessagesrelatingtodietresonate
Aswiththegeneralpopulation,effectivedietmessageswereoftenthosethatraisedparents’awarenessofthelong-term,negativeconsequencesofindulgentfoodpractices.
142 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Rationalmessagingrelatingphysicalactivitytoeducationismoresuccessfulthanemotionalmessages
Thepositiveemotionalmessagesthatconnectedphysicalactivitywithhappyfamilymemorieswereseenastoo‘soft’andemotional.Thisreflectstheinsightthatparentsinthesecommunitiesdonotconnecthealthwithhappinessinthesamewaythatmainstreamcommunitiesdo,andalsoreflectstheabsenceofphysicalactivitytraditionsintheirculturallife.Messagesthatmotivatedparentsmostwerethosethatlinkededucationalattainmentandphysicalactivityundertheheadingof‘energyforlearning’.Thisfittedparents’ownprioritiesandwaseasytounderstand.
Otherconsiderationsbasedonresearchfindings
• Itispossibletotalkdirectlytothesecommunitiesaboutthedangersofchildhoodobesity.Theissueisnotasemotiveinthesecommunitiesanddeselectionislesslikely.
• Extendedfamilywillbeanimportantadditionaltargetaudience,toensurethatgrandparentsdonotunderminemothers’attemptstoimprovechildren’sdiets.
• FormotherswithlowEnglishlanguagelevels,childrenareimportantconduitsforinformation.
• Thesecommunitiesaremorecomfortablewithface-to-facecommunicationthroughcommunityworkersthanwithcommunicationusingtelephone,internetservicesorleaflets.
• Engagingcommunityleadersandworkersislikelytobeimportant,particularlytocreate‘culturallicence’forincreasedactivitylevels.
TheNationalMarketingPlan–socialmarketingatanationallevelTheGovernmenthascommitted£75milliontoathree-yearmarketingprogrammetocombatobesity.Thisprogrammewillbeamplifiedbypartnershipworkwithcommercialorganisationsandnon-governmentalorganisations.Thisprogrammeisdrivenbyasubstantialbodyofresearch.LocalauthoritiesandPCTscanaccessadraftreportthatdescribesthisresearchviatheobesityleadintheirRegionalPublicHealthGroup,orbyemailinghealthyweight@dh.gsi.gov.uk.Afinalversionofthereportwillbepublishedinlate2008,informedbycontinuingresearch.Inthemeantime,theCross-GovernmentObesityUnitwelcomesfeedbackonthedraftreport.
TheaimofthisprogrammeistousemarketingasacatalystforasocietalshiftinlifestylesinEngland,resultinginfundamentalchangestothosebehavioursthatleadtopeoplebecomingoverweightandobese.Theprogrammewillnottellpeoplewhattodo;ratheritwillseektorecruitpeopletoalifestylemovement,whichtheycanjoinandinwhicheveryonecanplaytheirpart.
Theprogrammewill:
• createanew‘movement’calledChange4Life,whichwillspeaktoandforthepubliconthisissue;thenewmovementwillbetheauthorofallpublic-facingmarketingandcommunications
• directpeopletoasuiteoftargetedproductsandservices(includingthosedeveloped/deliveredlocally)
• buildacoalitionofpartners(acrossGovernment,localserviceproviders,commercialandthirdsector),allworkingtogetherunderacommonbanner
• createtargetedcampaignswhichuseamixofverysimpleuniversalmessagesandtailoredmessageswhichtakeaccountofpeople’sindividualneedsandcircumstances.
Theprogrammewillexplainthelong-termhealthconsequencesofpoordietandactivitylevelsandwillraisethisasanissuethatisrelevanttothewholeofsociety.
TOOLD10Communicatingwithtargetgroups–keymessages 143
Specifictargetedcampaignswillbedevelopedforthefollowinggroups:
• pregnantwomen
• parentsofchildrenaged0-2
• at-riskfamilies
• thoseminorityethnicgroupsthattheHealthSurveyforEnglandandDepartmentofHealthresearchshowstobemostatrisk.
Thecampaignwillinitallyfocusonclusters1,2and3(seeToolD4andpage59)asthehighestprioritysinceresearchindicatedthatthesefamilieshadthehighestriskoftheirchildrendevelopingobesity.
Thecampaignwillseekto‘re-frame’theissueofobesitysothatfamiliesbegintopersonalisetheissuesofpoordietandlowphysicalactivitylevels.TheDepartmentofHealthwillthenschedulemessagespromotingdietandphysicalactivitytofitintothenaturalcalendaroffamilylife.Forexample,messagesaboutphysicalactivitywillbetimedtocoincidewithschoolholidays.
Inlateryears,specificactivitywillbedevelopedfor:
• youngpeople
• at-riskadults
• stakeholders(suchastheNHSworkforce).
TherewillbeaChange4Lifewebsiteandhelplinegivingpeopleaccesstotools,support,adviceandinformation.Inparticular,therewillbeatoolthatletspeoplesearchforlocalservicesandactivities.
TheDepartmentofHealthteamwillmakedetailedmarketingplansavailableinadvanceofallactivityandwillprovideacampaigntoolkittogivelocalandregionalteamseverythingtheyneedtodevelopactivitylocally.Itisrecommendedthat,whereverpossible,localorganisationsjoinupanymarketingorcommunicationsactivitythatarerunsothat:
• localactivitycanbenefitfromtheumbrellasupportprovidedbythenationalcampaign,and
• peoplewhoaremotivatedbythenationalactivitycaneasilyfindlocally-deliveredproductsandservices.
Inaddition,theDepartmentofHealthrecommendsthatlocalareasdothefollowing.
• Designinterventionsorservicesthatsupportthenationalmovement:egopportunitiesforchildrentogettheirhouradayofphysicalactivity,oropportunitiesforfamiliestotrialdifferentwaysofachieving5ADAY.
• Ensuredetailsofallservices(suchasbreastfeedingcafés,walkingbuses,orcookeryclasses)areincludedwithinthesearchabletool.
• SynchroniseanybehaviouralguidancewiththatprovidedbytheDepartmentofHealthcampaign(sothatpeoplearenotgivenconflictingadvice).
• Explorewaysinwhichtheycanrecruitlocalpartners,whetherfromthecommercialorvoluntarysector,tothemovement.
• Whenappropriate,usethebrandnamefornewcommunications.
• Whenappropriate,usethecentralhelplineandwebsiteasthecall-to-actionincommunications.
144 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLD11Guidetotheprocurementprocess 145
TOOLD11GuidetotheprocurementprocessTOOLD11For: Commissionersinprimarycaretrusts(PCTs)
About: Thistoolprovidesdetailsregardingthecorrectproceduretofollowwhenprocuringservices.Itisnotacompleteandcomprehensiveprocurementguide.However,ithasbeendevelopedtoassistPCTcommissionerstobetterunderstandthetenderprocessforprocuringservicesthatwillhelptotackleobesity.ThistoolassumesthedecisionhasalreadybeenmadebythePCTtoprocureservices.PCTsarestronglyadvisedtoseektheirownlegaladvicewhenusingthisprocurementguidance;thisguidanceshouldnotbetakeninanywayasconstituting,orasasubstitutefor,legaladvice.
Purpose: Toprovidelocalareaswithahigh-levelsummaryofkeyfactorsforPCTstoconsiderwhencommissioningservices.
Use: TobeusedwhenprocuringservicesinconjunctionwiththePCTprocurementguideforhealthservices.199
Resource: PCTprocurementguideforhealthservices.199www.dh.gov.uk
1. CommissioningobesityservicesThistoolisdesignedtosupporttheoverallcommissioningofinterventionstotackleobesityandpromotehealthyweight,usingthefivesimplestepssetoutinHealthyWeight,HealthyLives:Guidanceforlocalareas2asaframework.Oncelocalauthorities,PCTsandtheirpartnersareclearontheinterventiontheyneedtocommissiontomeettheirlocallysetgoals,thenextstepistoprocurethoseinterventions.
Thistoolprovidesahigh-levelsummaryofkeyfactorsforPCTstoconsiderwhenprocuringservices.
2. Isaformalprocurementrequired?ThispapermustbereadinconjunctionwiththePCTprocurementguideforhealthservices199
documentwhichsetsoutguidancetoassistPCTsin:
i) decidingwhethertoprocure;and
ii) howtoprocurehealthcareservicesthroughformaltenderingandmarkettesting.
ThereisnogeneralpolicyrequirementfortheNHStobesubjecttoformalprocurementprocess.ItremainswiththePCTasaCommissionertodecidewhethertheywanttoformallytenderornotaftercarefullyconsideringtheirinternalgovernance,legaladviceandadviceinthePCTprocurementguideforhealthservices.199
However,theuseofindependentandthirdsectorProviderstoprovideNHS-fundedservicesisbecomingmoreandmorewidespreadandPCTCommissionerswouldbeexpectedtoselectanduseProviderswhoarebestplacedtodelivercost-effectiveandhigh-qualityservices.
IfPCTsdodecidetoprocuretherequiredservices,thegeneralprocurementthresholdscanassistPCTsinmakingadecisionastowhichprocurementroutetofollow.
146 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
3. EUProcurementRequirementsandRegulationsContractValueThresholdsandTenderProcess
PublicSectorprocurementisgovernedbyUKregulationsthatimplementEUprocurementdirectives;theseapplyspecificallytoanyprocurementwithatotalvalueoveraspecifiedthreshold.
WherecontractvalueisabovetheEUpublicprocurementthreshold,itisimportanttoreviewwhethertheservicefallswithin‘PartA’or‘PartB’oftheprocurementregulations.Contractsforhealthandsocialcareservicesandsometrainingservices,includingweightmanagementtrainingprogrammeservices(CAT24),aredefinedbyprocurementregulationsas‘PartB’servicecontracts.Undertheregulations,onlycertainprocurementobligationsapplytotheawardofPartBcontracts.Inparticular,ifacontractisforpurely‘PartB’publicservicesthenanOJEU(OfficialJournaloftheEuropeanUnion)noticepublicationisnotautomaticallyrequired.Forexample,itispossibletoadvertiseinlocalornationalnewspapersortradejournalsratherthanOJEUinsomecircumstances.Incontrast,thosecontractswhicharedesignated‘PartA’servicecontractsaresubjecttothefullextentoftherequirementsoftheprocurementregulations.
ThefollowingtablesetsoutbasicrulesforPartBservicesandisforinformationonly.
Thresholdforvalueofcontract
GuidanceTenderProcess
Contractvaluesupto£139,893
Alltenderprocessesmustbefair,openandtransparent.
Bidsshouldnormallybeobtainedinwritingdependingonthevalueandtypeofservice.PCTCommissionersareadvisedtoliaisewiththeirlegaladviserstoensuretheymeetthenecessaryrequirements.However,aPCTwouldnormallyissuetenders(withdetailedservicespecifications)toaminimumofthreeinterestedBidders,andfollowingevaluationagainstpredefinedcriteriatheBidderofferingthebestserviceandtherightpricewouldbeawardedacontract.
Contractvaluesatorabove£139,893
EUpublicprocurementthreshold,whichrequiresservicestobeadvertisedandtendered.
APCTwouldnormallyadvertisetheprocurementforservicesmorewidely.PCTsshouldconsiderpublishinganOJEU(OfficialJournaloftheEuropeanUnion)noticeandinadditionplaceadvertisementsinnationalnewspapersortradejournalsasappropriate.
Note:Ifthecontractisoneofaseriesofcontractsforsimilarservicesthentheaggregatevalueofallthecontractsmustbeusedinrelationtothefinancialthresholds.ThresholdsshouldbecheckedontheEUwebsiteastheymayberevised.Gotowww.tendersdirect.com
TheDepartmentofHealth’sProcurementCentreofExpertisehassetoutthefollowingdifferentproceduresfortheprocurementofPartAmanagementservices(only)whichsetsoutthetenderprocessesrequired.PCTsmaychoosetousethisasageneralguidewhenprocuringweightmanagementtrainingservices.
Upto£4,000 Onequote
£4,000to£10,000 Threewrittenquotes
£10,000to£90,319(uptoEUthreshold) Threeormoreformaltenders
£90,319+(overEUPartAthreshold) EUpublicprocurementlimitapplies
TOOLD11Guidetotheprocurementprocess 147
4. ProcurementRoute–FourOptionsOncethePCTCommissionerhasestablishedwhatthresholdstheservicestobetenderedfallinto,theycandecidewhichprocurementoptionismostsuitabletomeetitsneeds.Anumberofconsiderationsincludingthesizeandscopeoftheservices,theservicespecification,thetargetmarket,andkeystakeholderswilldrivethisdecision.
TherearefourmainoptionsavailabletoPCTsforprocurementsthatexceedtheEUthreshold:
i) OpenTender(allinterestedBiddersinvitedtotender)
AllinterestedProviders(Bidders)whorespondtoanOJEUnotice/advertisementmustbeinvitedtotender.Thisproceduredoesnotallowforprequalificationorselectionpriortofinalcontractawardstage.
ii) RestrictiveTender(entailslimiteddialoguewithBidders)
InterestedBiddersareinvitedtorespondtoanOJEUnotice/advertisementbysubmittingaprequalificationquestionnaire(PQQ)inwhichtheyreplyagainstdefinedcriteriarelatingtotheirorganisation’scapabilityandfinancialstanding.Followingreceiptandevaluation,ashortlistofBiddersareinvitedtotender.ThePCTCommissionercancarryoutsomelimiteddiscussionanddialoguewithBidderspriortoselectingthesuccessfulBidder.Thediscussioncan,forexample,enabletheCommissionertoclarifyminordetailsaboutthebid,butdoesnotallowforsubstantialnegotiationsaroundtheservicerequirementsandpricing.
TheinitialPQQselectionprocessallowsPCTCommissionerstorestrictthenumberofBiddersinvitedtotendertoamoremanageablenumber,allowingtheCommissionertofocusmoreonthequalityofbidsandtomaketheassessmentprocessmorecost-effective.
iii) CompetitiveDialogue(appropriateformorecomplexprocurementsandentailsdialoguewithBidders)
ThecompetitivedialogueprocedureisamoreflexibleprocedurethantheRestrictiveTenderprocedure,andenablesthePCTCommissionerandBidderstodiscussaspectsofthecontractandservicespriortoconcludingandagreeingthese.TheCommissionercanutilisethisprocess,forexample,tohelprefinetheservicerequirementsfurtherindiscussions/negotiationswithBidders.OnconclusionofthisstagetheCommissionerwillissueafinalInvitationtoTender(ITT),towhichBiddersmustrespondwithafinaltender.ThereisopportunityfortheCommissionertoaskBidderstotweakorfinetunetheirbidsfurther.ThepreferredBidder(s)canthenbeselected.
iv) CompetitiveNegotiatedProcedurewithaSingleProvider(shouldonlybeusedinveryexceptionalcircumstances)
Thisprocedureislimitedtospecificcircumstancesandshouldonlybeusedwhenotherprocedureswillnotwork,competitionisnotviableorappropriate,workisneededforresearchordevelopmentpurposes,orwhereprioroverallpricingisnotpossible.
Inalloftheoptionsoutlinedabove,thePCTCommissionermustensurethatanevaluationplanisinplaceandthattheevaluationagainstwhichBidderswillbeassessedareclearlysetout.
148 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
5. ThreeKeyStagesofProcurementForanyprocurementroute,andinlinewiththeOfficeofGovernmentCommerce(OGC)guidance,theprocesscanbebrokenintothreekeystages:
Stage 1 Pre Procurement
• HealthNeedsAssessmentandPlanning
• DevelopmentofServiceSpecifications
• Consultation
• StimulateMarket
• Strategic/OutlineBusinessCaseincludingAffordabilityExercise
• BuildaProjectTeam
Stage 2 Procurement
• ProcurementStrategyandPlan
• Advertise
• PrequalificationQuestionnaire(PQQ)
• MemorandumofInformation
• IssueITPD/ITTtenders
• Dialogue/Negotiations
• SelectPreferredProviders
• SignContract
Stage 3 Contract Management
• ServiceTransitionandMobilisation
• FullServiceCommencement
• OngoingContractManagement(includingPerformanceManagementofProviders)
ATypicalProcurementProcessthatPCTsmayconsider
Detailedguidanceandtoolsthatexpandontheinformationinthisguidearecurrentlybeingdevelopedandwillbeavailableinlate2008.Thiswill:
• provideafoundationforPCTstobuildacomprehensiveprocurementplan
• provideastep-by-stepguidetomanageaprocurement.
Thefollowingillustrationsetsoutahigh-levelprocurementprocesswheredialogueisrequiredwithBidders.TheInvitationtoParticipateinDialoguestage(ITPD)hasbeenmarkedasoptional.WhetherornottheDialoguerouteispursueddependsonthePCT’sindividualrequirements.
Typicalprocurementprocess
Advert (OJEU)
MOI & PQQ Shortlist bidders
ITPD1* Invitation to participate in
dialogue ITPD1* Evaluation of bid
responses
Service commencement
Contract award and signature
Selection of preferred bidders
ITT Evaluation Clarification/fine tuning possible
ITT End dialogue
and invite final tenders
ITPD1* Finalise evaluation
Invite shortlisted bidders to ITT stage
ITPD1* Dialogue
Elimination of bidders possible
at this stage
*Furtherstagesofdialoguearepossible,egITPD1,ITPD2.However,theseshouldbeplannedforattheoutset.
TOOLD11Guidetotheprocurementprocess 149
ProcurementTimelines
Thetimerequiredtoundertakeaprocurementcanvarygreatlydependingonthesizeandcomplexityoftheproduct(s)orservice(s)beingprocured(fromafewdaysorweeksto12monthsforlargerscaleprocurements).Procurementsmayvaryinsizeandduration–forexampleaPCTCommissionermaydecidetotenderonanindividualuser-by-userbasisorundertakeaprocurementtocoverallserviceusersoverthenextfourtofiveyears.SomePCTsmaychoosetoprocurecollaborativelyandmaximisetheopportunitytobenefitfromeconomiesofscale,whichmayalsohaveanimpactonthetimescale.
CompetitionChallenge
ThePCTprocurementguideforhealthservices199shouldbereadinconjunctionwiththe‘PrinciplesandRulesforCooperationandCompetition’,publishedasAnnexDofthe2008/9OperatingFramework,138andtheFrameworkforManagingChoice,CooperationandCompetition.200
ItisimportanttonotethataDepartmentofHealthCooperationandCompetitionPanelisbeingestablishedinOctober2008,whichwillneedtobesatisfiedthatPCTshaveconsultedandcompliedwiththePCTprocurementguideforhealthservices199asabasisforthedecisionstheyhavemade.MoreinformationabouttheCooperationandCompetitionPanelisavailableintheFrameworkforManagingChoice,CooperationandCompetition.200
FurtherGuidance
TheCross-GovernmentObesityUnithascommissionedthedevelopmentofasetoftoolstosupportPCTsandlocalauthoritiesinthespecificareaofcommissioningweightmanagementservices.Thetoolkitwillbeavailableinlate2008andwillprovidepracticalsupporttolocalareas,includingintheprocurementofweightmanagementservices.
MoredetailedadviceandtemplatedocumentsrelatingtoprocurementarecurrentlyavailableviatheEquitableAccesstoPrimaryCareweb-basedtoolkitwhichmanyPCTsarealreadyfamiliarwith.Gotowww.dh.gov.uk
150 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLD12Commissioningweightmanagementservices 151
TOOLD12Commissioningweightmanagementservicesforchildren,youngpeopleandfamilies
TOOLD12
For: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities
About: Thistooloffersaframeworkforcommissioningweightmanagementservicesforchildren,youngpeopleandfamilies.TheframeworkisacombinationoftheJointPlanningandCommissioningmodel,theCommissioningFrameworkforHealthandWell-BeingandamodelofferedbytheInstituteofPublicCareusedintheCommissioningeBookandfurtherdevelopedbytheCareServicesImprovementPartnershipNorthWest(CSIPNW).TheframeworkreflectstheprinciplesofWorldClassCommissioning,focusingonhowcommissionersachievethegreatesthealthgainsandreductionininequalities,atbestvalue,through‘commissioningforimprovedoutcomes’.Italsorecognisesthata)somechildren,youngpeopleandtheirfamilieswillbemotivatedtoachieveahealthyweightandwillrequireaminimumlevelofsupportandb)asindicatedinHealthyWeight,HealthyLives,1commissionersinlocalareaswillwanttocommissionarangeofinterventionsthatpreventandmanageexcessweight,includingweightmanagementservices.
Purpose: Toprovidelocalareaswithanunderstandingofthekeystepstocommissioningweightmanagementservicesforchildren,youngpeopleandfamilies.Thisisthefirsttoolandoverarchingframeworkofamorecomprehensiveresourcebeingdevelopedtosupportcommissionersspecificallyintheareaofweightmanagement.
Use: AsaguideforcommissionersinlocalauthoritiesandPCTstodevelop•commissioningplansforweightmanagementservices
Asachecklistofactivitiestobeagreed,andtomeasureprogressagainst,•aspartofthecommissioningprocessandjointperformancemanagementsystems
Inworkingwithpartnersandproviderstodevelopbothashared•languageandcommissioningmodel
Toengagechildren,youngpeopleandfamiliesandprovidersinthe•processofserviceplanninganddesign
Resource: PCTprocurementguideforhealthservices.199www.dh.gov.uk
TheJointPlanningandCommissioningmodeloutlinesninestepstocommissioningservicesforchildrenandyoungpeople(seediagramonnextpage).Eachoftheseninestepswillinvolveanumberof‘activities’thatcanbebroadlydividedintofoursections,whichalsoreflecttheprocessesandcompetenciesofWorldClassCommissioning:
• analysis
• planning
• doing,and
• reviewing.
152 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Thediagrambelowshowsthesenineplanningandcommissioningstepsdividedintothefoursections.Thetableonthenextpageoffers,throughaseriesofquestions,aguidedjourneythroughsomeofthekeycommissioningactivities,includingneedsassessment,servicespecification,contractmanagement,relationshipwithprovidersandworkforcedevelopment.Someoftheseactivitieswillbesupportedbymorespecifictoolsandtemplateswithcasestudiesandexamplesasbestpracticeemergesandthebodyofevidencegrows.
Stepsinvolvedincommissioningservicesforchildrenandyoungpeople
Review
Monitor and review services
and process
Plan for workforceand market
development
Look at outcomes for children and
young people
Analyse
Look at particulargroups of children and young people
Develop needs assessment with user
and staff views
Plan
Identify resources and set priorities
Plan pattern of services and focus
on prevention
Do
Commission – including use of pooled resources
Decide how to commission
services efficiently
Monitor and review services
and process
Look at particular groups of children and young people
Identify resources and set priorities
Commission – including use of pooled resources
Plan pattern of services and focus
on prevention
Decide how to commission
services efficiently
Develop needs assessment with user
and staff views
Plan for workforce and market
development
Look at outcomes for children and
young people
1.Analyse1.Whataresuccessfulhealthyweightoutcomesforchildren,youngpeopleandtheirfamilies?
2.Howwelldoweknowandunderstandtheweightmanagementneedsandlifestyleinterestsofchildren,youngpeopleandtheirfamilies?
3.Whatareourlocal,regionalandnationalprioritiesintermsofreachingandcaringforparticularchildren,youngpeopleandtheirfamilies?
4.Whatdoesthereviewofexistingweightmanagementservicestellus,includingGP-basedservices?
5.Whatisthecurrentlevelofcapacityandfinancialinvestmentacrossourpartnersintheseservices?
6.Whatisouranalysisofthecurrentmarketplaceandprovidersofweightmanagementservices?
7.Whatisthelegislativebaseandguidancetomeetingthehealthyweightmanagementneedsofourlocaland
nationalpopulation?
8.Whatisouranalysisoftheresearchandcurrentevidencebaseforthiswork,includingtheviewsand
experienceofpeopledeliveringservices?
2.Plan
1.Howdoweensurewehavechildren,youngpeopleandtheirfamiliesatthecentreofjointplanningand
commissioningofweightmanagementservices?
2.WhatarethegapsinserviceprovisionacrossPCTsandlocalauthorities,includingGP-basedservices,that
weneedtoplanfor?
3.Whatlevelsofresourcesareavailabletoaddressgapsinservicesandidentifiedinequalities?
4.Whowillbeinvolvedinourjointcommissioningstrategyplanningexercise?
5.Whenwillwecompleteourstrategy,whichcouldincludeworkingwithGPsthroughpractice-basedcommissioning?
6.Whatisthedesignoftheservicesandtherangeofcarepathwaysweareplanningtoputinplace?
7.Whatdoweneedtoincludeinourrangeofservicespecifications?
8.Whatneedstogointoservicelevelagreementsandcontractstoensurehighqualityservicesdeliveredbyhighqualityproviders?
3.Do
1.Whatisinourjointpurchasingplan–includingadvertising,tenderingprocess,selectionprocessandcontracting?
2.Whatneedstobeinplaceforjointcommissioningofweightmanagementservicestobecarriedoutefficiently,forexample,capability,leadershipandaccountability?
3.Howdowemanagejointcommissioningofweightmanagementserviceswithpooledresources?
4.Havingsecuredourrangeofweightmanagementservices,whowillmanagethecontracts?
5.Whatisinplacetoqualityassureservices?
6.Whowillmanagerelationshipswithprovidersandhowwillthisbedone?
7.Isourapproachtocontractinghelpingtobuildadynamicanddiversemarketplaceandsupplyofeffectiveservices?
4.Review1.Areweachievingtheintendedoutcomesforindividualchildren,youngpeopleandfamilies?
2.Isthemonitoringofservicesandprocessesgivingusthefinancialandactivitydatawerequire,includingGP-basedservices?
3.Canwedemonstratevalueformoney?
4.Arethecommissionedservicessupportedbyrelevantpoliciesandguidance?
5.Howdoesproviderperformancematchuptoourcommissioningstrategy?
6.Isaworkforcetrainingplanforweightmanagementservicesbeingimplemented?
7.Isthecapacityoftheprovidermarketdevelopingandareweconfidentthatitissustainable,dynamicandabletomeetthediversityofdemands?
8.Arewesharingandusingalltherelevantinformationcollectively?
9.Whatchanges,ifany,dowethereforeneedtomaketoourprocessforjointplanningandcommissioningtoensurethebestoutcomesforchildren,youngpeopleandtheirfamilies?
TOO
LD12C
om
missio
nin
gw
eigh
tman
agem
entservices
153
154 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLD13Commissioningsocialmarketing 155
TOOLD13CommissioningsocialmarketingFor: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities
About: Thistoolprovidesdetailsonhowtocommissionasocialmarketingagency.Itprovidesachecklistforassessinganagencyandsampleinterviewquestionswithanswerswhichcanbeusedwheninterviewingsocialmarketers.
Purpose: Toprovidelocalareaswithinformationaboutthekeyissuesrelatingtoprocuringasocialmarketingagency.
Use: Shouldbeusedinplanningsocialmarketinginterventions.•
Shouldbeusedincommissioningsocialmarketingagencies.•
Canbeusedasanassessmenttoolwheninterviewingagencies.•
Resource: NationalSocialMarketingCentre(NSMC):www.nsms.org.uk
TOOLD13
Ifcommissionersdecidetoprocureasocialmarketingagencytosupporttheirprogramme,thentheyshouldensurethatthecorrectprocurementprocedureisputinplacewhenapproachingsocialmarketingagencies.(SeeToolD11–Guidetotheprocurementprocess.)
Thistoolprovidesanevaluationchecklistforassessingsocialmarketingagenciesandsomesampleinterviewquestions(withrobustresponses).ThesehavebeendevelopedbytheNationalSocialMarketingCentre(NSMC)inordertoassistlocalareasintheprocessofcommissioningasocialmarketingagency.
Assessingsocialmarketingagencies–achecklistEssentially,asocialmarketingagencytenderingforprogrammeworkshouldbeabletodemonstrate:
• aclearunderstandingofsocialmarketing
• experienceofsocialmarketing,especiallyinthehealthsector
• aclearapproachtoasocialmarketingcommission,basedupontheNationalBenchmarkCriteria201
• soundcompanyhistory
• adequatecapacity–suchaspersonnelandinfrastructure
• capabilityofdelivery
• financialcompetence.
156 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Toassessthesuitabilityofanagencytenderingforsocialmarketingworkmorecomprehensively,thefollowingchecklistcanbeusedbycommissioners.
Checklistforagency Yes No Unsure Action
Cantheagencydemonstrateaclearunderstandingoftheproject’sobjectivesandbroaderstrategicgoals?
Cantheagencyprovideexamplesofclearstrategicplanning,monitoringandevaluationofpastprojects?
Istheagencysuggestingclearindicatorstodemonstratereturnonyourinvestment?Thesemayincluderelevantmeasurestodemonstrateinfluenceonbehaviour,awareness,attitudes,orotherrelevantprocessorinterimmeasuressuchasevidenceofstakeholderengagement.
Cantheagencydemonstrateanabilitytounderstandyourresearchneeds?Havetheyinsistedthatallsecondarydatabeutilisedbeforeundertakingnewmarketresearchatlocallevel?
Cantheagencyprovideevidenceofgenuinestakeholderengagement,partnerships,andcollaborativedelivery?
Istheagencyproposingthatlocaldeliverystaffbeinvolvedinthedevelopmentandsupportoftheprogramme?
Hasanadequatebudgetbeenallocatedforeachstageoftheproposedsocialmarketingintervention?
Isthereevidencethattheagencycancustomiseasolutiontomeetaspecificchallengeratherthansimplyrepeatingasimilarapproachtheyhaveusedelsewhere?
Cantheagencydemonstrateanabilitytouseresearchtechniquestosegment,targetanddesigninterventionsthatmeettheneedsofdistincttargetaudiences?
Hastheagencyofferedpromotionalfreebies,materials,ordiscountsbeforedemonstratingaclearunderstandingofthestrategicobjectivesandthespecificneedsofthetargetaudiencetheprojecthopestoreach?
Istheagencyconsideringamulti-prongedapproachthatconsidersamixtureofinterventionstoenhancecustomerbenefitsorachievepolicyandenvironmentalobjectives?
Istheagencyclearabouttheconsequencesoffailingtodeliver(forexample,built-inpenaltyclauses)?
TOOLD13Commissioningsocialmarketing 157
SampleinterviewquestionsforinterviewingsocialmarketersTheNationalSocialMarketingCentrehasdevelopedeightquestionstoassistcommissionerswheninterviewingagenciesbiddingforsocialmarketingprojects.Examplesofrobustresponseshavealsobeengiven.TheNationalBenchmarkCriteria201canalsobeusedtohelpguidetheinterviewprocess.GototheNationalSocialMarketingCentrewebsiteatwww.nsms.org.uk
Question Answer
Explaintouswhatsocialmarketingisandhowitcanhelpusatalocallevel.
Informalterms,socialmarketinghasbeendefinedas‘thesystematicapplicationofmarketing,alongsideotherconceptsandtechniques,toachievespecificbehaviouralgoals,forasocialgood’.202Thisdefinitionhighlightsthesystematicnatureofsocialmarketing,whilealsoemphasisingitsbehaviouralfocusanditsprimaryconcernwitha‘socialgood’.
Socialmarketinghasbeenusedsuccessfullyinavarietyoflocalinterventions.[Atthispointacompetentcompanyshouldbeabletotalkaboutasocialmarketingcasestudy,anddiscusslessonslearntfromtheexample.Thecasestudymaybeinternational,astheBritishevidencebaseisstillinitsinfancy.]
Socialmarketingisastagedandsystematicprocess.Pleasetakemethroughthedifferentstagesofthesocialmarketingprocess.
Successfulsocialmarketingprogrammesreflectalogicalplanningprocess,whichcanbeusedatbothindividualandstrategicpolicydevelopmentlevels.Thetotalprocessplanningmodel(seewww.nsms.org.uk)isasimpleconceptualisationoftheprocess,whichinpracticecanbechallengingtoaction.Thekeystagesare:
scope:examineanddefinetheissue•
develop:testoutthepropositionandpre-test,refineandadjustit•
implement:commenceinterventions/campaign,and•
evaluate:impact,processandcostassessment.•
Theemphasisisplacedonthe‘scopingstage’ofthemodelanditsroleinestablishingclear,actionableandmeasurablebehaviourgoalstoensurefocuseddevelopmentacrosstherestoftheprocess.Althoughthemodelappearslinear,people’sneeds,wantsandmotivationschangeovertimesoitisimportantthatfollow-upisconductedtomakesuretheneedsoftheconsumersarestillbeingmetbytheintervention.
Howlongdoesthescopingtodevelopmentphaseusuallytake?
Itcandependonavarietyoffactors,suchaseaseofrecruitmentfromthetargetaudienceforthequalitativeresearch,etc.However,scopingdonethoroughlyusuallytakesbetweentwoandfourmonths.Thedevelopmentphaseusuallytakesaroundthesameamountoftime.However,again,thiscandependonvariousfactors–forexample,onhowmanytimestheinterventionneedstobepre-testedandrefinedbeforeitisreadytorollout.
Howinvolvedwilltheprimarycaretrust/strategichealthauthoritybeinthesocialmarketingprocess?
WehopethatthePCT/SHAwillbeheavilyinvolvedinthescopingandthedevelopmentphasesofthesocialmarketingprocess.Fromourexperiencelocalemployeessitonvastamountsofinvaluablelocalknowledge.Weattempttoharnessthisknowledgebyinterviewingkeystakeholdersduringthescopingphase.WealsohopethatthePCT/SHAwillwishtobeinvolvedinallfourstagesofthesocialmarketingprocess.
Talkmethroughwhatyouplantodointhescopingphaseandwhy.
Duringthescopingphasewewillmaptheissueweareaddressing(usingepidemiological/prevalencedata)andtrytobuildupadetailedpsychographicpictureofthetargetaudience–whattheircurrentbehaviouris,theirattitudes,values,etc.Thismappingexercisewillbecompletedusingsecondarydata(bothnationalandlocal).Wheretherearegapsintheexistingdata,thesewillbefilledbycollectingqualitativedataatthelocallevel.
Duringthescopingphasethefollowingactionswillalsobecompleted:areviewofpastinterventions–whathasworked/whatdidnotworknationallyandlocally;acompetitionanalysis;apolicyreview–howthetopicarea/targetaudiencefitsintothecurrentpoliticalclimate;audiencesegmentation;andinterviewswithkeystakeholders.
158 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Question Answer
Whatresearchmethodsdoyouthinkwouldbeapplicableforunderstandingthetargetaudience?
Itreallydependsonwhothetargetaudienceis.Oftenqualitativemethods,suchasfocusgroupsandindividualinterviews,ifperformedinarobustmanner,canprovideusefulinsight.However,sometimesthesecommonlyemployedmethodsarenotsuitableforcertainaudiences.Insomecases,usingethnographictechniquestocollectthedatamayprovemoreinsightful.(Ethnographyisamethodofobservinghumaninteractionsintheirsocial,physicalandcognitiveenvironments.)
Howwouldyouevaluatetheinterventionandatwhatstagesintheprocess?
Itisimportanttothinkaboutevaluationduringthescopingphaseoftheprocessandthataclearbehaviouralbaselineisidentifiedearlyon.Qualitativeresearchcanbeusedwhenundertakingaprocessevaluationwhichmightinvolvespeakingtomembersoftheprojectteam,stakeholdersanduserstoseehowtheinterventioniscurrentlydoing–withtheoptionofadaptationifneeded.Otherformsofevaluationcanincludequantitativeanalysislookingattheuptakeofaparticularservice,orhowsatisfiedcustomerswerewithit.Mediaevaluationisanotherformofassessingtheeffectivenessofcampaigns.Thiscaninvolveananalysisofpresscoverage.Budgetandtimepermitting,itmaybeadvantageoustorunacontrolgrouptocompareagainst,toassesstheeffectivenessofaparticularintervention.
Whatdoyouthinktheinterventionwillbe?
Untilwehaveconductedthescopingphase,itisnotpossibletoknowwhattheinterventionwillbeandhowmuchitwillcostexactly.However,itismostlikelythattheinterventionwillbemulti-facetedandbuildonexistinggoodservicesandworkthatiscurrentlybeingdoneinthelocalarea.
TOOLD14Monitoringandevaluation:aframework 159
TOOLD14Monitoringandevaluation:aframeworkFor: Commissionersinprimarycaretrusts(PCTs)andlocalauthorities•
Programmemanagers•
About: Thistoolprovidesaframeworkforevaluatingandmonitoringlocalinterventions.Itpresentsa12-stepguideonthekeyelementsofevaluation,anevaluationandmonitoringchecklist,andaglossaryofterms.
Purpose: Toprovidelocalareaswithanunderstandingofthebasicsofevaluatingandmonitoringinterventions.
Use: Shouldbeusedasaguidetoplanandimplementanevaluationandmonitoringframeworkforinterventionstotackleobesity.
Resource: Passporttoevaluation.203See:www.homeoffice.gov.uk
TOOLD14
Whenanevaluationofaninterventionisundertaken,itisimportantthatitis:
• planned
• organised,and
• hasclearobjectivesandmethodsforachievingthem.
Therearethreestagestothemonitoringandevaluationframework:
1 Pre-implementation(planning)
2 Implementation
3 Post-implementation.
Thediagramonthenextpageoutlinestheframework,withdetailedinformationprovidedonpages160-170.
160 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Aframeworkforevaluatingandmonitoringlocalinterventions
Step Two Establish outputs
Pre-implementation
Post-implementation
Step Three Establish performance indicators
and starting baseline
Step One Confirm objectives/
expected outcomes and outputs
Step Five Identify methods of
gathering data
Step Four Identify data to be collected
Step Six Formulate a timetable for
implementation
Step Seven Estimate the cost of
planned inputs
Implementation
Step Eight (Optional) Identify a comparable
area
Step Ten Monitor progress
Step Nine Implement intervention
and gather data
Step Eleven Analyse data
Step Twelve Report and disseminate
results
Pre-implementation(planning)StepOne:Confirmobjectives/expectedoutcomesandoutputs
Objectivesarethekeytoeverysuccessfulprogrammeandevaluation.Everyevaluationisaboutmeasuringwhethertheobjectiveshavebeenachieved.Beforestartingtheevaluation,localareasmustbeclearaboutwhattheobjectivesare.
Unless you have a clear idea about what the project is trying to achieve, you cannot measure whether or not it has been achieved.
AsimplewaytosetobjectivesistouseSMARTobjectives:
• Specific–Objectivesshouldspecifywhatyouwanttoachieve.
• Measureable–Youshouldbeabletomeasurewhetheryouaremeetingtheobjectivesornot.
• Achievable–Aretheobjectivesyouhavesetachievableandattainable?
• Realistic–Canyourealisticallyachievetheobjectiveswiththeresourcesyouhave?
• Time–Whendoyouwanttoachievethesetobjectives?
TOOLD14Monitoringandevaluation:aframework 161
TheNationalIndicatorsofsuccesscanguidelocalareasinestablishinginterventionoutcomes.SeeToolD5foralistofindicatorsrelevanttoobesity.
StepTwo:Establishoutputsfortheintervention
Outputsarethethingsthatneedtobeproducedordoneinordertoachievethedesiredobjectives/outcomes.Forexample,iftheinterventionistosetupalocalfootballclubtoincreasetheamountofphysicalactivityamongchildren,theoutputsmightbe:organisepublicityfortheclubinlocalschoolsandcommunities,employandtrainvolunteers,organisethelocationfortheclubandsoon.
StepThree:Establishperformanceindicatorsandstartingbaseline
Onceyourlocalareaisclearabouttheobjectivesandoutcomesoftheintervention,thenextstepistothinkabouthowtomeasuretheextenttowhichtheyhavebeenachieved.Performanceindicators(PIs)areameansbywhichyoucandothis.Theycanbequantitative,whichmeansthattheyusestatisticalinformationtomeasuretheeffectsofapieceofaction.Ortheycanbequalitative,whichmeansthattheymeasurethingssuchasfeelingsandperceptions.
Performanceindicatorscanuseanyinformation,fromanysource,thatshowswhetherobjectivesarebeingmet.ObesityprevalencefiguresarequantitativePIs–theyareadirectmeasureofthedegreeoftheprobleminyourarea.OtherPIs,suchasthosethatmeasureparents’perceptionsoftheirchild’sdiet,arequalitative.Ifanintervention’sobjectiveistoeducateparentsinthetargetclustersabouthealthyeating,qualitativePIsmustbeusedtomeasurethis.
Whenyouaredevelopingperformanceindicators,itisimportanttoestablishastartingbaselinefortheinterventionagainstwhichperformancewillbemeasured.Performanceindicatorsareakeypartofanymonitoringandevaluationframework,astheyenablethemeasurementofwhatactionshavebeenachieved.
Keypoints• Beclearaboutwhatyouaremeasuring.Havingaclearideaofwhatyouaretryingtoachieve
willhelpinselectingtherightindicators.Alwaysensurethatthedatarequiredareavailableandeasilycollected.
• Thinkaboutthecontext.Performanceindicatorsmayneedtotakeaccountofunderlyingtrends,ortheenvironmentinwhichtheinterventionisoperating.
• Performanceindicatorscanneverbeconclusiveproofthataprojectissuccessful;theycanonlyeverbeindicators.Thisisbecauseexternalfactors,whichhavenotbeenmeasured,canhaveanimpactonaninterventionwithoutalocalareabeingawareofthem.However,wellchosenindicatorsthatcomefromawiderangeofsourcesandillustratedifferentaspectsofaninterventioncanprovidegoodevidenceofitssuccess.
StepFour:Identifydatatobecollected
Thenextstepintheframeworkistodecidewhatdataneedtobecollectedtomeasuretheintervention’ssuccessagainsttheperformanceindicators.Itisimportanttocollecttherightinformation,attherighttimeandintherightformat.Somequestionstobeaskedatthebeginningare:
• Whatdataareneededtocalculatetheperformanceindicators?
Itisimportanttowritealistofthedatathatmightbeavailablealready,eglocalGPlists,healthinequalitiesdata,healthylifestylebehaviourdata,landusestatistics,indicesof
162 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
deprivation,NationalStatisticsSocio-economicClassification(NS-SeC)data,distancetravelledtoworkdata,andsoon.
• Howmuchdetailisneeded?
Thelevelofdatarequireddependsonwhatthedataaregoingtobeusedfor.Generallyspeaking,detaileddatahelptopinpointproblemsandprovideanaccuratepictureofwhathashappened,andhigherleveldataareusefulforshowinggeneraltrends.Collectingandanalysingdetaileddatacanbeexpensiveandtime-consuming,soplanaheadandonlycollectasmuchasisneeded.
• Whenandhowoftenaredataneeded?
Itisimportanttohavedataatthestartoftheinterventionforcomparisonpurposesandattheendsothatthelong-termeffectscanbemeasured.
• Whatformatarethedatarequiredin?
ItisimportanttorememberthatdatacomeindifferentformsbecauseofdifferentITpackages.Ifthedataarenotinanaccessibleformat,thismayincurextraworktogetitintherightformat.Thinkabouttheextraworkandcostsinvolved.
• Wheredothedatacomefrom?
Datacancomefrommanydifferentsources,egpartnerorganisations,GPsurgeries,NationalStatistics,voluntaryorganisations,censusinformation,andexistingperceptionsurveys.
• Arethedataavailable,accurateandreliable?
– Availability:Ifthedataarenotavailable,localareasmayneedtocollectitthemselves.Somequestionstoaskare:Arethedatavitaltotheevaluation?Arethetimeandcostworthwhile?Willresourceswillavailable?(SeeStepFive–Identifymethodsofgatheringdata.)
– Accuracy:Thisisvital.Someimportantquestionstoaskare:Isthesampleofpopulationthedataweretakenfromrepresentativeofthetargetpopulation?Arethedatarecord-edcorrectly?Didtheanalyticalpackageusedproduceanaccuratepictureoftherawdata?Havedatabeencollectedobjectivelyorhasthecollectorintroducedbias?
– Reliability:Somequestionstoaskare:Arethedataavailableatthetimesrequired?Arethedatameasuringthesameorasimilarthingtowhatyouareevaluating?Arethedatacurrent?
StepFive:Identifymethodsofgatheringdata
Ifdataarenotavailableorarenotofsufficientqualityorrelevance,localareasmayneedtocollectdatathemselves.Aselectionofmethodsandtechniquesforcollectingdataisshowninthetableonthenextpage.Theseareprovidedtogivelocalareasanideaofwhatmethodsareavailabletothem.
TOOLD14Monitoringandevaluation:aframework 163
Methodsofgatheringdata
Method Typicaltechniques
Typicalcontextofuse Prosandcons
Surveys Interviews
Mapping
Questionnaires
All-purpose.
Operational:mappinginteractionsbetweenactors.
Summative:usersatisfaction;userimpacts.
Learning:surveysofparticipants’experiences.
Easytocarryout.
Canproducelargenumbersofresponses.
Limiteddepthinquestionnairesurveys(moredepthininterviewsandfocusgroups).
Goodinoutcome-linkedevaluations.
Fieldstudies Observation
Taskanalysis
Criticalincidents
Casestudies
Diaries
All-purpose.
Summative:howusersrespondtointervention.
Operational:howinstitutionalstructuresoperate.
Learning:retrospectiveanalysisofwhathappened.
Comparisonofdifferentsettings.
In-depthdata,givinginsightsonsocialconstructionofintervention.
Time-consumingandskill-intensive.
Difficulttoutiliseinoutcome-linkedevaluations.
Modelling Simulations
Softsystems
Usuallyoperationalandlearningmodes.
Assessingorganisationalstructure,dynamicsandchange.
Cost-benefitanalysis.
Optimisationofmanagementfunctions.
Canpredictpossibleoutcomestoadjustmentsinuncertainandcomplexcontexts.
Sometimeshighlyabstracted.Requireshighlevelofskill.
Interpretative Contentanalysis Allpurpose.
Usedinoperational(analysisofmeetingsetc),summative(analysisofmaterialsorreports)andlearning(deconstructionofprogrammereports).
Deconstructionof‘hidden’meaningsandagendas.
Richinterpretationofphenomena.
Inherentriskofideologicalbias.
Critical Discourseanalysis Moretheoretical(usuallycriticaltheory)basedthancontentanalysis.Typicallyusedtoassessstructure,coherenceandvalueoflarge-scaleprogrammesforlearningpurposes.
Asforinterpretativemethods,butemphasisesestablishmentofgeneralisablelaws.
Perceivedtobeunscientific,especiallybyexperimentalistpractitioners.
Participatory Actionresearch Typicallyindevelopmentalevaluationmode.
Encouragesrealengagementofsubjectsofintervention.Goodinhighlyuncertaincontexts.
Evaluatorssometimesgettooinvolvedininterventionitself.
164 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Thetablebelowsummarisesthebroadtypesofinterventionsusedintacklingobesity,andgivessomeexamplesofevaluationquestionsandevaluationmethodsthatwouldbeassociatedwithaparticulartypeofintervention.
Typeofinitiative Evaluationquestions Evaluationmethods
Awareness-raisingcampaigns
Whichclustergroup(s)changedtheirattitudestowardshealthyeatingandinwhatways?
Howmanyarticleswerepublishedinthelocalmediaandwhatwasthecontent?
Cross-sectionalsurveys
Focusgroups
Contentanalysisofmedia
Publicparticipation Howcanmorepeoplebecomephysicallyactive?
ShouldGPsbeprovidingmoreadvice?
Focusgroups
Questionnairesurveys
Interactiveevents(outreach,theatre,demonstrations)
Howmanyandwhattypeofpeopleattendedtheevent?
Howengagedwastheaudience?
Inwhatwaysdidparticipants’viewsofobesitychange?
Exitpolls
Quotasample
Analysisofattendancerecords
Observation
Interviews
Educationandtraining
Howmanyhealthcareprofessionalsattendedobesitytrainingcourses?
Howmanyoverweightandobesepatientswereprovidedwithadvicebyhealthcareprofessionals?
Statisticalanalysis
Questionnairesurveys
Interviews
Ongoingprofile-raising
Towhatdegreeandinwhatwayisobesitycoveredinpopularmedia?
Whatcontributiondoesprofile-raisinginvestmentmaketoobesitypolicyandimprovingtheknowledgebase?
Contentanalysisofsampleofnewspapers
Citationanalysisofacademicjournals
Targetedaccessandinclusionactions
Areminorityethnicgroupsmorereceptivetoadviceonhealthyeatingorphysicalactivitythanthegeneralpopulation?
Hasthishadaneffectonthenumberofobesepeopleinthetargetclustergroup?
Statisticalanalysis
Questionnairesurveys
Policyactions Hastheimplementationoftheconsultationexercisecreatednewpartnerships?
Focusgroups
Documentation
Analysis
Horizontalandsupportingactions
HowmanyschoolsaretakingpartintheNationalChildMeasurementProgramme?
Statisticalsurveys
Documentation
Analysis
Operationalreviews Whichpublicengagementapproachismostcost-effective?
Processevaluation
Cost-effectiveness
Analysis
KeypointAnalysis requirements: Bearinmindthattheselectionofparticularmethodsandtechniquesalsoimpliesusingtheappropriatetypeofdataanalysis(whichhasitsownresourceandskillsimplications).Ingeneral,largedatasets(suchasthosederivedfromsurveys)normallyneedstatisticalsoftwaresystemssuchasSPSS.Interpretativedata(derived,forexample,fromcontentanalysis)canbeanalysedwithproprietaryqualitativesoftwarepackagessuchasNVivo.Inanycase,aclearcodingframetoanalysesuchdataisnecessary.
TOOLD14Monitoringandevaluation:aframework 165
StepSix:Formulateatimetableforimplementation
Inorderthattheprogrammerunsassmoothlyaspossibleandmeetsdeadlines,localareasshouldputtogetheratimetableofimplementation.Asaminimum,thetimetableshould:
• listallthekeystagesofworkincludingmilestonesforkeyactivities,egfootballclubtobesetupby(date)
• showthedatesbywhicheachstageneedstobecompleted
• showwhatresourcesareneededforeachstage
• showwhoneedstobeinvolvedateachstage
• includemilestonesforregularreviewoftheinputsandoutputs,and
• beregularlyupdatedtoreflectanychanges.
Anexampleofatimetablegridforimplementationispresentedbelow:
No. Intervention Leadofficer
Inputs Outputs Outcome Baseline Performancemeasures
Timetable
1
2
3
StepSeven:Estimatethecostsofplannedinputs
Estimatingthecostsofplannedinputsatthebeginningofandduringtheinterventionwillenableanalysisofthecost-effectivenessoftheintervention.Someexamplesofinputcostsarestafftime,publicitycosts,equipmentandtransportcosts,anduseofleisurecentre.Itisimportanttoreviewinputcostsduringtheinterventiontoensurethatanaccurateanalysisofcost-effectivenessisundertaken.
StepEight(Optional):Identifyacomparablearea
Comparingchangesintheinterventionareawithwhatishappeninginanotherareaisusefulinhelpingtoestablishwhetheranychangesarearesultoftheinterventionorcouldhavehappenedanyway.Iflocalareasundertakethisstep,theyshouldidentifyacomparisonarea(similarinsizeandcharacteristics)notcoveredbytheinterventionsothatacomparisonatthepost-implementationstagecanbeundertaken.Itisimportanttolookatthewiderareaaroundtheinterventionforcomparison.
ImplementationStepNine:Implementinterventionandgatherdata
Thefollowingaresomeimportantaspectstoconsiderfortheimplementationstepoftheevaluationframework.
• Contingencyplanning:Aswithplanninganevaluationingeneral,anticipatingadjustmentsandchangestodatacollectionistobeencouraged.Itisusefultohavea‘planB’withalternativearrangementsfordatacollectionshoulditbecomeapparentthat,forexample,time,skillsoroperationalconstraintsarelikelytoconspireagainstplannedactivities.
166 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
• Triangulation:Theevaluationshouldalreadyhavebeendesignedwithregardtotheresourcerequirementsofthechoicesspecifiedandwiththe‘insurance’ofcontingencyplanninginmind.Itisalsoworthnotingthat‘insurance’alsohasamethodologicalcomponent:triangulation.Triangulationmeansutilisingdifferentmethodstocovertheevaluationfromdifferentangles(forexample,assessingtheeffectivenessoforganisationalstructuresofaninterventionfromthepointsofviewofdifferentactors).
• Operationalrules:Theevaluationshouldbeabletotrack(andhavearecordof):whatdataarebeingcollected,whocollectsthedata,andinwhatformandlocationthedataarestored.Clearrulesaboutoperationalproceduresshouldbesetoutanddistributedtoallthoseinvolvedindatacollectionandanalysis.Similarly,itisusefultodrawup‘evaluationcontracts’withotherstakeholders,especiallythosesupplyinginformation.Thesecontractsshouldspecifytheobjectivesoftheevaluationandanyguaranteesthatapply(forexample,onconfidentiality).
StepTen:Monitorprogress
Makeanynecessaryadjustmentstoimplementation,structuresandprocessesusingthepre-implementationsteps.
• Monitorinputs.
• Monitoroutputandoutcomedatausingtheperformanceindicatorsidentified.
• Monitorkeymilestones.
• Considerwhetherthereareanycoretrackingdatathatdonotrelatedirectlytotheinputs,milestones,outputsoroutcomesthatitmayalsobeusefultocollectandmonitor.
• Allowtheresultsofthemonitoringtodictateanychangestotheongoingimplementationoftheintervention.
Anexampleofmonitoringtheinterventionwouldbe:Keeparecordoftheresourcesusedinrunningtheintervention,egnumberofstaff,whothestaffare,howmanyhoursstaffwork,andcostsincurredbytheintervention.
Once a framework is established, those running the intervention monitor the data and feed back the relevant information to the partnership.
Post-implementationStepEleven:Analysedata
Beforeanalysingdata,localareasneedtoaskthefollowingquestions:
• Arethedataintherightformattoapplytotheperformanceindicators?
• Aretherein-housefacilitiesforanalysingthedataordotheyneedtobeboughtin?
• Whatmethodsofanalysisarethere?
KeypointItisimportantthatdataanalysisisundertakenbyanexpertinstatisticalanalysis.
Oncetheinterventionhasbeenimplementedanddatacollectedforevaluation,localareasshould:
• compareoutcomedatawiththebaseline
• calculatethecost-effectivenessoftheintervention
TOOLD14Monitoringandevaluation:aframework 167
• calculatethecostsoftheintervention,includinganyinputsmonitoredduringtheintervention
• examinecomparableareas
• examinetrendsinthewiderareaandanysimilarcomparisonareatoassesstheimpactoftheintervention.
StepTwelve:Reportanddisseminateresults
Thisstepshouldbeacontinuationoftheevaluationprocess.Inthissense,itisimportanttogivethoseinvolvedintheinterventionbeingevaluated,aswellasintheevaluationitself,andprojectparticipantsasenseofclosureoftheprojectandtheevaluation,whereappropriate,byrunningconcludingfeedbackevents.
Moregenerally,itisimportanttothereputation,valueandimpactoftheevaluationtogivefinalformalfeedbacktoeverybodywhohascontributedinsomewaytotheevaluation(forexample,bysendingthemacopyofthereportorinvitingthemtoafinalfeedbackevent).
Disseminationshouldnotberestrictedtothecirculationofafinalreport–especiallyinthecaseofdevelopmentalprocessevaluation.Differentstakeholdersmayrequiredifferentcommunicationapproaches.Thesemightinclude:
• shortsummariesoftheevaluation,tailoredtodifferentaudiences
• journalarticlesforotherresearchers
• topicalarticlesinthe‘trade’press
• workshopsforspecificaudiences
• feedbackseminarsforkeydecisionmakers.
The results from the evaluation should always be fed back into the future planning of interventions.
168 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Monitoringandevaluationframeworkchecklist
Yes No Action
Pre-implementation
StepOne:Confirmobjectives/expectedoutcomesandoutputs
HaveSMARTobjectivesbeendevelopedtoshowwhattheinterventionistryingtoachieve?
Areoutcomesinplacetoshowwhatthefinalachievementoftheinterventionwillbe?(Thisshouldrelatetotheoverallaim.)
StepTwo:Establishoutputsfortheintervention
Haveoutputsbeenestablishedtoshowwhattasksarebeingcarriedouttoachievetheoutcomes(egestablishingabaseline,producingquarterlyreports)?
StepThree:Establishperformanceindicatorsandstartingbaseline
Haveperformanceindicatorsbeenestablished,takingintoaccountdataavailability,surroundingenvironmentandunderlyingtrendsoflocalarea?
Hasastartingbaselinebeenestablished?
StepFour:Identifydatatobecollected
Hasthesourceofdatabeenidentifiedtocalculatetheperformanceindicators?
Dothedataneedtobecollected?
Havethedatabeencheckedforaccuracyandreliability?
Isextraworkrequiredtoformatthedataforanalysis?
StepFive:Identifymethodsofgatheringdata
Havethemethodsofdatacollectionbeenagreed?
Haveappropriateanalyticalmethodsbeenagreed?
Havestatisticalspecialistsbeenemployedtocompletetheanalysis?
StepSix:Formulateatimetableforimplementation
Hasanimplementationtimetablebeenformulatedtoensuretheinterventionrunsandfinishesontime?
Havemilestonesforkeyactivitiesoftheinterventionbeenestablished?
Havemilestonesforregularreviewoftheinputsandoutputsbeenestablished?
StepSeven:Estimatethecostsofplannedinputs
Havetheinputcostsbeenestimated,toenabletheanalysisofcost-effectivenessoftheintervention?
StepEight(Optional):Identifyacomparablearea
Hasacomparableareabeenidentifiedtoensureanychangesarearesultoftheintervention?
TOOLD14Monitoringandevaluation:aframework 169
Yes No Action
Implementation
StepNine:Implementinterventionandgatherdata
Hasacontingencyplanbeenorganised?
Haveoperationalrulesbeenwrittenandsenttoallpartners?
StepTen:Monitorprogress
Aretheinputsbeingmonitored?
Aretheoutputandoutcomedatabeingmonitored?
Arethekeymilestonesbeingmonitored?
Post-implementation
StepEleven:Analysedata
Havetheoutcomedatabeencomparedwiththebaseline?
Hasthecost-effectivenessoftheinterventionbeencalculated?
Havethecostsoftheintervention,includinganyinputsmonitoredduringtheintervention,beencalculated?
Hasthecomparableareabeenexamined?
Havethetrendsinthewiderareaandanysimilarcomparisonareabeenexamined,toassesstheimpactoftheintervention?
StepTwelve:Reportanddisseminateresults
Havetheresultsbeendisseminatedtostakeholdersinanappropriateform?
Havetheresultsbeenfedbackintothefutureplanningofinterventions?
170 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
GlossaryAim Asimplestatementthatsetsoutthepurposeoftheintervention.
Baseline Thesituationatthestartofanintervention,beforeanypreventiveworkhasbeencarriedout.Theinformationthathelpstodefinethenatureandextentoftheproblem.
Evaluation Evaluationistheprocessofassessing,ataparticularpointintime,whetherornotparticularinterventionsareachievingorhaveachievedtheirobjectives.Evaluationisaboutmeasuringtheoutcomesofaparticularintervention.Anoutcomeistheoverallresultofanintervention.Evaluationcanalsobeusedtomeasurewhethertheprocessesusedinaninterventionareworkingproperly.Thisiscalledprocessevaluationanditmeasurestheinputsandoutputsofanintervention.
Input Theinputstoaninterventionaretheresourcesusedtocarryoutthework.Resourcescanbefinancial,materialorhuman.
Milestones Keypointsduringthelifeofanintervention.Theyaredecidedattheplanningstageandcanbetime-basedorevent-based.
Monitoring Theprocessofcontinuallyassessingwhetherornotparticularinterventionsareachievingorhaveachievedtheirobjectives.Monitoringisalsousedtocheckwhethertheprocessesbeingusedareworkingeffectively.Monitoringiscarriedoutthroughoutthelifeofanintervention,whileevaluationisonlycarriedoutatspecificpointsintime.
Objective Astatementthatdescribessomethingyouwanttoachieve–adesiredoutcomeofaninterventionoranevaluationstudy.
Outcome Theoutcomeofaninterventionistheoverallresultofapplyingtheinputsandachievingtheoutputs.
Output Apieceofworkproducedforanintervention.Anoutputisnotnecessarilythefinalpurposeofanintervention.Outputsareusuallythingsthatneedtobedoneinordertoproducethedesiredresult.Duringthelifeofanintervention,outputsaremonitoredtomakesuretheyarebeingachievedontimeandwiththeresourcesavailable.
Performanceindicator(PI)
Themeansbywhichyouknowwhetherornotyouhaveachievedyourtargetsandobjectives.APIisanyinformationthatindicateswhetheraparticularobjectivehasbeenmet.YoucanalsousePIsthatmeasurewhethertheinputsandoutputsinaninterventionareworking.Forexample,ifaprojectisusingpublicmeetingsasoneofitsinputs,aPIcouldbeusedtomeasurethenumberofmeetingsheldandthenumberofpeoplewhoattendeachmeeting.ThesekindofPIsarecalledprocessPIs.
Processevaluation
Processevaluationmeasurestheinputsandoutputsofaproject.
Programme Aprogrammeisagrouporcollectionofinterventionsdesignedtoachieveparticularobjectives.Theinterventionsinaprogrammeareusuallylinkedtoaparticularproblemoraparticularareaandfallunderacommonaim.
QualitativePI PIsthatmeasurequalities,whichareusuallyquiteintangiblethings,suchastheperceptionsandfeelingsofindividualsandgroups.
QuantitativePI PIsthatmeasuretangiblethings,suchasthenumberofobesechildreninanarea.
TOOLD15Usefulresources 171
TOOLD15UsefulresourcesFor: Allpartnersinvolvedinplanningandimplementinganobesitystrategy
About: Thistoolprovidesalistoftrainingprogrammes,publications,usefulorganisationsandwebsitesandtoolsforhealthcareprofessionals.
Purpose: Toprovidelocalareaswiththeresourcestobuildlocalcapability.
Use: Canbeusedforkeepinguptodatewiththelatestdevelopmentsin•obesity.
Canbeusedtogathermoredetailedinformationonscienceandpolicy.•
Resource: SeetheOrganisationsandwebsitessectionofthistoolonpage185.
TOOLD15
NationalHeartForume-NewsBriefingServiceTheNationalHeartForume-NewsBriefingServiceprovidessubscriberswithelectronicinformationonthelatestreportsanddevelopmentsrelevanttothepreventionofavoidablechronicdiseasesincludingcardiovasculardiseases,cancer,diabetesandrelatedconditionssuchasobesity.
Itcoversabroadrangeoftopicsincludingnutrition,physicalactivity,alcohol,cancer,obesity,tobaccocontrol,stroke,diabetes,hypertension,childpovertyandhealthinequalities.
Theservicecontainsdetailsofcurrentmediareports,trainingcourses,consultations,policydevelopment,campaigns,careeropportunities,latestpublichealthguidance,newresourcesandforthcomingevents.
Itisanessentialinformationsourceforallpolicymakers,strategichealthauthorities,localauthorities,researchers,publichealthandprimarycareprofessionalsandotherswithaninterestindiseasepreventionandhealthpromotion.
Tosubscribe
Thee-NewsBriefingServiceisFREEbye-maileitherthreetimesaweek(Monday,WednesdayandFriday)oronceaweek(Wednesdayonly).Youcansubscribebyemailingbriefings@heartforum.org.uk.Inthesubjectheading,requesteither“e-NewsBriefingService–weekly”or“e-NewsBriefingService–3xperweek”.
FurtherinformationonthisserviceandarchivedversionsoftheWeeklye-Newsbriefingscanbefoundatwww.heartforum.org.uk/News_Media_eNewsbrief.aspx
Promotionopportunity
TheNationalHeartForumalsoencouragesyoutotakeadvantageofthisfreeresourcetopromoteyourorganisation’sactivitiesbyforwardinganypressreleases,newresourceinformationorforthcomingeventstobriefings@heartforum.org.uk
172 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
TrainingprogrammesObesitytrainingcoursesforprimarycare
Producedby:DietitiansinObesityManagementDOMUK,NationalObesityForum(NOF)andTheAssociationfortheStudyofObesity(ASO)(2005)Availableat:domuk.org
Thisisatrainingdirectoryforprimarycaretrusts(PCTs)togiveanoverviewofthedifferenttypesoftrainingcoursesavailableforobesitypreventionandmanagement.ThiscanprovideastartingpointforPCTs.Thisdirectoryiscurrentlybeingupdated.ThenewversionwillbeavailablebySpring2009.
Obesity:Aguidetopreventionandmanagement–inassociationwithNICE
Developedby:BMJLearningincollaborationwiththeNationalInstituteforHealthandClinicalExcellence(NICE)Availableat:learning.bmj.com
ThismodulehasbeendesignedtotrainGPsandotherhealthcareprofessionals,onthefollowing:
• BMIandothermeasuresofadiposity
• whatlevelofadviceorinterventiontousewithapatient,dependingontheirBMI,waistcircumferenceandco-morbidities
• howtoexploreapatient’sreadinesstochange
• advicetopatientsondiet,physicalactivity,andcommunity-basedinterventions
• whentorefertoaspecialist.
Themoduleisonlineandtakesaboutanhourtocomplete.
ExpertPatientsProgramme(forpatients)
Establishedby:DepartmentofHealth(In2007,theEPPwasestablishedasaCommunityInterestCompanytoincreasethecapacityofcourseplaces)Toaccesscoursedetails:www.expertpatients.co.uk
TheExpertPatientsProgramme(EPP)isanationalNHS-basedself-managementtrainingprogrammewhichprovidesopportunitiesforpeoplewholivewithlong-termconditionstodevelopnewskillstomanagetheirconditionbetteronaday-to-daybasis.Forexample,intermsoftacklingoverweightandobesity,patientswithdiabetesorheartdiseasecanlearnhowtostartandmaintainanappropriateexerciseorphysicalactivityprogramme.Trainingprogrammesareavailableacrossthecountry.
TOOLD15Usefulresources 173
PublicationsPrevalenceandtrendsofoverweightandobesity
HealthSurveyforEnglandHealthSurveyforEngland2006.Volume1:CardiovasculardiseaseandriskfactorsinadultsRCraigandJMindell(eds.)(2008).London:TheInformationCentreforHealthandSocialCare.Availablefrom:www.ic.nhs.uk
HealthSurveyforEngland2006.Volume2:ObesityandotherriskfactorsinchildrenRCraigandJMindell(eds.)(2008).London:TheInformationCentreforHealthandSocialCare.Availablefrom:www.ic.nhs.uk
HealthSurveyforEngland2005:Updatingoftrendtablestoinclude2005dataTheInformationCentreforHealthandSocialCare(2006).London:TheInformationCentreforHealthandSocialCare.Availablefrom:www.ic.nhs.uk
HealthSurveyforEngland2004.Volume1:ThehealthofminorityethnicgroupsTheInformationCentreforHealthandSocialCare(2006).London:TheInformationCentreforHealthandSocialCare.Availablefrom:www.ic.nhs.uk
HealthSurveyforEngland2003.Volume2:RiskfactorsforcardiovasculardiseaseKSprostonandPPrimatesta(eds.)(2004).London:TSO.Availablefrom:www.dh.gov.uk
HealthSurveyforEngland2002:ThehealthofchildrenandyoungpeopleKSprostonandPPrimatesta(eds.)(2003).London:TSO.Availablefrom:www.archive2.official-documents.co.uk
ForesightpublicationsForesighttacklingobesities:Futurechoices–projectreport,2ndeditionBButland,SJebb,PKopelman,KMcPherson,SThomas,JMardellandVParry(2007).London:DepartmentforInnovation,UniversitiesandSkills.Availablefrom:www.foresight.gov.uk
Modellingfuturetrendsinobesityandtheimpactonhealth.Foresighttacklingobesities:Futurechoices,2ndeditionKMcPherson,TMarshandMBrown(2007).London:DepartmentforInnovation,UniversitiesandSkills.Availablefrom:www.foresight.gov.uk
174 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
OtherForecastingobesityto2010PZaninotto,HWardle,EStamatakis,JMindellandJHead(2006).London:JointHealthSurveysUnit.Availablefrom:www.dh.gov.uk
Obesityamongchildrenunder11DJotangia,AMoody,EStamatakisandHWardle(2005).London:NationalCentreforSocialResearch,DepartmentofEpidemiologyandPublicHealthattheRoyalFreeandUniversityCollegeMedicalSchool.Availablefrom:www.dh.gov.uk
NationalChildMeasurementProgramme:2006/07schoolyear,headlineresultsTheInformationCentre(2008).London:TheInformationCentre.Availablefrom:www.ic.nhs.uk
PCOlevelmodelbasedestimatesofobesity(adults)TheInformationCentre(2008).London:TheInformationCentre.Availablefrom:www.ic.nhs.uk
Storingupproblems.ThemedicalcaseforaslimmernationWorkingPartyoftheRoyalCollegeofPhysiciansofLondon,RoyalCollegeofPaediatricsandChildHealth,andFacultyofPublicHealth(2004).London:RoyalCollegeofPhysiciansofLondon.
Thehealthrisksofoverweightandobesity,andthehealthbenefitsoflosingexcessweight
Foresighttacklingobesities:Futurechoices–projectreport,2ndeditionBButland,SJebb,PKopelman,KMcPherson,SThomas,JMardellandVParry(2007).London:DepartmentforInnovation,UniversitiesandSkills.Availablefrom:www.foresight.gov.uk
Obesity:Guidanceontheprevention,identification,assessmentandmanagementofoverweightandobesityinadultsandchildren.NICEclinicalguideline43NationalInstituteforHealthandClinicalExcellence(NICE)(2006).London:NICE.Availablefrom:www.nice.org.uk
Storingupproblems:ThemedicalcaseforaslimmernationWorkingPartyoftheRoyalCollegeofPhysiciansofLondon,RoyalCollegeofPaediatricsandChildHealth,andFacultyofPublicHealth(2004).London:RoyalCollegeofPhysiciansofLondon.
TacklingobesityinEnglandNationalAuditOffice(2001).London:TSO.Availablefrom:www.nao.org.uk
TOOLD15Usefulresources 175
Obesity:Preventingandmanagingtheglobalepidemic.ReportofaWHOconsultation.TechnicalReportSeries894(3)WorldHealthOrganization(2000).Geneva:WHO.
ObesityinScotland.Integratingpreventionwithweightmanagement.ANationalClinicalGuidelinerecommendedforuseinScotland(Underreview)ScottishIntercollegiateGuidelinesNetwork(1996).Edinburgh:SIGN.Availablefrom:www.sign.ac.uk
NationalObesityForumtrainingresourceforhealthprofessionalsNationalObesityForum.London:NationalObesityForum.Availablefrom:www.nationalobesityforum.org.uk
Theeconomiccostsofoverweightandobesity
EconomiccostsofobesityandthecaseforgovernmentinterventionBMcCormackandIStone(2007).ObesityReviews;8(s1):161-164.Availablefrom:www.foresight.gov.uk
Obesity:CostingtemplateandObesity:CostingreportNationalInstituteforHealthandClinicalExcellence(NICE)(2006).London:NICE.Availablefrom:www.nice.org.uk
SeealsoForesight publicationsonpage173.
Causesofoverweightandobesity
Foresighttacklingobesities:Futurechoices–projectreport,2ndeditionBButland,SJebb,PKopelman,KMcPherson,SThomas,JMardellandVParry(2007).London:DepartmentforInnovation,UniversitiesandSkills.Availablefrom:www.foresight.gov.uk
Foresighttacklingobesities:Futurechoices–obesitysystematlasIPVandenbroeck,JGoossens,MClemens(2007).London:DepartmentforInnovation,UniversitiesandSkills.Availablefrom:www.foresight.gov.uk
Preventingchronicdisease:Avitalinvestment.WHOglobalreportWorldHealthOrganization(2005).Geneva:WorldHealthOrganization.Availablefrom:www.who.int
Storingupproblems:ThemedicalcaseforaslimmernationWorkingPartyoftheRoyalCollegeofPhysiciansofLondon,RoyalCollegeofPaediatricsandChildHealth,andFacultyofPublicHealth(2004).London:RoyalCollegeofPhysiciansofLondon.
176 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Governmentactiononoverweightandobesity
KeypublicationsHealthyWeight,HealthyLives:Across-governmentstrategyforEnglandCross-GovernmentObesityUnit(2008).London:DepartmentofHealthandDepartmentforChildren,SchoolsandFamilies.Availablefrom:www.dh.gov.uk
HealthyWeight,HealthyLives:GuidanceforlocalareasCross-GovernmentObesityUnit(2008).London:DepartmentofHealthandDepartmentforChildren,SchoolsandFamilies.Availablefrom:www.dh.gov.uk
SeealsoForesight publicationsonpage173andChildren: Healthy growth and healthy weightbelow.
Children:Healthygrowthandhealthyweight
TheChildHealthPromotionProgramme:PregnancyandthefirstfiveyearsoflifeSShribmanandKBillingham(2008).London:DepartmentofHealthandDepartmentforChildren,SchoolsandFamilies.Availablefrom:www.dh.gov.uk
Improvingthenutritionofpregnantandbreastfeedingmothersandchildreninlow-incomehouseholds.NICEpublichealthguidance11NationalInstituteforHealthandClinicalExcellence(NICE)(2008).London:NICE.Availablefrom:www.nice.org.uk
StatutoryFrameworkfortheEarlyYearsFoundationStage.Settingthestandardsforlearning,developmentandcareforchildrenfrombirthtofiveDepartmentforChildren,SchoolsandFamilies(2008).London:DepartmentforChildren,SchoolsandFamilies.Availablefrom:www.standards.dfes.gov.uk
PracticeguidancefortheEarlyYearsFoundationStage.Settingthestandardsforlearning,developmentandcareforchildrenfrombirthtofiveDepartmentforChildren,SchoolsandFamilies(2008).London:DepartmentforChildren,SchoolsandFamilies.Availablefrom:www.standards.dfes.gov.uk
Eatingwellforunder-5sinchildcare.PracticalandnutritionalguidelinesHCrawley(2006).StAustell:CarolineWalkerTrust.Availablefrom:www.cwt.org.uk
TheNationalChildMeasurementProgramme.GuidanceforPCTs:2008-09schoolyearCross-GovernmentObesityTeam(2008).London:DepartmentofHealthandDepartmentforChildren,SchoolsandFamilies.Availablefrom:www.dh.gov.uk
TOOLD15Usefulresources 177
NationalChildMeasurementProgramme:2006/07schoolyear,headlineresultsTheInformationCentre(2008).London:TheInformationCentre.Availablefrom:www.ic.nhs.uk
Tacklingchildobesity–firststepsTheAuditCommission,theHealthcareCommissionandtheNationalAuditOffice(2006).London:TheStationeryOffice.Availablefrom:www.nao.org.uk
Eatingwellatschool.NutritionalandpracticalguidelinesHCrawley,onbehalfoftheCarolineWalkerTrustandtheNationalHeartForum(2005).TheCarolineWalkerTrust.Fordetailssee:www.cwt.org.uk
FoodinSchoolstoolkitDepartmentofHealth(2005).London:DepartmentofHealth.Availablefrom:www.foodinschools.org
ObesityguidanceforhealthyschoolscoordinatorsandtheirpartnersDepartmentofHealth(2007).London:DepartmentofHealth.Availablefrom:www.dh.gov.uk
Preventingchildhoodobesity:HealthinthebalanceInstituteofMedicineoftheNationalAcademies(2005).WashingtonDC:InstituteofMedicineoftheNationalAcademies.Availablefrom:www.nap.edu
Towardsagenerationfreefromcoronaryheartdisease:Policyactionforchildren’sandyoungpeople’shealthandwell-beingNationalHeartForum(2002).London:NationalHeartForum.
SeealsoChoosing interventionsonpage182.
Promotinghealthierfoodchoices
Choosingabetterdiet:AfoodandhealthactionplanDepartmentofHealth(2005).London:DepartmentofHealth.Availablefrom:www.dh.gov.uk
Familyfoodin2006.ANationalStatisticspublicationbyDefraDepartmentforEnvironment,FoodandRuralAffairs(2008).London:TSO.Availablefrom:statistics.defra.gov.uk
Familyspending.2007editionEDunn(2007).London:OfficeforNationalStatistics.Availablefrom:statistics.defra.gov.uk
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SeealsoChoosing interventionsonpage182.
Buildingphysicalactivityintoourlives
Atleastfiveaweek:Evidenceontheimpactofphysicalactivityanditsrelationshiptohealth.AreportfromtheChiefMedicalOfficerDepartmentofHealth(2004).London:DepartmentofHealth.Availablefrom:www.dh.gov.uk
Buildinghealth:Creatingandenhancingplacesforhealthy,activelives:Whatneedstobedone?NationalHeartForum,LivingStreets,CABE(2007).London:NationalHeartForum.Availablefrom:www.heartforum.org.uk
Buildinghealth:Creatingandenhancingplacesforhealthy,activelives.BlueprintforactionNationalHeartForum,LivingStreets,CABE(2007).London:NationalHeartForum.Availablefrom:www.heartforum.org.uk
NationalTravelSurvey:2007DepartmentforTransport(2007).London:DepartmentforTransport.Availablefrom:www.dft.gov.uk
Promotingandcreatingbuiltornaturalenvironmentsthatencourageandsupportphysicalactivity.NICEpublichealthguidance8NationalInstituteforHealthandClinicalExcellence(NICE)(2008).London:NICE.Availablefrom:www.nice.org.uk
SeealsoChoosing interventionsonpage182.
Creatingincentivesforbetterhealth
Workingforahealthiertomorrow.DameCarolBlack’sreviewofthehealthofBritain’sworkingagepopulationCross-governmentHealth,WorkandWellbeingProgramme(2008).London:TSO.Availablefrom:www.workingforhealth.gov.uk
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TOOLD15Usefulresources 179
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Clinicalguidance:AustraliaandUnitedStatesClinicalpracticeguidelinesforthemanagementofoverweightandobesityinchildrenandadolescentsNationalHealthandMedicalResearchCouncil(2003).Canberra,ACT:NHMRC.Availablefrom:www.health.gov.au
ClinicalpracticeguidelinesforthemanagementofoverweightandobesityinadultsNationalHealthandMedicalResearchCouncil(2003).Canberra,ACT:NHMRC.Availablefrom:www.health.gov.au
Thepracticalguide:Identification,evaluation,andtreatmentofoverweightandobesityinadultsNationalHeart,LungandBloodInstitute(2000).Bethesda,MD:NationalInstitutesofHealth.Availablefrom:www.nhlbi.nih.gov
Clinicalguidelinesontheidentification,evaluation,andtreatmentofoverweightandobesityinadults:TheevidencereportNationalHeart,LungandBloodInstitute(1998).Bethesda,MD:NationalInstitutesofHealth.Availablefrom:www.nhlbi.nih.gov
NICEclinicalguidanceimplementationsupporttoolsObesity:Costingtemplate,Costingreport,Auditcriteria,PresenterslidesandGuidetoresourcestosupportimplementationNationalInstituteforHealthandClinicalExcellence(NICE)(2006).London:NICE.Availablefrom:www.nice.org.uk
TOOLD15Usefulresources 181
ReferraltoservicesFourcommonlyusedmethodstoincreasephysicalactivity:briefinterventionsinprimarycare,exercisereferralschemes,pedometersandcommunity-basedexerciseprogrammesforwalkingandcyclingNationalInstituteforHealthandClinicalExcellence(2006).London:NICE.Availablefrom:www.nice.org.uk
Overweighthealthprofessionalsgivingweightmanagementadvice:TheperceptionsofhealthprofessionalsandoverweightpeopleVLawsonandCShoneye(2008).London:WeightConcern.
GPcontractStandardGeneralMedicalServicescontract(2006)Availablefrom:www.dh.gov.uk
RevisionstotheGMScontract,2006/07.DeliveringinvestmentingeneralpracticeBritishMedicalAssociationandNHSEmployers(2006).London:BMAandNHSEmployers.Availablefrom:www.nhsemployers.org
WorldClassCommissioning
WorldClassCommissioning:CompetenciesDepartmentofHealth(2008).London:DepartmentofHealth.Availablefrom:www.dh.gov.uk
Settinglocalgoals
Howtosetandmonitorgoalsforprevalenceofchildobesity:Guidanceforprimarycaretrusts(PCTs)andlocalauthoritiesCross-GovernmentObesityUnit(2008).London:DepartmentofHealthandDepartmentforChildren,SchoolsandFamilies.Availablefrom:www.dh.gov.uk
NationalChildMeasurementProgramme:2006/07schoolyear,headlineresultsTheInformationCentre(2008).London:TheInformationCentre.Availablefrom:www.ic.nhs.uk
ThenewPerformanceFrameworkforlocalauthoritiesandlocalauthoritypartnerships:SinglesetofNationalIndicatorsDepartmentforCommunitiesandLocalGovernment(2007).London:DepartmentforCommunitiesandLocalGovernment.Availablefrom:www.communities.gov.uk
182 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Choosinginterventions
NICEguidanceObesity:Guidanceontheprevention,identification,assessmentandmanagementofoverweightandobesityinadultsandchildren.NICEclinicalguideline43NationalInstituteforHealthandClinicalExcellence(NICE)(2006).London:NICE.Availablefrom:www.nice.org.uk
Fourcommonlyusedmethodstoincreasephysicalactivity:briefinterventionsinprimarycare,exercisereferralschemes,pedometersandcommunity-basedexerciseprogrammesforwalkingandcycling.Publichealthinterventionguidanceno.2NationalInstituteforHealthandClinicalExcellence(NICE)(2006).London:NICE.Availablefrom:www.nice.org.uk
Behaviourchangeatpopulation,communityandindividuallevels.NICEpublichealthguidance6NationalInstituteforHealthandClinicalExcellence(NICE)(2007).London:NICE.Availablefrom:www.nice.org.uk
Promotingandcreatingbuiltornaturalenvironmentsthatencourageandsupportphysicalactivity.NICEpublichealthguidance8NationalInstituteforHealthandClinicalExcellence(NICE)(2008).London:NICE.Availablefrom:www.nice.org.uk
Improvingthenutritionofpregnantandbreastfeedingmothersandchildreninlow-incomehouseholds.NICEpublichealthguidance11NationalInstituteforHealthandClinicalExcellence(NICE)(2008).London:NICE.Availablefrom:www.nice.org.uk
Workplacehealthpromotion:Howtoencourageemployeestobephysicallyactive.NICEpublichealthguidance13NationalInstituteforHealthandClinicalExcellence(NICE)(2008).London:NICE.Availablefrom:www.nice.org.uk
PromotinghealthierfoodchoicesNutritionandfoodpoverty.AtoolkitforthoseinvolvedindevelopingorimplementingalocalnutritionandfoodpovertystrategyVPress,onbehalfoftheNationalHeartForumandtheFacultyofPublicHealth(2004).London:NationalHeartForum.Availablefrom:www.heartforum.org.uk
Thinkfit!Eatwell!AguidetodevelopingaworkplacehealthyeatingprogrammeBritishHeartFoundation(2008).London:BritishHeartFoundation.Fordetailssee:www.bhf.org.uk
TOOLD15Usefulresources 183
PhysicalactivityTheeffectivenessofpublichealthinterventionsforincreasingphysicalactivityamongadults:Areviewofreviews.2ndeditionMHillsdon,CFoster,BNaidooandHCrombie(2005).London:HealthDevelopmentAgency.Availablefrom:www.publichealth.nice.org.uk
Let’sgetmoving!AphysicalactivityhandbookfordevelopinglocalprogrammesAMaryon-Davis,LSarch,MMorris,BLaventure(2001).London:FacultyofPublicHealthandNationalHeartForum.
Thinkfit!AguidetodevelopingaworkplaceactivityprogrammeBritishHeartFoundation.London:BritishHeartFoundation.Fordetailssee:www.bhf.org.uk
Activeforlaterlife–Promotingphysicalactivitywitholderpeople.AresourceforagenciesandorganisationsBHFNationalCentreforPhysicalActivityandHealth(2003).London:BritishHeartFoundation.
GeneralWeightmanagementinprimarycare:Howcanitbemademoreeffective?AMaryon-Davis(2005).ProceedingsoftheNutritionSociety;64:97-103.Fordetailssee:www.ingentaconnect.com
Creatingahealthyworkplace(Leafletandaccompanyingbooklet.)London:FacultyofPublicHealthandFacultyofOccupationalMedicine(2006).Availablefrom:www.fph.org.uk
DiabetescommissioningtoolkitDepartmentofHealth(2006).London:DepartmentofHealth.Availablefrom:www.dh.gov.uk
SeealsoChildren: Healthy growth and healthy weight,onpage176.
Commissioningservices
PCTprocurementguideforhealthservicesDepartmentofHealth(2008).London:DepartmentofHealth.Availablefrom:www.dh.gov.uk
SeealsoNational Social Marketing Centreatwww.nsms.org.uk
184 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Monitoringandevaluation
Obesity:AuditcriteriaNationalInstituteforHealthandClinicalExcellence(NICE)(2006).London:NICE.Availablefrom:www.nice.org.uk
PassporttoevaluationHomeOffice(2002).York:HomeOffice.Availablefrom:www.crimereduction.gov.uk
EvaluationresourcesforcommunityfoodprojectsPMcGlone,JDallisonandMCaraher(2005).London:HealthDevelopmentAgency.Availablefrom:www.nice.org.uk
HEBSResearchandevaluationtoolboxHealthEducationBoardforScotland(HEBS).Availablefrom:www.hebs.com
Self-evaluation:AhandyguidetosourcesNewOpportunitiesFund(2003).London:NewOpportunitiesFund.Availablefrom:www.biglotteryfund.org.uk
Buildinglocalcapabilities
ObesitytrainingcoursesforprimarycareDietitiansinObesityManagementDOMUK(2005)London:DOMUKAvailablefrom:domuk.org(Pleasenotethisdirectoryisbeingupdated.ThenewversionwillbeavailablebySpring2009.)
ExpertPatientsProgrammeFordetailssee:www.expertpatients.nhs.uk
Obesity:AguidetopreventionandmanagementSeelearning.bmj.comforinformationaboutthistrainingmodule.(Seealsopage172.)
TOOLD15Usefulresources 185
OrganisationsandwebsitesAlcoholConcernwww.alcoholconcern.org.uk
AmericanHeartAssociation(AHA)www.americanheart.org
ArthritisResearchCampaign(ARC)www.arc.org.uk
AssociationfortheStudyofObesity(ASO)www.aso.org.uk
AssociationofBreastfeedingMotherswww.abm.me.uk
AsthmaUKwww.asthma.co.uk
AustralasianSocietyfortheStudyofObesity(ASSO)www.asso.org.au
Beat(Beatingeatingdisorders)www.b-eat.co.uk
BritishAssociationofSportandExerciseSciences(BASES)www.bases.org.uk
BritishCardiacSocietywww.bcs.com
BritishDieteticAssociation(BDA)www.bda.uk.com
BritishHeartFoundation(BHF)www.bhf.org.uk
BritishHeartFoundationNationalCentreforPhysicalActivityandHealth(BHFNC)www.bhfactive.org.uk
BritishNutritionFoundation(BNF)www.nutrition.org.uk
BritishObesitySurgeryPatientAssociation(BOSPA)www.bospa.org
BritishTrustforConservationVolunteers(BTCV)www.btcv.org
CancerResearchUKwww.cancerresearch.org.uk
CentralCouncilforPhysicalRecreationwww.ccpr.org.uk
ChildGrowthFoundationwww.childgrowthfoundation.org
Children’sPlayCouncilwww.ncb.org.uk/cpc
186 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
CleanerSaferGreenerCommunitieswww.cleanersafergreener.gov.uk
CommunitiesandLocalGovernmentwww.communities.gov.uk
CommunityPractitioners’andHealthVisitors’Association(CPHVA)www.msfcphva.org
TheCounterweightProgrammewww.counterweight.org
CyclingEngland(previouslytheNationalCyclingStrategyBoard)www.cyclingengland.co.uk
DepartmentforChildren,SchoolsandFamilieswww.dcsf.gov.uk
DepartmentforCulture,MediaandSportwww.culture.gov.uk
DepartmentforTransportwww.dft.gov.uk
DepartmentofHealthwww.dh.gov.uk
DiabetesUKwww.diabetes.org.uk
DietitiansinObesityManagement(UK)–DOM(UK)www.domuk.org
EuropeanAssociationfortheStudyofObesity(EASO)www.easoobesity.org
EuropeanChildhoodObesityGroupwww.childhoodobesity.net
EuropeanCommission(HealthandConsumerProtectionDirectorate-General)europa.eu.int
TheEuropeanMen’sHealthForum(EMHF)www.emhf.org
FacultyofPublicHealthwww.fph.org.uk
FitnessIndustryAssociation(FIA)www.fia.org.uk
TheFoodCommissionwww.foodcomm.org.uk
FoodStandardsAgencywww.food.gov.ukwww.eatwell.gov.uk
Foresightwww.foresight.gov.uk
FreeSwimmingwww.freeswimming.org
TOOLD15Usefulresources 187
HeartUKwww.heartuk.org.uk
InternationalAssociationfortheStudyofObesity(IASO)www.iaso.org
InternationalDiabetesFederationwww.idf.org
InternationalObesityTaskforce(IOTF)www.iotf.org
LocalGovernmentAssociation(LGA)www.lga.gov.uk
MaternityAlliancewww.maternityalliance.org.uk
MENDProgrammewww.mendprogramme.org
Men’sHealthForumwww.menshealthforum.org.uk
NationalHeartForumwww.heartforum.org.uk
NationalInstituteforHealthandClinicalExcellence(NICE)www.nice.org.uk
NationalInstitutesofHealth(NIH)www.nih.gov
NationalObesityForum(NOF)www.nationalobesityforum.org.uk
NationalSocialMarketingCentrewww.nsms.org.uk
NorthAmericanAssociationfortheStudyofObesity(NAASO),TheObesitySocietywww.naaso.org
NutritionSocietywww.nutritionsociety.org
ObesityManagementAssociation(OMA)www.omaorg.com
OfficeforNationalStatistics(ONS)www.statistics.gov.uk
TheOverweightandObesityOrganizationwww.oo-uk.org
PE,SchoolSportandClubLinks(PESSCL)www.teachernet.gov.uk/pe
RegisterforExerciseProfessionals(REPS)www.exerciseregister.org
RoyalCollegeofGeneralPractitionerswww.rcgp.org.uk
188 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
RoyalCollegeofMidwiveswww.rcm.org.uk
RoyalCollegeofNursingwww.rcn.org.uk
RoyalCollegeofPaediatricsandChildHealthwww.rcpch.ac.uk
RoyalCollegeofPhysiciansofLondonwww.rcplondon.ac.uk
RoyalInstituteofPublicHealthwww.riph.org.uk
RoyalPharmaceuticalSocietyofGreatBritainwww.rpsgb.org.uk
RoyalSocietyforthePromotionofHealthwww.rsph.org
RoyalSocietyofMedicinewww.rsm.ac.uk
SafeRoutestoSchoolswww.saferoutestoschools.org.uk
ScottishIntercollegiateGuidelinesNetwork(SIGN)www.sign.ac.uk
SportEnglandwww.sportengland.org
TheStrokeAssociationwww.stroke.org.uk
Sustain:Theallianceforbetterfoodandfarmingwww.sustainweb.org
Sustranswww.sustrans.org.uk
TOAST(TheObesityAwarenessandSolutionsTrust)www.toast-uk.org.uk
TravelWisewww.travelwise.org.uk
UnitedKingdomPublicHealthAssociation(UKPHA)www.ukpha.org.uk
WalkingtheWaytoHealthInitiative(WHI)www.whi.org.uk
WeightConcernwww.weightconcern.org.uk
WeightLossSurgeryInformationandSupport(WLSINFO)www.wlsinfo.org.uk
WorldHealthOrganizationwww.who.int/en
TOOLD15Usefulresources 189
ToolsforhealthcareprofessionalsThefollowingtoolsareinsectionEofthistoolkit.
Toolnumber
Title Page
ToolE1 Clinicalcarepathways 195
Assessmentofweightproblems
ToolE2 Earlyidentificationofpatients 201
ToolE3 Measurementandassessmentofoverweightandobesity–ADULTS 203
ToolE4 Measurementandassessmentofoverweightandobesity–CHILDREN 211
Raisingtheissueofweightwithpatients–assessingreadinesstochange
ToolE5 Raisingtheissueofweight–DepartmentofHealthadvice 217
ToolE6 Raisingtheissueofweight–perceptionsofoverweighthealthcareprofessionalsandoverweightpeople
221
Resourcesforhealthcareprofessionals
ToolE7 Leafletsandbookletsforpatients 225
ToolE8 FAQsonchildhoodobesity 227
ToolE9 TheNationalChildMeasurementProgramme(NCMP) 231
190 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
E Resources for healthcare professionals
192 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
This section provides tools for healthcare professionals. It has been divided into three sub-sections: tools to help healthcare professionals assess weight problems; tools to help raise the issue of weight with patients; and tools which give information about further resources.
Assessment of weight problems
• The tools in this sub-section give details of ways of assessing a patient’s weight. Tool E1 contains care pathways from the National Institute of Health and Clinical Exellence (NICE) and the Department of Health. Tool E2 provides information on ways to identify patients who are most at risk of becoming obese later in life and are in most need of assistance before formal assessments of overweight are made. Tools E3 and E4 provide information on measuring and assessing overweight and obesity among children and adult patients.
Raising the issue of weight with patients – assessing readiness to change
• This sub-section follows on from assessment to raising the issue of weight with the patient and assessing their readiness to change. Tool E5 details the Department of Health’s advice for raising the issue. Tool E6 provides the findings of research undertaken to gain insight into the perceptions – both of overweight patients and overweight healthcare professionals – when overweight healthcare professionals give advice on weight.
Resources for healthcare professionals
• This sub-section provides information on resources available to patients (Tool E7), and FAQs on childhood obesity (Tool E8). It also gives information on the National Child Measurement Programme (NCMP), including FAQs from parents (Tool E9). For information about training courses, see Tool D15 Useful resources in section D.
Resourcesforhealthcareprofessionals 193
Tools
Toolnumber
Title Page
ToolE1 Clinicalcarepathways 195
Assessmentofweightproblems
ToolE2 Earlyidentificationofpatients 201
ToolE3 Measurementandassessmentofoverweightandobesity–ADULTS 203
ToolE4 Measurementandassessmentofoverweightandobesity–CHILDREN 211
Raisingtheissueofweightwithpatients–assessingreadinesstochange
ToolE5 Raisingtheissueofweight–DepartmentofHealthadvice 217
ToolE6 Raisingtheissueofweight–perceptionsofoverweighthealthcareprofessionalsandoverweightpeople
221
Resourcesforhealthcareprofessionals
ToolE7 Leafletsandbookletsforpatients 225
ToolE8 FAQsonchildhoodobesity 227
ToolE9 TheNationalChildMeasurementProgramme(NCMP) 231
194 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLE1Clinicalcarepathways
TOOLE1Clinicalcarepathways 195
For: Healthcareprofessionals,particularlyprimarycareclinicians
About: ThistoolcontainsguidancefromtheNationalInstituteforHealthandClinicalExcellence(NICE)andtheDepartmentofHealth.Itprovidesclinicalcarepathwaysforchildrenandadults.
Purpose: Toprovidehealthcareprofessionalswiththeofficialdocumentsthatcliniciansshouldbeusingtoassessoverweightandobeseindividuals.
Use: Tobeusedwheninconsultationwithanoverweightorobesepatient.
Resource: Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children.6 www.nice.org.uk
Care pathway for the management of overweight and obesity.120
www.dh.gov.uk
TOOLE1
NICEguidelineonobesityNICEhasdevelopedclinicalcarepathwaysforchildrenandadultsforusebyhealthcareprofessionals.FurtherdetailscanbefoundinObesity: the prevention, identification, assessment and management of overweight and obesity in adults and children.6Inaddition,asummaryofNICErecommendationsandtheclinicalcarepathwayscanbefoundin:Quick reference guide 2: For the NHS,204whichcanbedownloadedfromtheNICEwebsiteatwww.nice.org.uk
Clinicalcarepathw
ayforchildren
Note:PleaserefertotheNICEguidelinesforpagereferences.
196H
ealthyW
eigh
t,Health
yLives:Ato
olkitfo
rdevelo
pin
glo
calstrategies
Clinicalcarepathw
ayforadults
Note:PleaserefertotheNICEguidelinesforpagereferences.
TO
OLE1C
linicalcarep
athw
ays197
198 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
CarepathwaysfromtheDepartmentofHealthCarepathwayforthemanagementofoverweightandobesity
Thisbookletoffersevidencebasedguidancetohelpprimarycarecliniciansidentifyandtreatchildren,youngpeople(under20years)andadultswhoareoverweightorobese.120Thebookletincludes:
• Adultcarepathway• Childrenandyoungpeoplecarepathway• Raisingtheissueofweightinadults• Raisingtheissueofweightinchildrenandyoungpeople.
TheRaising the issue of weighttoolsprovidetipsonhowtoinitiatediscussionwithpatients.(SeeToolE5formoreonthis.)
Thepathwaysarealsoavailableasseparatelaminatedposters(seepages198200).
Toaccessthesematerials,visitwww.dh.gov.ukorordercopiesfrom:
DHPublicationsOrderlinePOBox777LondonSE16XHEmail:[email protected]
Tel:03001231002Fax:01623724524Minicom:03001231003(8amto6pm,MondaytoFriday)
TOOLE1Clinicalcarepathways 199
Adultcarepathway
Laminatedposter205 –availablefromDepartmentofHealthPublications(seepage198)
Assessment of weight/BMI in adults
Adult Care Pathway (Primary Care)
Maintenance and local support options
BMI >30 or >28 with related
co-morbidities or relevant ethnicity?
Offer lifestyle advice, provide Your Weight,
Your Health booklet and monitor
Offer future support if/when ready
Provide Why Weight Matters card and discuss value
of losing weight; provide contact information
for more help/support
Raise the issue of weight
Ready to change?
No
No
No
No
Yes Yes
Yes
Yes
Previous literature provided?
Recommend healthy eating, physical activity, brief behavioural advice and drug therapy if indicated,
and manage co-morbidity and/or underlying causes. Provide
Your Weight, Your Health booklet
Weight loss? Repeat previous options and,
if available, refer to specialist centre or surgery
ASSESSMENT
• BMI • Waist circumference • Eating and physical activity • Emotional/psychological issues • Social history (including alcohol and smoking) • Family history eg diabetes, coronary heart disease (CHD)
• Underlying cause eg hypothyroidism, Cushing’s syndrome • Associated co-morbidity eg diabetes, CHD, sleep apnoea, osteoarthritis, gallstones, benign intracranial hypertension, polycystic ovary syndrome, non-alcoholic steato-hepatitis
YOURWEIGHT,
YOURHEALTH
Part of the
Series
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274540 1p 60k Apr06 (BEL). Produced by COI for the Department of Health. First published April 2006
200 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Childrenandyoungpeoplecarepathway
Laminatedposter206 –availablefromDepartmentofHealthPublications(seepage198)
Maintenance and local support options
Offer further discussion and future support if/when ready
Provide Why Weight Matters card and discuss the value
of managing weight; provide contact information for
more help/support
Raise the issue of weight
Child and family ready to change?
No
No
No
Yes Yes
Yes
Previous literature provided?
Recommend healthy eating, physical activity, brief behavioural advice
and manage co-morbidity and/or underlying causes. Provide Your Weight, Your Health
booklet
Progress/ weight loss?
Assessment of weight in children and
young people
Children and Young People Care Pathway (Primary Care)
Re-evaluate if family/child ready to change
Repeat previous options for management
or If appropriate and available,
consider referral to paediatric endocrinologist for assessment
of underlying causes and/or co-morbidities
or Referral for surgery
ASSESSMENT
• Eating habits, physical patterns, TV viewing, dieting history • BMI – plot on centile chart • Emotional/psychological issues • Social and school history • Level of family support • Stature of close family relatives (for genetic and environmental information) • Associated co-morbidity eg metabolic syndrome, respiratory problems, hip (slipped capital femoral epiphysis) and knee (Blount’s) problems, endocrine problems, diabetes, coronary heart disease (CHD), sleep apnoea, high blood pressure
• Underlying cause eg hypothyroidism, Cushing’s syndrome, growth hormone deficiency, Prader-Willi syndrome, acanthosis nigricans • Family history • Non-medical symptoms
eg exercise intolerance, discomfort from clothes, sweating • Mental health
YOURWEIGHT,
YOURHEALTH
Part of the
Series
© Crown copyright 2006
274542 1p 60k Apr06 (BEL). Produced by COI for the Department of Health. First published April 2006
TOOLE2Earlyidentificationofpatients 201
TOOLE2EarlyidentificationofpatientsTOOLE2For: Allhealthcareprofessionalswhoareparticularlyincontactwithchildrenand
pregnantwomen–midwives,healthvisitors,GPs,obstetricians,paediatricians,andsoon
About: Thistoolprovidesinformationonwaystoidentifythosepatients–particularlychildrenandpregnantwomen–whoaremostatriskofbecomingobeselaterinlifeandwhoareinmostneedofassistance,beforeformalassessmentsofoverweightaremade.HealthcareprofessionalswillneedtoconsulttheChildHealthPromotionProgramme(CHPP)publication151formoredetailedinformation,particularlyabouttheCHPPschedule.
Purpose: Toprovidebackgroundinformationonhowhealthcareprofessionalscanidentifypatientsmostatriskofbecomingobeselaterinlife.
Use: Tobeusedtoidentifypatientsmostatriskofbecomingobeselaterinlife.
Resource: TheinformationisreproducedfromThe Child Health Promotion Programme: Pregnancy and the first five years of life.151PleaseseetheCHPP scheduleasitsetsoutboththecoreuniversalprogrammetobecommissionedandprovidedforallfamilies,andadditionalpreventiveelementsthattheevidencesuggestsmayimproveoutcomesforchildrenwithmediumandhighriskfactors.Gotowww.dh.gov.uktodownloadthedocument.
Assessment:KeypointsPatientsneedaskilledassessmentsothatanyassistancecanbepersonalisedtotheirneedsandchoices.Anysystemofearlyidentificationhastobeableto:
• identifytheriskfactorsthatmakesomechildrenmorelikelytoexperiencepooreroutcomesinlaterchildhood,includingfamilyandenvironmentalfactors
• includeprotectivefactorsaswellasrisks
• beacceptabletobothparents
• promoteengagementinservicesandbenonstigmatising
• belinkedtoeffectiveinterventions
• capturethechangesthattakeplaceinthelivesofchildrenandfamilies
• includeparentalandchildrisksandprotectivefactors,and
• identifysafeguardingrisksforthechild.
SocialandpsychologicalindicatorsAt-riskindicators:Children
Genericindicatorscanbeusedtoidentifychildrenwhoareatriskofpooreducationalandsocialoutcomes(forexample,thosewithparentswithfewornoqualifications,pooremploymentprospectsormentalhealthproblems).Neighbourhoodsalsoaffectoutcomesforchildren.Familiessubjecttoahigherthanaverageriskofexperiencingmultipleproblemsinclude:
• familieslivinginsocialhousing
• familieswithayoungmotheroryoungfather
• familieswherethemother’smainlanguageisnotEnglish
202 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
• familieswheretheparentsarenotcoresident,and
• familieswhereoneorbothparentsgrewupincare.
At-riskindicators:Pregnantwomen
Itcanbedifficulttoidentifyrisksearlyinpregnancy,especiallyinfirstpregnancies,asoftenlittleisknownabouttheexperienceandabilitiesoftheparents,andthecharacteristicsofthechild.Usefulpredictorsduringpregnancyinclude:
• youngparenthood,whichislinkedtopoorsocioeconomicandeducationalcircumstances
• educationalproblems–parentswithfewornoqualifications,nonattendanceorlearningdifficulties
• parentswhoarenotineducation,employmentortraining
• familieswhoarelivinginpoverty
• familieswhoarelivinginunsatisfactoryaccommodation
• parentswithmentalhealthproblems
• unstablepartnerrelationships
• intimatepartnerabuse
• parentswithahistoryofantisocialoroffendingbehaviour
• familieswithlowsocialcapital
• ambivalenceaboutbecomingaparent
• stressinpregnancy
• lowselfesteemorlowselfreliance,and
• ahistoryofabuse,mentalillnessoralcoholisminthemother’sownfamily.
Obesity-specificindicatorsTherearespecificriskfactorsandprotectivefactorsforobesity.Forexample,achildisatagreaterriskofbecomingobeseifoneorbothoftheirparentsisobese.
Key point Some of the indicators listed are more difficult to identify than others. Health professionals need to be skilled at establishing a trusting relationship with families and be able to build a holistic view.
TOOLE3Measurementandassessmentofoverweightandobesity–ADULTS 203
TOOLE3Measurementandassessmentofoverweightandobesity–ADULTS
For: Allhealthcareprofessionalsmeasuringandassessingoverweightandobesechildren
About: Thistoolcontainsdetailedinformationonthemeasurementandassessmentofoverweightandobesityinadults.ItprovidesdetailsonhowtomeasureoverweightandobesityusingBodyMassIndex(BMI);howtomeasurewaistcircumference;howtoassessoverweightandobesityusingBMIandwaistcircumference;howtoassesstherisksfromoverweightandobesity;andhowtoassessoverweightandobesityusingtheheightandweightchart.ItprovidesspecificdetailsonAsianpopulationsandbriefdetailsonthewaisthipratio.ThistoolisconsistentwithNICEguidanceandDepartmentofHealthrecommendations.
Purpose: Toprovideanunderstandingofhowadultsaremeasuredandassessed.
Use: Tobeusedasbackgroundinformationwheninconsultationwithanoverweightorobesepatient.
Resource: Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children.6 www.nice.org.uk
Measuring childhood obesity. Guidance to primary care trusts.207
www.dh.gov.uk
MeasuringoverweightandobesityusingBodyMassIndexAdults
TheNationalInstituteforHealthandClinicalExcellence(NICE)recommendsthatoverweightandobesityareassessedusingBodyMassIndex(BMI).6Itisusedbecause,formostpeople,BMIcorrelateswiththeirproportionofbodyfat.
BMIisdefinedastheperson’sweightinkilogramsdividedbythesquareoftheirheightinmetres(kg/m2).Forexample,tocalculatetheBMIofapersonwhoweighs95kgandis180cmtall:
95 95 BMI = = = 29.32kg/m2
(1.80 x 1.80) 3.24
ThustheirBMIwouldbeapproximately29kg/m2.
NICEclassifies‘overweight’asaBMIof25to29.9kg/m2and‘obesity’asaBMIof30kg/m2ormore.6ThisclassificationaccordswiththatrecommendedbytheWorldHealthOrganization(WHO).21Furtherclassificationslinkedwithmorbidityareshownonthenextpage.ThesecutoffpointsarebasedonepidemiologicalevidenceofthelinkbetweenmortalityandBMIinadults.21
TOOLE3
204 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Classificationofoverweightandobesityamongadults
Classification BMI(kg/m2) Riskofco-morbidities*
Underweight Lessthan18.5 Low(butriskofotherclinicalproblemsincreased)
Healthyweight 18.5–24.9 Average
Overweight(orpre-obese) 25–29.9 Increased
Obesity,classI 30–34.9 Moderate
Obesity,classII 35–39.9 Severe
Obesity,classIII(severelyormorbidlyobese)
40ormore Verysevere
Note:NICErecommendsthattheBMImeasurementshouldbeinterpretedwithcautionbecauseitisnotadirectmeasureofadiposity(amountofbodyfat).6
*Comorbiditiesarethehealthrisksassociatedwithobesity,ietype2diabetes,hypertension(highbloodpressure),stroke,coronaryheartdisease,cancer,osteoarthritisanddyslipidaemia(imbalanceoffattysubstancesintheblood).
Source:NationalInstituteforHealthandClinicalExcellence,2006,6adaptedfromWorldHealthOrganization,200021
AdultsofAsianorigin
TheconceptofdifferentcutoffsfordifferentethnicgroupshasbeenproposedbytheWHO*
becausesomeethnicgroupshavehighercardiovascularandmetabolicrisksatlowerBMIs.Thismaybebecauseofdifferencesinbodyshapeandfatdistribution.Asianpopulations,inparticular,haveahigherproportionofbodyfatcomparedwithpeopleofthesameage,genderandBMIinthegeneralUKpopulation.Thus,theproportionofAsianpeoplewithahighriskoftype2diabetesandcardiovasculardiseaseissubstantialevenatBMIslowerthantheexistingWHOcutoffpointforoverweight.
However,levelsofmorbidityvarybetweendifferentAsianpopulationsandforthisreasonitisdifficulttoidentifyoneclearBMIcutoffpoint.209Thusintheabsenceofworldwideagreement,NICErecommendsthatthecurrentuniversalcutoffpointsforthegeneraladultpopulation(seetableabove)beretainedforallpopulationgroups.6ThisisinagreementwiththeWHOexpertconsultationgroupwhichalsorecommendstriggerpointsforpublichealthactionforadultsofAsianorigin–23kg/m2forincreasedriskand27.5kg/m2forhighrisk.210NICEhasrecommendedthathealthcareprofessionalsshoulduseclinicaljudgementwhenconsideringriskfactorsinAsianpopulationgroups,eveninpeoplenotclassifiedasoverweightorobeseusingthecurrentBMIclassification.6ThisapproachissupportedbytheDepartmentofHealthandtheFoodStandardsAgency.
UsingtheBMImeasurementinisolation
AlthoughBMIisanacceptableapproximationoftotalbodyfatatthepopulationlevelandcanbeusedtoestimatetherelativeriskofdiseaseinmostpeople,itisnotalwaysanaccuratepredictorofbodyfatorfatdistribution,particularlyinmuscularindividuals,becauseofdifferencesinbodyfatproportionsanddistribution.Someotherpopulationgroups,suchasAsiansandolderpeople,havecomorbidityriskfactorsthatwouldbeofconcernatdifferentBMIs(lowerforAsianadultsasdetailedaboveandhigherforolderpeople).Therefore,NICErecommendsthatwaistcircumferenceshouldbeusedinadditiontoBMItomeasurecentralobesityanddiseaseriskinindividualswithaBMIlessthan35kg/m2.6(SeeMeasuring BMI and waist circumference in adults to assess health risksonpage206.)
* Theproposedcutoffsare18.522.9kg/m2(healthyweight),23kg/m2ormore(overweight),2324.9kg/m2(atrisk),2529.9kg/m2(obesityI),30kg/m2ormore(obesityII).208
TOOLE3Measurementandassessmentofoverweightandobesity–ADULTS 205
MeasuringwaistcircumferenceAdults
Waistcircumferencehasbeenshowntobepositively,althoughnotperfectly,correlatedtodiseaserisk,andisthemostpracticalmeasurementtoassessapatient’sabdominalfatcontentor‘central’fatdistribution.125Centralobesityislinkedtoahigherriskoftype2diabetesandcoronaryheartdisease.
NICErecommendsthatwaistcircumferencecanbeused,inadditiontoBMI,toassessriskinadultswithaBMIoflessthan35kg/m2.6However,whereBMIisgreaterthan35kg/m2,waistcircumferenceaddslittletotheabsolutemeasureofriskprovidedbyBMI.6,126ThisisbecausepatientswhohaveaBMIof35kg/m2willexceedthewaistcircumferencecutoffpoints(detailedbelow)usedtoidentifypeopleatriskofthemetabolicsyndrome.125
Waistcircumferencethresholdsusedtoassesshealthrisksinthegeneralpopulation
Atincreasedrisk Male Female
Increasedrisk 94cm(37inches)ormore 80cm(31inches)ormore
Greatlyincreasedrisk 102cm(40inches)ormore 88cm(35inches)ormore
Source:NationalInstituteforHealthandClinicalExcellence,2006,6InternationalDiabetesFederation(2005),210WHO/IASO/IOTF(2000),208
WorldHealthOrganization(2000)21
AdultsofAsianorigin
DifferentwaistcircumferencecutoffsfordifferentethnicgroupshavebeenproposedbytheWorldHealthOrganization208andtheInternationalDiabetesFederation.210 *ThisisbecauseethnicpopulationshavehighercardiovascularriskfactorsatlowerwaistcircumferencesthanWesternpopulations.211Forexample,inSouthAsians(ofPakistani,BangladeshiandIndianorigin)livinginEngland,agivenwaistcircumferencetendstobeassociatedwithmorefeaturesofthemetabolicsyndromethaninEuropeans.6
However,auniquethresholdforallAsianpopulationsmaynotbeappropriatebecausedifferentAsianpopulationsdifferinthelevelofriskassociatedwithaparticularwaistcircumference.Forexample,astudyevaluatingtheaveragewaistcircumferenceofmorethan30,000individualsfromEastAsia(China,HongKong,Korea,andTaiwan),SouthAsia(IndiaandPakistan)andSoutheastAsia(Indonesia,Malaysia,thePhilippines,Singapore,ThailandandVietnam)foundthatthereweremajordifferencesbetweenregions.Thus,theresearchersconcludedthattheimpactofobesitymaybeginatdifferentthresholdsindifferentAsianpopulations.212
Becauseagloballyapplicablegradingsystemofwaistcircumferenceforethnicpopulationshasnotyetbeendeveloped,NICEdoesnotrecommendseparatewaistcircumferencecutoffsfordifferentethnicgroupsintheUK.6
Usingthewaistcircumferencemeasurementinisolation
Waistcircumferenceshouldneverbeusedinisolation,asaproportionofsubjectswhorequireweightmanagementmaynotbeidentified.126ThusNICErecommendstheuseofthetableonthenextpagetoassessthelevelofweightmanagementrequired.6
* TheInternationalDiabetesFederation(IDF)andtheWorldHealthOrganizationhaveproposedseparatewaistcircumferencethresholdsforadultsofAsianoriginof90cm(35inches)ormoreformen,and80cm(31inches)ormoreforwomen.NotethattheIDFdefinitionisforSouthAsiansandChinesepopulationsonly.21,208,210
206 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
NICEstatesthat:“Thelevelofinterventionshouldbehigherforpatientswithcomorbidities,regardlessoftheirwaistcircumference.”6
Assessingthelevelofweightmanagement:aguide
BMIclassification Waistcircumference Co-morbiditiespresent
Low High Veryhigh
Overweight
ObesityI
ObesityII
ObesityIII
Generaladviceonhealthyweightandlifestyle
Dietandphysicalactivity
Dietandphysicalactivity;considerdrugs
Dietandphysicalactivity;considerdrugs;considersurgery
Source:NationalInstituteforHealthandClinicalExcellence,20066
MeasuringBMIandwaistcircumferenceinadultstoassesshealthrisksTheWorldHealthOrganization(WHO)hasrecommendedthatanindividual’srelativehealthriskcouldbemoreaccuratelyclassifiedusingbothBMIandwaistcircumference.21Thisisshownbelowforthegeneraladultpopulation.
CombiningBMIandwaistmeasurementtoassessobesityandtheriskoftype2diabetesandcardiovasculardisease–generaladultpopulation21,6,126
Classification BMI(kg/m2) Waistcircumferenceandriskofco-morbidities
Men:94–102cm Men:Morethan102cm
Women:80-88cm Women:Morethan88cm
Underweight Lessthan18.5 – –
Healthyweight 18.5–24.9 – Increased
Overweight(orpre-obese) 25–29.9 Increased High
Obesity 30ormore High Veryhigh
Source:NationalInstituteforHealthandClinicalExcellence,20066
TOOLE3Measurementandassessmentofoverweightandobesity–ADULTS 207
Measuringwaist-hipratioAdults
Waisthipratioisanothermeasureofbodyfatdistribution.Thewaisthipmeasurementisdefinedaswaistcircumferencedividedbyhipcircumference,iewaistgirth(inmetres)dividedbyhipgirth(inmetres).Althoughthereisnoconsensusaboutappropriatewaisthipratiothresholds,araisedwaisthipratioiscommonlytakentobe1.0ormoreinmen,and0.85ormoreinwomen.6,208
However,neitherNICEnortheDepartmentofHealthrecommendstheuseofwaisthipratioasastandardmeasureofoverweightorobesity.
AssessmentAssessmentofoverweightandobesityusingBMIandwaistcircumference
Managementshouldbeginwiththeassessmentofoverweightandobesityinthepatient.BMIshouldbeusedtoclassifythedegreeofobesity,andwaistcircumferencemaybeusedinpeoplewithaBMIlessthan35kg/m2todeterminethepresenceofcentralobesity.NICErecommendsthattheassessmentofhealthrisksassociatedwithoverweightandobesityinadultsshouldbebasedonBMIandwaistcircumferenceasshownbelow.6
Assessingrisksfromoverweightandobesity
BMIclassification Waistcircumference
Low High Veryhigh
Overweight Noincreasedrisk Increasedrisk Highrisk
ObesityI Increasedrisk Highrisk Veryhighrisk
Formen,waistcircumferenceoflessthan94cmislow,94–102cmishighandmorethan102cmisveryhigh.Forwomen,waistcircumferenceoflessthan80cmislow,80–88cmishigh,andmorethan88cmisveryhigh.
Source:NationalInstituteforHealthandClinicalExcellence,20066
Assessmentsalsoneedtoincludeholisticaspectsfocusingonpsychological,socialandenvironmentalissues.Thereisaneedfortrainingforprofessionalswhocarryoutassessmentsduetothesensitiveandmultifacetednatureofoverweightandobesity.Professionalsneedtobeawareofpatients’motivationsandexpectations.Effectiveassessmentandinterventionrequiresupport,understandingandanonjudgementalapproach.
208 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Assessingandclassifyingoverweightandobesityinadults
NICErecommendsthefollowingapproachtoassessingandclassifyingoverweightandobesityinadults.
Determine degree of overweight or obesity • Useclinicaljudgementtodecidewhentomeasureweightandheight
• UseBMItoclassifydegreeofobesity...butuseclinicaljudgement:
– BMImaybelessaccurateinhighlymuscularpeople
– forAsianadults,riskfactorsmaybeofconcernatlowerBMI
– forolderpeople,riskfactorsmaybecomeimportantathigherBMIs
• UsewaistcircumferenceinpeoplewithaBMIlessthan35kg/m2toassesshealthrisks
• BioimpedanceisnotrecommendedasasubstituteforBMI
• Tellthepersontheirclassification,andhowthisaffectstheirriskoflongtermhealthproblems.
Assess lifestyle, comorbidities and willingness to change, including: • presentingsymptomsandunderlyingcausesofoverweightorobesity
• eatingbehaviour
• comorbidities(suchastype2diabetes,hypertension,cardiovasculardisease,osteoarthritis,dyslipidaemiaandsleepapnoea)andriskfactors,usingthefollowingtests–lipidprofileandbloodglucose(bothpreferablyfasting)andbloodpressuremeasurement
• lifestyle–dietandphysicalactivity
• psychosocialdistressandlifestyle,environmental,socialandfamilyfactors–includingfamilyhistoryofoverweightandobesityandcomorbidities
• willingnessandmotivationtochange
• potentialofweightlosstoimprovehealth
• psychologicalproblems
• medicalproblemsandmedication.
Source:ReproducedfromNationalInstituteforHealthandClinicalExcellence,20066
Assessmentofoverweightandobesityusingtheheightandweightchart
Theheightandweightchartshownonthenextpagecanbeusedasacrudeassessmentofoverweightandobesity.Tousethechartfollowthesimpleinstructionsatthetopofthechart.
ToolE1providesfurtherinformationonNICEandDepartmentofHealthguidanceforassessingandmanagingoverweightandobesityinaclinicalsetting.
Note:
TheNHSLocalDeliveryPlanmonitoringlineonadultobesitystatusrequiresgeneralpracticestomonitorandreturndataontheobesitystatus(BMI)ofGPregisteredadultswithinthepast15months.
TOOLE3Measurementandassessmentofoverweightandobesity–ADULTS 209
Heightandweightchart
Takeastraightlineacrossfromtheperson’sheight(withoutshoes),andalineupordownfromtheirweight(withoutclothes).Putamarkwherethetwolinesmeettofindoutifthepersonneedstoloseweight.
Weight (in kilos)
Hei
ght
(in m
etre
s)
Hei
ght
(in f
eet
and
inch
es)
Weight (in stones)
Underweight(BMIlessthan18.5kg/m2)Amorecaloriedensedietmaybeneededtomaintaincurrentactivitylevels.Incasesofverylowweightforheight,medicaladviceshouldbeconsidered.
OK(BMI18.5–24.9kg/m2)Thisistheoptimal,desirableor‘normal’range.Calorieintakeisappropriateforcurrentactivitylevels.
Overweight(BMI25–29.9kg/m2)Somelossofweightmightbebeneficialtohealth.
Obese(BMI30–39.9kg/m2)Thereisanincreasedriskofillhealthandaneedtoloseweight.Regularhealthchecksarerequired.
Veryobese(BMI40kg/m2orabove)Thisissevereor‘morbid’obesity.Thereisagreatlyincreasedriskofdevelopingcomplicationsofobesityandanurgentneedtoloseweight.Specialistadviceshouldbesought.
210 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLE4Measurementandassessmentofoverweightandobesity–CHILDREN 211
TOOLE4Measurementandassessmentofoverweightandobesity–CHILDREN
For: Allhealthcareprofessionalsmeasuringandassessingoverweightandobesechildren
About: Thistoolcontainsdetailedinformationonthemeasurementandassessmentofoverweightandobesityinchildren.ItprovidesinformationonhowtomeasureoverweightandobesityusingBodyMassIndex(BMI)andgrowthreferencecharts;providesinformationonmeasuringwaistcircumference;andprovidesdetailsonhowtoassessoverweightandobesityinchildren.BMIchartsareprovidedattheendofthistoolforgirlsandboys.ThistoolisconsistentwithNICEguidanceandalsoDepartmentofHealthrecommendations.
Purpose: Toprovideanunderstandingofhowchildrenaremeasuredandassessed.
Use: Tobeusedasbackgroundinformationwheninconsultationwithanoverweightorobesechild.
Resource: Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children.6 www.nice.org.uk
Measuring childhood obesity. Guidance to primary care trusts.207
www.dh.gov.uk
MeasuringoverweightandobesityusingBodyMassIndex
TheNationalInstituteforHealthandClinicalExcellence(NICE)recommendsthatBMI(adjustedforageandgender)shouldbeusedasapracticalestimateofoverweightinchildrenandyoungpeople.TheBMImeasurementinchildrenandyoungpeopleshouldberelatedtotheUK1990BMIgrowthreferencechartstogiveageandgenderspecificinformation.Pragmaticindicatorsforactionhavebeenrecommendedasthe91stcentileforoverweight,andthe98thcentileforobesity.6(Forreferencecharts,seepages215and216.)
BMIiscalculatedbydividinganindividual’sweightinkilogramsbythesquareoftheirheightinmetres(kg/m2).
ThereiswidespreadinternationalsupportfortheuseofBMItodefineobesityinchildren,3,23,120
eventhoughthereisnouniversallyacceptedBMIbasedclassificationsystemforchildhoodobesity.Thisisbecauseforchildrenandyoungpeople,BMIisnotastaticmeasurement,butvariesfrombirthtoadulthood,andisdifferentbetweenboysandgirls.InterpretationofBMIvaluesinchildrenandyoungpeoplethereforedependsoncomparisonswithpopulationreferencedata,usingcutoffpointsintheBMIdistribution(BMIpercentiles).3
Differentgrowthreferencechartscanbeusedtoassessthedegreeofoverweightorobesityofachild.Thesearecalculatedtoallowforage,sexandheight.NICEhasrecommendedthattheBMImeasurementinchildrenandyoungpeopleshouldberelatedtotheUK1990BMIgrowthreferencecharts4togiveageandgenderspecificinformation.6TheGrowthReferenceReviewGroup,aworkinggroupconvenedbytheRoyalCollegeofPaediatricsandChildHealth(RCPCH),hasalsorecommendedthatforchildrenundertheageof2years,theUK1990referencecharts213
aretheonlysuitablechartsforweight,lengthandheadcircumference.Italsorecommendedthat
TOOLE4
212 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
theUK1990BMIreferenceistheonlysuitablereferenceforassessingweightrelativetoheight.214
However,theAustralianNHMRCguidelinesforchildrenhighlightedseveraldifficultieswiththeBMIforagepercentilecutoffs:
• Dataarederivedfromareferencepopulation.• ClassifyingachildasoverweightorobeseonthebasisofBMIbeingaboveacertainpercentile
isanarbitrarydecisionandisnotbasedonknownmedicalorhealthrisk.127
ThesedifficultieshaveresultedindifferentBMIcentilesbeingused.Forexample,theNHMRCguidelineshaverecommendedthataBMIabovethe95thpercentileisindicativeofobesityandaBMIabovethe85thpercentileisindicativeofoverweight.127However,theSIGNguidelineshaverecommendedthataBMIatthe98thpercentileoroverisindicativeofobesity(ontheUK1990referencechartsforBMIcentilesforchildren213),andaBMIatthe91stpercentileisindicativeofoverweight.23TheDepartmentofHealthhasalsorecommendedthatthe98thand91stcentilesoftheUK1990referencechartforageandsexbeusedtodefineobesityandoverweight,respectively.120ThisisbecausewhenusingtheBMIofmorethanthe91stcentileontheUK1990charts,sensitivityismoderatelyhigh(itdiagnosesfewobesechildrenaslean)andspecificityishigh(itdiagnosesfewleanchildrenasobese)whichisparamountforroutineclinicaluse.23,215
Note:NICErecommendationforspecificcutoffsforoverweightandobesity–NICEconsideredthattherewasalackofevidencetosupportspecificcutoffsinchildren.However,therecommendedpragmaticindicatorsforactionarethe91stand98thcentiles(overweightandobese,respectively).6
Seepages215and216forcentileBMIchartsforboysandgirls.
Useofgrowthreferencechartsinclinicalsettings
ThegrowthreferenceorBMIchartsareusedintwobroadclinicalsettings:fortheassessmentandmonitoringofindividualchildren,andforscreeningwholepopulations.214
Assessing and monitoring individual children • BMIreferencecurvesfortheUK,1990213–NICErecommendsthatthe91stcentile
(overweight)andthe98thcentile(obese)ofthe1990UKreferencechartbeusedforassessingandmonitoringindividualchildren.6TheDepartmentofHealthandSIGNmakethesamerecommendation.23,120
Screening whole populations • UK National BMI Percentile Classification213–Themajorityofpublishedepidemiological
workhasusedadefinitionofobesityasaBMIofmorethanthe95thcentile,andoverweightasaBMIofmorethanthe85thcentileoftheUK1990referencechartforageandsex.23SIGNhasrecommendedthat,forcomparativeepidemiologicalpurposes,itisimportanttoretainthisdefinition.
TOOLE4Measurementandassessmentofoverweightandobesity–CHILDREN 213
• International Classification –AnalternativemethodformeasuringchildhoodobesityistheInternationalObesityTaskForce(IOTF)internationalclassification216usingdatacollectedfromsixcountries(UK,Brazil,HongKong,theNetherlands,SingaporeandtheUnitedStates)ofatotalof190,000subjectsagedfrom0to25years.Thisclassificationlinkschildhoodandadultobesity/overweightstandardsusingevidenceofclearassociationsbetweentheadultBMIcutoffvaluesof25kg/m2and30kg/m2andhealthrisk.However,ithasbeenreportedthattheinternationalcutoffsexaggeratethedifferencesinoverweightandobesityprevalencebetweenboysandgirlsbyunderestimatingprevalenceinboys.Otherpossiblelimitationsincludeconcernsaboutsensitivity(theabilitytoidentifyallobesechildrenasobese),thelimitedsamplesizeofthereferencepopulationandthelackofBMIcutoffpointsforunderweight.217
MeasuringwaistcircumferenceUntilrecently,waistcircumferenceinchildrenhadnotbeenregardedasbeinganimportantmeasureoffatness.Althoughthehealthrisksassociatedwithanexcessiveabdominalfatdistributioninchildrenincomparisonwithadultsremainunclear,mountingevidencesuggeststhatthisisanimportantmeasurement.Forexample,datafromtheBogalusaHeartStudyshowedthatanabdominalfatdistribution(indicatedbywaistcircumference)inchildrenagedbetween5and17yearswasassociatedwithadverseconcentrationsoftriglyceride,LDLcholesterol,HDLcholesterolandinsulin.218ThefirstsetofworkingwaistcircumferencepercentileswasproducedusingdatacollectedfromBritishchildren.219Althoughthereisnoconsensusabouthowtodefineobesityamongchildrenusingwaistmeasurement,forclinicalusethe99.6thor98thcentilesarethesuggestedcutoffsforobesityandthe91stcentileisthecutoffforoverweight.219
NICE6andtheDepartmentofHealth120donotcurrentlyrecommendusingwaistcircumferenceasameansofdiagnosingchildhoodobesityasthereisnoclearthresholdforwaistcircumferenceassociatedwithmorbidityoutcomeinchildrenandyoungpeople.127, 207Thus,NICErecommendsthatwaistcircumferenceisnotusedasaroutinemeasurementinchildrenandyoungpeople,butmaybeusedtogiveadditionalinformationontheriskofdevelopingotherlongtermhealthproblems.
AssessmentNICErecommendsthatassessmentshouldbeginbymeasuringBMIandrelatingittotheUK1990BMIchartstogiveageandgenderspecificinformation.6Seechartsonpages215and216.
Itrecommendstheapproachtoassessingandclassifyingoverweightandobesityinchildrenshownintheboxonthenextpage.
214 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Assessmentandclassificationofoverweightandobesityinchildren
Determine degree of overweight or obesity • Useclinicaljudgementtodecidewhentomeasureweightandheight.
• UseBMI;relatetoUK1990BMIchartstogiveageandgenderspecificinformation.
• Donotusewaistcircumferenceroutinely;however,itcangiveinformationonriskoflongtermhealthproblems.
• Discusswiththechildandfamily.
Consider intervention or assessment • ConsidertailoredclinicalinterventionifBMIat91stcentileorabove.
• ConsiderassessingforcomorbiditiesifBMIat98thcentileorabove.
Assess lifestyle, comorbidities and willingness to change, including: • presentingsymptomsandunderlyingcausesofoverweightorobesity
• willingnessandmotivationtochange
• comorbidities(suchashypertension,hyperinsulinaemia,dyslipidaemia,type2diabetes,psychosocialdysfunctionandexacerbationofasthma)andriskfactors
• psychosocialdistresssuchaslowselfesteem,teasingandbullying
• familyhistoryofoverweightandobesityandcomorbidities
• lifestyle–dietandphysicalactivity
• environmental,socialandfamilyfactorsthatmaycontributetooverweightandobesityandthesuccessoftreatment
• growthandpubertalstatus.
Source:ReproducedfromNationalInstituteforHealthandClinicalExcellence,20066
TheDepartmentofHealth,120theRoyalCollegeofPaediatricsandChildHealth(RCPCH)andtheNationalObesityForum(NOF)122providesimilarrecommendationsforassessingchildhoodoverweightandobesity.
ToolE1providesfurtherinformationonNICEandDepartmentofHealthguidanceforassessingandmanagingoverweightandobesityinaclinicalsetting.
Recordingofchildren’sdataTheDepartmentofHealthandtheDepartmentforChildren,SchoolsandFamilieshavedevelopedguidanceforPCTsandschoolsonhowtomeasuretheheightandweightofchildren.139,140AllchildreninReception(45yearolds)andYear6(1011yearolds)shouldbemeasuredonanannualbasisaspartoftheNationalChildMeasurementProgramme(NCMP).Theguidanceisavailableatwww.dh.gov.uk/healthyliving
SeealsoToolE9formoreinformationabouttheNCMP.
TOOLE4Measurementandassessmentofoverweightandobesity–CHILDREN 215
CentileBMIcharts–CHILDRENBoysBMIchart–Identification213,216
Note:ThischartisbasedontheUKpopulation,nottheIOTFpopulations.
ReproducedwithkindpermissionoftheChildGrowthFoundation(CharityRegistrationNumber274325)©ChildGrowthFoundation1997/12MayfieldAvenue,LondonW41PW
216 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
GirlsBMIchart–Identification213,216
Note:ThischartisbasedontheUKpopulation,nottheIOTFpopulations.
ReproducedwithkindpermissionoftheChildGrowthFoundation(CharityRegistrationNumber274325)©ChildGrowthFoundation1997/12MayfieldAvenue,LondonW41PW
TOOLE5Raisingtheissueofweight–DepartmentofHealthadvice 217
TOOLE5Raisingtheissueofweight–DepartmentofHealthadvice
For: Healthcareprofessionals,particularlyinprimarycare
About: Thistoolcontainsguidanceforhealthprofessionalsonraisingtheissueofweightwithpatients,producedbytheDepartmentofHealth.
Purpose: Toprovideguidanceonhowhealthcareprofessionalscanraisetheissueofweightwithpatients.
Use: Tobeusedasaconciseandhandytoolwheninconsultationwithanoverweightorobesepatient.
Resource: TheseitemsarecontainedinaDepartmentofHealthpublicationcalledCare pathway for the management of overweight and obesity120(seeToolE1).Theyarealsoavailableasseparatelaminatedposters.
Toaccessthesematerials,visitwww.dh.gov.ukorordercopiesfrom:
DHPublicationsOrderlinePOBox777LondonSE16XHEmail:[email protected]
Tel:03001231002Fax:01623724524Minicom:03001231003(8amto6pm,MondaytoFriday)
TOOLE5
Raising the Issue of Weight in Adults
YOURWEIGHT,
YOURHEALTH
Part of the
Series
1 RAISE THE ISSUE OF WEIGHT If BMI is >25 and there are no contraindications to raising the issue of weight, initiate a dialogue:
‘We have your weight and height measurements here. We can look at whether you are overweight. Can we have a chat about this?’
2 IS THE PATIENT OVERWEIGHT/OBESE?
BMI (kg/m2) Weight classification
<18.5 Underweight
18.5–24.9 Healthy weight
>25–29.9 Overweight
>30 Obese
Using the patient’s current weight and height measurements, plot their BMI with them and use this to tell them what category of weight status they are.
‘We use a measure called BMI to assess whether people are the right weight for their height. Using your measurements, we can see that your BMI is in the [overweight or obese] category [show the patient where they lie on a BMI chart]. When weight goes into the [overweight or obese] category, this can seriously affect your health.’
WAIST CIRCUMFERENCE
Increased disease risk
Men Women
>40 inches (>102cm) >35 inches (>88cm)
Asian men Asian women
>90 cm >80 cm
Waist circumference can be used in cases where BMI, in isolation, may be inappropriate (eg in some ethnic groups) and to give feedback on central adiposity. In Asians, it is estimated that there is increased disease risk at >90cm for males and>80cmforfemales.
Measuremidwaybetweenthelowestribandthetopoftherightiliaccrest.Thetapemeasureshouldsitsnuglyaroundthewaistbutnotcompresstheskin.
3 EXPLAIN WHY EXCESS WEIGHT COULD BE A PROBLEM IfpatienthasaBMI>25andobesity-relatedcondition(s):
‘Yourweightislikelytobeaffectingyour[co-morbidity/condition].Theextraweightisalsoputtingyouatgreaterriskofdiabetes,heartdiseaseandcancer.’
IfpatienthasBMI>30andnoco-morbidities:
‘Yourweightislikelytoaffectyourhealthinthefuture.Youwillbeatgreaterriskofdevelopingdiabetes,heartdiseaseandcancer.’
IfpatienthasBMI>25andnoco-morbidities:
‘Anyincreaseinweightislikelytoaffectyourhealthinthefuture.’
4 EXPLAIN THAT FURTHER WEIGHT GAIN IS UNDESIRABLE ‘Itwillbegoodforyourhealthifyoudonotputonanymoreweight.Gainingmoreweightwillputyourhealthatgreaterrisk.’
5 MAKE PATIENT AWARE OF THE BENEFITS OF MODEST WEIGHT/WAIST LOSS ‘Losing5–10%ofweight[calculatethisforthepatientinkilosorpounds]atarateofaround1–2lb(0.5–1kg)perweekshouldimproveyourhealth.Thiscouldbeyourinitialgoal.’
Ifpatienthasco-morbidities:
‘Losingweightwillalsoimproveyour[co-morbidity].’
Notethatreductionsinwaistcircumferencecanlowerdiseaserisk.ThismaybeamoresensitivemeasureoflifestylechangethanBMI.
6 AGREE NEXT STEPS Providepatientliteratureand:
• If overweight without co-morbidities: agreetomonitorweight.
• If obese or overweight with co-morbidities: arrangefollow-upconsultation.
• If severely obese with co-morbidities: considerreferraltosecondarycare.
• If patient is not ready to lose weight: agreetoraisetheissueagain(eginsixmonths).
BACKGROUND INFORMATION Raising the issue of weight Manypeopleareunawareoftheextentoftheirweightproblem.Around30%ofmenand10%ofwomenwhoareoverweight
1believethemselvestobeahealthyweight.Thereisevidencethatpeoplebecomemoremotivatedtoloseweightifadvisedtodoso
2byahealthprofessional.
Health consequences of excess weight Thetablebelowsummarisesthehealthrisks
3ofbeingoverweightorobese. Inaddition,obesityisestimatedtoreducelifeexpectancybybetween3and14years.Manypatientswillbeunawareoftheimpactofweightonhealth.
Greatly increased risk
• type2diabetes• gallbladderdisease• dyslipidaemia• insulinresistance• breathlessness• sleepapnoea
Moderately increased risk
• cardiovasculardisease• hypertension• osteoarthritis(knees)• hyperuricaemiaandgout
Slightly increased risk
• somecancers(colon,prostate,postmenopausalbreastandendometrial)
• reproductivehormoneabnormalities• polycysticovarysyndrome• impairedfertility• lowbackpain• anaestheticcomplications
1WardleJandJohnsonF(2002)Weightanddieting:examininglevelsofweightconcerninBritishadults.IntJObes26:1144–9.
2GaluskaDAetal(1999)Arehealthcareprofessionalsadvisingobesepatientstoloseweight?JAMA282:1576–8.
3JebbSandSteerT(2003)TacklingtheWeightoftheNation.MedicalResearchCouncil.
4DepartmentofHealth(2002)ProdigyGuidanceonObesity.CrownCopyright.
5NHMRC(2003)Clinicalpracticeguidelinesforthemanagementofoverweightandobesityinadults.CommonwealthofAustralia.
6RollnickSetal(2005)Consultationsaboutchangingbehaviour. BMJ331:961–3.
7O’NeilPMandBrownJD(2005)Weighingtheevidence:Benefitsofregularweightmonitoringforweightcontrol.JNutrEducBehav37:319–22.
8LancasterTandSteadLF(2004)Physicianadviceforsmokingcessation.CochraneDatabaseofSystematicReviews,4.
4Benefits of modest weight loss Patientsmaybeunawarethatasmallamountofweightlosscanimprovetheirhealth.
Condition Health benefits of modest (10%) weight loss
Mortality • 20–25%fallinoverallmortality
• 30–40%fallindiabetesrelateddeaths
• 40–50%fallinobesityrelatedcancerdeaths
Diabetes • uptoa50%fallinfastingbloodglucose
• over50%reductioninriskofdevelopingdiabetes
Lipids • 10%fallintotalcholesterol,15%inLDL,and30%inTG,8%increaseinHDL
Bloodpressure • 10mmHgfallindiastolicandsystolicpressures
Realistic goals for modest weight/waist loss5
(adapted from Australian guidelines)
Duration Weight change Waist circumference
change
Shortterm 2–4kgamonth 1–2cmamonth
Mediumterm 5–10%ofinitialweight
5%aftersixweeks
Longterm 10–20%ofinitialweight
aimtobe<88cm(females)
aimtobe<102cm(males)
Patientsmayhaveunrealisticweightlossgoals.
The need to offer support for behaviour change Thesuccessofsmokingcessationinterventionsshowsthat,inadditiontoraisingahealthissue,healthprofessionalsneedtoofferpracticaladviceandsupport.Rollnicketalsuggestsomewaystodothiswithintheprimarycaresetting.Providingalistofavailableoptionsinthelocal
6areamayalsobehelpful.
Importance of continued monitoring of weight Weightmonitoringcanbeahelpfulwayofmaintainingmotivationtoloseweight.Patientsshouldbeencouragedtomonitortheirweight
7regularly. Interventionsforsmokingcessationhavefoundthatbehaviourchangeismoresuccessfulwhenfollowupsareincludedin
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Raising the Issue of Weight in Children and Young People
YOURWEIGHT,
YOURHEALTH
Part of the
Series
1 WHEN TO INITIATE A DISCUSSION ABOUT WEIGHT
• If the family expresses concern about the child’s weight.
• If the child has weight-related co-morbidities.
• If the child is visibly overweight.
2 RAISE THE ISSUE OF OVERWEIGHT Discuss the child’s weight in a sensitive manner because parents may be unaware that their child is overweight. Use the term ‘overweight’ rather than ‘obese’. Let the maturity of the child and the child’s and parents’ wishes determine the level of child involvement.
If a parent is concerned about the child’s weight: ‘We have [child’s] measurements so we can see if he/she is overweight for his/her age.’
If the child is visibly overweight: ‘I see more children nowadays who are a little overweight. Could we check [child’s] weight?’
If the child presents with co-morbidities: ‘Sometimes [co-morbidity] is related to weight. I think that we should check [child’s] weight.’
3 ASSESS THE CHILD’S WEIGHT STATUS Refer to UK Child Growth Charts and plot BMI centile. Explain BMI to parent: eg ‘We use a measure called BMI to look at children’s weight. Looking at [child’s] measurements, his/her BMI does seem to be somewhat higher than we would like it to be.’
If the child’s weight status is in dispute, consider plotting their BMI on the centile chart in front of them. In some cases this approach may be inappropriate and upsetting for the family.
Overweight Severely overweight
BMI centile BMI centile >85th centile >95th centile
4 ASSESS SERIOUSNESS OF OVERWEIGHT PROBLEM AND DISCUSS WITH PARENT If child is severely overweight with co-morbidities, consider raising the possibility that their weight may affect their health now or in the future.
This could be left for follow-up discussions or raised without the child present as some parents may feel it is distressing for their child to hear.
‘If their overweight continues into adult life, it could affect their health. Have either you [or child] been concerned about his/her weight?’
Consider discussing these points with the parent at follow-up:
• Age and pubertal stage: the older the child and the further advanced into puberty, the more likely overweight will persist into adulthood.
• Parentalweightstatus:if parents are obese, child’s overweight is more likely to persist into adulthood.
• Co-morbidities:(see overleaf) increase the seriousness of the weight problem
5REASSURETHEPARENT/CHILDIf this is the first time that weight has been raised with the family, it is important to make the interaction as supportive as possible:
‘Together, if you would like to, we can do something about your child’s weight. By taking action now, we have the chance to improve [child’s] health in the future.’
6AGREENEXTSTEPSProvide patient information literature, discuss as appropriate and:
• Ifoverweightandnoimmediateactionnecessary:arrange followup appointment to monitor weight in three to six months: ‘It might be useful for us to keep an eye on [child’s] weight for the next year.’
• Ifoverweightandfamilywanttotakeaction:offer appointment for discussion with GP, nurse or other health professional; arrange threetosixmonth followup to monitor weight.
• Ifoverweightandfamilydonotwishtotakeactionnow:monitor child’s weight and raise again in six months to a year.
• Ifoverweightwithco-morbidities:consider referral to secondary care: ‘It might be useful for you and [child] to talk to someone about it.’
BACKGROUNDINFORMATION
IdentifyingtheproblemAscertaining a child’s weight status is an important first step in childhood weight management. Parents who do not recognise the weight status of their overweight children may be less likely to provide them with support to achieve a healthy weight. In a British survey of parental perception of their child’s weight, the overwhelming majority (94%) of parents with overweight or obese
1children misclassified their child’s weight status. Given this low level of parental awareness, health professionals should take care to establish a child’s weight status in a sensitive manner.
AssessingweightstatusinchildrenThe child growth charts for the UK allow easy calculation of BMI based on a child’s known
2weight and height. Measures of body fat in children can also be a useful way of assessing a child’s weight status. Details of body fat
3reference curves for children are now available, although, in practice, body fat cannot be assessed without the necessary equipment.
AssessingtheseverityoftheproblemA number of factors are known to increase the risk of childhood obesity and the likelihood that a weight problem will persist into adult life. Consideringthesefactorswillhelpyoutomakeaninformeddecisionaboutthemostappropriatemodeofaction.
• Theolderthechild,themorelikelyitisthattheirweightproblemwillcontinueintolaterlifeandthelesstimetheyhaveto‘growinto’theirexcessweight.
• Achildis20–40%morelikelytobecomeobeseifoneparentisobese.Thefigurerisestoaround80%ifbothparentsareobese.
• Whileweightproblemscanleadtopsychosocialissuessuchasdepressionandlowselfesteem,weightlossmaynotnecessarilyresolvetheseproblems,sodon’truleoutreferraltoCAMHS.
1CarnellSetal(2005)Parentalperceptionsofoverweightin3–5yearolds.
IntJObes29:353–5.2ColeTetal(2002)Acharttolinkchildcentilesofbodymassindex,weight
andheight.EurJClinNutr56:1194–9.3JebbSetal(2004)Newbodyfatreferencecurvesforchildren.ObesRev
(NAASOSuppl)A156.4McCallumZandGernerB(2005)Weightymatters:Anapproachtochildhood
overweightingeneralpractice.AusFamPhys34(9):745–8.5BritishMedicalAssociationBoardofScience(2005)Preventing Childhood Obesity.BMA.
Healthrisksofexcessweightinchildhood
4,5
Beingobeseinchildhoodoradolescenceincreasestheriskofobesityinadultlife.Childhoodobesitywillalsoincreasethechancesofdevelopingchronicdiseasestypicallyassociatedwithadultobesity:
• insulinresistanceandtype2diabetes;
• breathingproblemssuchassleepapnoeaandasthma;
• psychosocialmorbidity;
• impairedfertility;
• cardiovasculardisease;
• dyslipidaemia;
• hypertension;
• somecancers;
• orthopaediccomplications.
ImportanceofweightcontrolFormanyoverweightchildren,preventionoffurtherweightgainisthemaingoalbecauseaslongastheygainnomoreweight,theycan‘growinto’theirweightovertime.Thisgoalcanbeachievedthroughlifestylechanges:
• improvingthediet,egbyincreasingfruitandvegetableconsumption,reducingfatintakeandportionsizes,consideringintakeofsugarydrinks,andplanningmeals;
• increasingactivity,egplayingfootball,walkingthedog;
• reducingsedentarybehaviourssuchastimespentwatchingTVorplayingcomputergames.
Ifthechildismoreseverelyoverweight,orhasalreadyreachedadolescence,‘growinginto’weightismoredifficultandweightlosshastobeconsidered.
NeedtooffersolutionsUnlessthechildisseverelyoverweightwithcomorbidities,beledbytheparents’and/orchild’swishes.Encourageactionifappropriate.Healthprofessionalsshouldbereadytoofferreferralsupportsothattheyareseenastakingtheissueseriously. Ifthechildisveryoverweightandhascomorbidities,thechild(andfamily)mayrequireongoingsupportdespitereferrals,egthroughcontinuedweightmonitoring,additionalspecialistreferrals,orhelpwithfamilybasedlifestylemodification.
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220 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLE6Raisingtheissueofweight–Perceptions 221
TOOLE6Raisingtheissueofweight–perceptionsofoverweighthealthcareprofessionalsandoverweightpeople
TOOLE6
For: Healthcareprofessionals,particularlythosewhoareoverweight
About: Thistoolprovidestheresultsofresearchundertakentoinvestigatetheexperiencesandbeliefsofoverweighthealthcareproviderswhoprovideweightmanagementadvice,andtheviewsandperceptionofinformationofpatientsreceivingweightrelatedinformationfromoverweighthealthcarepractitioners.
Purpose: Toprovideanunderstandingoftheperceptionsofoverweighthealthcareprofessionalsandoverweightpeople.
Use: Overweighthealthcareprofessionalscanusethistooltohelpthemraisetheissueofweightwithoverweightpatients.
Resource: Overweight health professionals giving weight management advice: The perceptions of health professionals and overweight people222
Likethepopulationasawhole,somehealthcareprofessionalsareoverweightorobese.Anecdotally,itisknownthatthesehealthpractitionerscanfinditdifficulttogiveadvicetooverweightpatients.Researchwasthereforecommissionedtolookattheattitudesofoverweighthealthcareprofessionalsandoverweightpatients.Theresultsarenotconclusiveandmoreresearchisrequiredtoprovideoverweightpractitionerswithguidanceonhowtoraisetheissueofweightwiththeirpatients,buttheresearchcontainssomemessagesthatareworthconsiderationbyhealthprofessionals.
PerceptionsofoverweighthealthcareprofessionalsCredibilityandprofessionalism
• Overall,mosthealthprofessionalsfelttheirexpertiseandempatheticmannerweremostimportanttotheircredibility.Althoughsomeacknowledgedthattheirweightmayaffecthowtheirpatientsviewthem,manythoughtthatbeingoverweightor‘notskinny’wouldhaveapositiveeffectinbuildingarelationshipwithoverweightpatients.“I often discuss whether I can be taken credibly in my role (dietitian) given that I myself am obese.”
“Despite being overweight as a practitioner you still have valid expert advice on weight management. However, patients may feel that it is not such valid advice if you cannot follow it yourself!”
• Interestingly,nearlyallhealthprofessionalsthoughtthatoverweightandparticularlyobesecolleagueswerelesscrediblethantheyperceivedthemselvestobe:“The trainer was morbidly obese and although clearly technically competent, his physical appearance was distracting and caused me to question his validity as a trainer. There is no rational thought behind this perception, but clearly this has been instilled into my psyche by the continuous cultural and media-driven accepted norms.”
222 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
• Somehealthprofessionalsthoughtthatbeingoverweight–andparticularlybeingobese–wouldhinderthecredibilityandprofessionalreputationofahealthprofessional.“How can a health professional who does not value a healthy weight help other people?”
“I remember a dietitian who was very overweight and thinking, ‘How can she give advice?’”
Underplayingthesignificanceofpersonalweight
Althoughallhealthprofessionalswhoparticipatedintheresearchselfselectedthemselvesasan‘overweight health professional’ definedashavingaBMIofover25kg/m2,andmanyreportedweightsandheightsindicatingaBMIwellover30kg/m2,severalviewedthemselvesorthoughttheywereperceivedasahealthyweight.
“….. although my BMI is 34, I don’t necessarily look that big because of my age and height; I’m just sturdy.”
Reflexivity
Intervieweesfounditdifficulttoansweraquestionaboutwhateffecttheirownweightmighthaveonwhetherthesubjectofweightisdiscussed.Thiswasnotsomethingtheyhadthoughtofbefore:
“It’s not something I have really thought about until now.”
“It’s impossible to know if my weight has any effect. I mean, how would we ever know and how could you measure that?”
Perceivedadvantagesofoverweighthealthprofessionals
Healthprofessionalsthoughtthatsharingpersonalexperienceofweightmanagementhelpedthemtobemoreempatheticandbuildrapportwiththeirpatients.Asaresult,somesaidtheyreferredtotheirownweightorusedpersonalexamplesofbehaviourchange.
“I can relate to them. I gained five stone in a year so normally I would not have had an issue with my weight and now I have a huge issue with my weight. I can say ‘I understand what you are going through.’”
Mentioninghealthprofessionals’ownweightduringconsultations
• Mosthealthprofessionals(70%)saidthattheymentionedtheirownweightandlifestyleinconsultations.Thiswasoftenusedtodemonstratestrategiestochangeeatingbehaviourandincreasephysicalactivity.Thosewhomentionedtheirweightfeltthatithelpedthemtoempathisewithpatients.“I have found the patients I do mention it [weight] to are more likely to be open and honest with me.”
“A patient has said that they would much rather be seen by someone who wasn’t skinny so would have an understanding of how difficult it is.”
• Asmallproportionofthesamplesaidtheywouldnotmentiontheirownweight.Participantsinthisgroupweregenerallyagainsttheideaofusingpersonalreferencesintheconsultations.Afewreferredtothenotionoftalkingabouttheirownweightasunprofessionalandnotpatientcentred.
TOOLE6Raisingtheissueofweight–Perceptions 223
“No – I work in a patient-centred way and use the skill of immediacy to direct the conversation back to the person.”
“No, I don’t mention my weight as it’s a patient-centred consultation.”
• Sotheyviewedreferencetotheirownweightasshiftingthefocusawayfrombeingpatientcentredtohealthprofessionalcentred.Thiswasadominantthemeamongthosewhodidnotmentiontheirweight.
Impactofhealthprofessionals’ownweightonraisingweightasanissue
Somehealthprofessionalssaidtheirownweightmadeitlesslikelyormoredifficulttodiscussweightlosswithpatients:
“It does hinder me. How can I provide advice if I am clearly struggling to follow my own advice?”
“I do feel uncomfortable about discussing weight management because I am overweight. I think I may be more likely to discuss weight opportunistically if I was not overweight myself.”
PerceptionsofoverweighthealthcareprofessionalsbyoverweightpeopleValueofadvicefromanoverweighthealthcareprofessional
Somepeoplethoughtthatseeinganoverweighthealthcareprofessionalwashelpful.Themainbenefitswerethoughttobegreaterempathyandinsightfromthehealthcareprofessionalandafeelingoftrust:
“She was sensitive and understanding and very encouraging. She acknowledged her weight and said if it was easy to lose weight, she’d be a size zero! She was funny and I felt understood and not demeaned in any way.”
Mentioninghealthcareprofessionals’ownweight
Itwasfelttherewasaneedforoverweightprofessionalstomentiontheirownweight,particularlyasitcouldbedistractingotherwise.Peoplealsowantedtohearpersonalweightloss‘tips’,yetthisislikelytobeproblematicbecauseitmovesthediscussionawayfromapatientcentred,evidencebasedapproach.
However,thereweresomeproblemsassociatedwithhealthcareprofessionalswhohadlostweight,withthembeing:
“… like a reformed smoker.”
“They hate fat and forget how hard it is.”
Negativeperceptions
• Therewasastrongreactionamongoverweightpeoplethatadvicefromanoverweighthealthprofessional,particularlythosewhowerenotempathetic,washypocriticalanduninspiring,withrespondentsquestioningthevalidityoftheadvice:“They can only give text book advice and it’s slightly hypocritical.”
“They should practise what they preach.”
224 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
“I was relieved to find an overweight doctor – I thought that she would understand the problems and how difficult it is to address the issues but ... she was very dismissive and quite patronising. I went into the surgery feeling low and came out feeling guilty and thought I was a total waste of her valuable time as I wasn’t ill in the conventional sense. After that, I tended to avoid the doctor. Even though it was a few years ago now, it still affects the way I feel and act at the doctor’s.”
• Severalparticipantsraisedtheissueofthestigmaaroundhealthprofessionalsbeingoverweight.Thisattitudedemonstratesthecrucialneedforreflexivityinweightmanagementpractice.Insomeinstances,healthprofessionalswhowereoverweightwereperceivedasmorejudgemental,withpatientssuggestingthathealthprofessionalstakeouttheirownweightissuesonpatientsorthattheyareselfconsciousaboutbeingoverweight.
• Therewassomehostilitytowardsoverweighthealthprofessionalsbecauseoftheirweight,demonstratinghowpervasiveweightbiascanbe.
TOOLE7Leafletsandbookletsforpatients 225
TOOLE7LeafletsandbookletsforpatientsFor: Allhealthcareprofessionalsincontactwithpatients,egGPs,nurses,
pharmacists,psychologists,dentists,healthvisitors
About: Thistoolprovidesdetailsofleafletsandbookletsthathavebeenproducedforpatientswhoareworriedaboutbeingoverweightorobeseorwhoareoverweightorobese.Theleafletsprovidedetailsonhealthylifestyles,losingweight,treatmentandmaintainingahealthyweight.
Purpose: Toprovidehealthcareprofessionalswithdetailsofleafletsthatcanbeorderedtooffertopatients.
Use: Healthcareprofessionalsshouldordertheseleafletsfortheirworkplaceandmakethemavailabletopatientswhoareeitherworriedaboutexcessweightorwhoareoverweightorobese.
Resource: www.nice.org.uk,www.dh.gov.uk,bhf.org.uk/publications
TOOLE7
TheleafletsandbookletsforpatientslistedonthenextpagehavebeenproducedbytheNationalInstituteforHealthandClinicalExcellence(NICE),theDepartmentofHealthandtheBritishHeartFoundation.
Howtoorder
NICEpublications
Availablefromwww.nice.org.uk
DepartmentofHealthPublications
Visitwww.dh.gov.ukororderacopybycontacting:
DHPublicationsOrderlinePOBox777LondonSE16XHEmail:[email protected]
Tel:03001231002Fax:01623724524Minicom:03001231003(8amto6pm,MondaytoFriday)
BritishHeartFoundationpublications
BHFOrderline:08706006566email:[email protected],website:bhf.org.uk/publications
226 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
GenerallifestyleadviceFromNICE
NICEhasproducedaninformationbookletforpatients.(Seepage225fordetailsofhowtoobtaincopies.)
Understanding NICE guidance – Preventing obesity and staying a healthy weight223
Thisbookletisaboutthepreventionofobesityandstayingahealthyweight,forpeopleinEnglandandWales.ItexplainstheNICEguidanceforhealthprofessionals,localauthorities,schools,earlyyearsproviders,employersandthepublic.Itiswrittenforpeoplewhowanttoknowhowtomaintainahealthyweight,butitmayalsobeusefulfortheirfamilies,carersoranyoneelsewithaninterestinobesity.
AdviceforoverweightandobesepatientsFromtheDepartmentofHealth
TheDepartmentofHealthhaspublishedanumberofleafletsforpatientswhoareoverweightorobese.Theleafletsprovideadviceonlosingweightandthehealthrisksassociatedwithexcessweight.(Seepage225fordetailsofhowtoordercopies.)
Why weight matters224
Aleafletforoverweightpatientswhoarenotyetcommittedtolosingweight.Itdiscussestherisksassociatedwithoverweight,thebenefitsofmodestweightloss,andpracticaltipsforpeopletoconsider.
Your weight, your health: How to take control of your weight225
Abookletforoverweightpatientswhoarereadytothinkaboutlosingweight.
Healthy Weight, Healthy Lives: Why your child’s weight matters 226
TheleafletprovidesinformationforparentsabouttheNationalChildMeasurementProgramme(NCMP).Italsoincludespracticaltipsonhowtohelpchildreneatwellandbecomemoreactive,whymaintainingahealthyweightisimportant,andstepsthatparentscantaketohelptheirfamilyleadahealthylifestyle.
FromNICE
Understanding NICE guidance – Treatment for people who are overweight or obese227
ThisbookletisabouttheNHScareandtreatmentinEnglandandWalesavailableforpeoplewhoareoverweightorobese.ItexplainstheguidancefromNICE.Itiswrittenforpeoplewhomayneedhelpwiththeirweightproblemsbutitmayalsobeusefulfortheirfamiliesorcarersoranyonewithaninterestinobesity.(Seepage225fordetailsofhowtoordercopies.)
FromtheBritishHeartFoundation
So you want to lose weight ... for good228
Thisisaguideformenandwomenwhowouldliketoloseweight.Itprovidesguidanceonfoodportionsizesforweightloss.(Seepage225fordetailsofhowtoordercopies.)
TOOLE8FAQsonchildhoodobesity 227
TOOLE8FAQsonchildhoodobesity
For: Healthcareprofessionals,particularlyinprimarycare
About: Thistoolprovidessuggestedresponsestofrequentlyaskedquestionsregardingchildhoodobesity.Itincludesonlyaselectednumberofquestions.Formoreinformationgotowww.nhs.uk
Purpose: Toprovidehealthcareprofessionalswithaconciseandhandytoolthattheycanusetoanswerqueriesaboutchildhoodobesity.
Use: Tobeusedasaquickmethodofansweringqueriesfromparents/patientsworriedabouttheirchildbeingoverweightorobese.
Resource: NHSChoiceswebsitewww.nhs.uk
TOOLE8
RecognisingobesityWhyhaveIbeentoldmychildisoverweight/obese?Mychilddoesnotlookoverweightorobese.
Today,manymoreofus–adultsandchildren–areabovetheweightthatweshouldbetoremainhealthyandhappy.Therearemanyreasonsforthis.However,oneresultofthefactthatweasasocietyaregettinglargeristhatwehavelostsightofwhatahealthyweightactuallylookslike,becausewearenowusedtoseeinglargerpeopleandwecompareourselvesandourchildrentoothersaroundus.
Anotherresultofusgettinglargeristhattherehasbeenagreatdealofmediaattentionrelatingtoobesitywhichhastendedtofocusonsomeofthemostextremecasesofobesityintheworld,ratherthanthe‘everyday’weightproblemsthatweandourchildrenarefacing,andthishasdistortedourthinking.
Becauseoftheabove,itissometimesdifficultforustorecogniseweightconcerns,particularlyinourownchildren.However,weightcanbecomeahugeproblemforchildrenintermsoftheirphysicalandemotionalhealth.Ifyourchildisoverweightorobese,thebestthingtodoforthemistobeopentothefactthattheywillneedyoursupportinchangingbehaviourtoachieveahealthyweightnowandfortheirfuture.
CausesofchildhoodobesityAregenesthemaincauseofobesity?
No.Somepeoplemayhaveageneticpredispositiontowardsobesity,buttherealityisthatmany,manymoreofusareoverweightorobesethanusedtobethecase–andourgeneshaven’tchanged.Eventhosewhodohaveageneticpredispositiontoobesitywillnotdefinitelybecomeandremainoverweightorobese.Weshouldnevergiveuptryingtoadoptandmaintainthelifestylesthatwillhelpusandourchildrenachieveahealthyweight.
Whyaresomechildrenobeseoroverweight?
Atitssimplestlevel,children(andadults)canbecomeoverweightorobesebecause,overaperiodoftime,theymoveabouttoolittleandeattoomuch.Eating‘toomuch’canmeanhavingportionsthataretoobig,snackingtoomuch,orhavingtoomuchofthefood(anddrink)thatis
228 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
highincalories.Asasociety,manyofusareeatingmorethanweshould.Highenergyfoodisreadilyavailable.Mostofusarealsofarlessactivethanweusedtobe–wetendtodriveeverywhereratherthanwalk,andstayinsidemore.Becauseofthis,lotsandlotsofus–adultsandchildren–arenowoverweightorobese.Maintainingahealthyweightisalotharderthanitusedtobe.
Weightproblemscanbeginataveryearlyageanditisimportantthatwedon’tignorethis,asthisisjuststoringuphealthproblemsforthefuture.Childrenwithweightproblemscandevelopverylowselfesteemandbecomedepressed.Oneresearchstudyshowedthatthequalityoflifeofyoungchildrenwhowereobesewassimilartothatofchildrenlivingwithcancer.Weneedtobedoingeverythingwecantostopchildrendevelopingweightproblemsinthefirstplace,andhelpingthemadopthealthierlifestylestoreducetheirweightiftheydobecomeoverweight.
TacklingchildhoodobesityWhatcanIdotohelpmychildbemorephysicallyactive?
Tobehealthy,childrenneedtodoatleastonehourofphysicalactivityeveryday.Childrenwhoareoverweightneedtodomorethanthis.Anhour’sactivityeverydaymaysounddifficulttoachieve.Oneofthebestwaystoensureregularactivityistobuildthisintotheschoolday,byencouragingyourchildtocycleorwalkatleastpartofthewaytoschooleachdayormostdaysoftheweek.Joininginwiththemisagreatwayofsharingqualitytimewiththemandkeepingfityourself.OtherwaysaredevotingsomeregulartimetofamilyactivitiesateveningsandweekendsandlimitingtheamountoftimethatchildrenareallowedtospendinfrontoftheTVorcomputer–childrenwhospendthemosttimeinfrontoftheTVtendtobethosewhoaremostoverweight.
Mychildisn’tthesportytypeandwon’ttakepartinanythingsporty.
Notallchildrenenjoytakingpartintraditionalsportsandthiscanparticularlybethecaseforthosewhoareconsciousoftheirweight.Themostimportantthingistofindactivitiesthatyourchildfindsfun.Thisdoesn’thavetobefootballornetball.Anyactivitythatgetsachildslightlyoutofbreathcounts–forexample,walkingatagoodpace,playingwithpetsordancing.
It’salsoimportanttorealisethattheonehourofphysicalactivityadaythatisrecommendedforchildren(andthe30minutesmostdaysforadults)doesnotneedtobecontinuous.Itcanbemadeupofshortburstsofactivitythataddupto60minutes,forexample,two15minutewalkstoandfromschooladay,and30minutesofactivityintheparkintheeveningforachild,orforanadult,15minutesplayingwithyourchildand15minutesdoinghousework.
Mychildconstantlysnacksoncrisps,chocolatesandfizzydrinks.HowdoIstophim/her?
Thereisroomwithinahealthybalanceddietforyourchildtoenjoytheoccasionalunhealthysnack.Whenthesefoodsareformingpartoftheeverydaydietitistimetotrysomechanges.Mostofuswouldbenefitfromreducingtheamountofsalt,sugarandsaturatedfatinourdiets,sotrytograduallyreplacefoodshighinthesewithhealthieroptions–forexample,waterinsteadoffizzydrinksonmostdays,orfruitinsteadofchocolateandcrispsforsnacking.Thebestthingtodoisintroduceyourchildgraduallytoarangeofdifferent,healthiermealsandsnacksandpersist–itcantakechildrenalongtimetogetusedtotastesthatareunfamiliar.
TOOLE8FAQsonchildhoodobesity 229
Doesjunkfoodduringpregnancygivechildrenasweettooth?
Thereisapossiblerelationshipbetweenfoodconsumedbythemotherduringpregnancyandthesubsequenttastesofherchildren,althoughthishasnotyetbeenprovenconclusively.However,itisveryimportantforpregnantwomentotakegoodcareofthemselvesbyeatingabalanceddiet.
Areworkingmotherstoblameforchildhoodobesity?
OnelargestudyintheUKfoundthatchildrenweremorelikelytobeoverweightatbirthiftheirmotherworked,particularlyiftheyworkedlonghours.Thisdoesnotmeanmothersaretoblameforobesity.Fewofusintoday’ssocietyareinapositionwhereaparentisableorwillingtoremaininthehome.However,clearlysocietyhaschangedandwithlongworkinghours,itisnowmuchharderforfamiliestofindtimetocookandbeactive.
Arechildrenwhodon’tgetenoughsleepmorelikelytobeobesewhentheygrowup?
Somestudieshavefoundarelationshipbetweensleepproblemsinchildhoodandweightinadulthood.However,thereisnoclearevidencetoshowthatthetwoaredirectlyrelated.
ObesityandpregnancyIamstrugglingtogetpregnant.IhavealsobeentoldIamobese.Arethetworelated?
IfyourBodyMassIndex(BMI–themeasureusedtocalculateweightstatus)isover29,thismaymakeitlesslikelythatyouwillbecomepregnant,andthegreateryourBMI,thelowerthelikelihoodofpregnancy.Thereareotherreasonsforhavingproblemsconceiving(includingBMIoftheman).Ifyouarehavingproblems,askyourdoctorforadvice.Yourdoctormayreferyoutoanappropriatespecialist.
IampregnantandhavebeentoldIamobeseandneedtodosomethingaboutit.Whydoesthismatter?Iwanttogivemybabythebeststartinlifeandameatingfortwo.
Therearemanyreasonsformaintainingahealthyweightatallstagesoflife,includingduringpregnancy.Womenwhoareobesewhilepregnanthaveahigherriskofhavinganinfantwithspinabifida,heartdefects,smallerarmsandlegsthanaverage,herniainthediaphragmandotherbirthdefects.Theselinksarenotyetfullyunderstood,andmaybeduetoundiagnoseddiabetes.
230 Healthy Weight, Healthy Lives: A toolkit for developing local strategies
TOOLE9TheNationalChildMeasurementProgramme(NCMP) 231
TOOLE9TheNationalChildMeasurementProgramme(NCMP)
TOOLE9
For: HealthcareprofessionalswhomaybeinvolvedintheNationalChildMeasurementProgramme(NCMP)
About: ThistoolbrieflyoutlinesthepurposeoftheNCMPandincludesFAQsfromparentsabouttheNCMP.
Purpose: TogivehealthcareprofessionalsbackgroundinformationontheNCMPandtoprovideanswerstoquestionsthatmayberaisedbyparentsofchildreninvolvedintheNCMP.
Use: TobeusedifparentshaveaqueryabouttheNCMP.
Resource: Information–guidanceandresources–ontheNCMPcanbefoundatwww.dh.gov.uk/healthyliving
PurposeoftheNCMPTheNCMPisonepartoftheprogrammeofworktoimplementtheHealthy Weight, Healthy Lives strategy,andisoverseenbytheCrossGovernmentObesityUnit(DepartmentofHealthandtheDepartmentforChildren,SchoolsandFamilies).EveryyearchildreninReceptionYearandYear6areweighedandmeasuredduringtheschoolyearaspartofthisprogramme.TheprimarypurposeoftheNCMPisto:
• helplocalareastounderstandtheprevalenceofchildobesityintheirarea,andhelpinformlocalplanninganddeliveryofservicesforchildren
• gatherpopulationlevelsurveillancedatatoallowanalysisoftrendsingrowthpatternsandobesity,and
• enablePCTsandlocalauthoritiestousethedatafromtheNCMPtosetlocalgoalsaspartoftheNHSOperatingFrameworkvitalsignsandtheirLAANationalIndicatorSet,agreethemwithstrategichealthauthoritiesandgovernmentoffices,andthenmonitorperformance.
Theprogrammealsoincreasespublicandprofessionalunderstandingofweightissuesinchildren,andengagesparentsandfamiliesinhealthylifestylesandweightissues,throughtheprovision(whetherroutinelyorbyrequest)oftheresultsandadditionalinformationtoparents.
FAQsfromparentsQ:Whyismychildbeingweighedandmeasured?
A:TheNHSwantstoknowhowhealthychildreninEnglandare.RecordingtheheightsandweightsofchildreninReceptionandYear6helpsthemtoworkthisout,sothattheycandecidewhatmoretheyneedtodotohelpchildrenbehealthierandlivehealthierlives.
Q:Willmychild’sheightorweightbeshowntootherpeople?
A:No.Onlythepersonweighingyourchildwillseetheirheightorweight.Theywillwriteitdownsecretlyanditwillbekeptconfidential.Nobodywillbeshownyourchild’sweight,exceptyou.Yourprimarycaretrustcouldautomaticallycontactyouaboutyourchild’sweight,butifyoudonothearfromthem,youcanaskyourprimarycaretrustfortheresults.
232 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Q:Willmychild’sfriendsknowwhatmychild’sheightandweightare?
A:No,yourchild’sfriendsandclassmateswillnotbetoldandwillnotseewhatyourchildweighsorhowtalltheyare.
Q:Willmychildhavetotaketheirclothesoff?
A:No.Yourchildwillremainfullyclothedatalltimes,buttheywillbeaskedtotakeofftheirshoes.Ifyourchildiswearingheavyoutdoorclothing,suchasacoatorathickjumper,theywillbeaskedtotakethisofftoo.
Q:Willotherpeopleseemychildbeingweighedandmeasured?
A:Yourchildwillbeweighedandmeasuredawayfromotherpeople.Whenitisyourchild’sturn,theywillbecalledintotheroomorthescreenedoffarea.Theonlypeopleinthisareawillbeyourchildandthepersonweighingthem,althoughtheycantakeafriendinwiththemiftheyprefer.
Q:Whathappensduringtheprocess?
A:Yourchildwillbecalledintotheprivateareawheretheweighingandmeasuringwilltakeplace.Thepersonwillmeasureyourchild’sheightusingaspecialheightmeasure(likeabigruler).Theywillalsorecordtheirweightbyaskingthemtostandonasetofscales.Theywillthenwriteyourchild’sheightandweightdownandkeepitconfidential.Thatisallthereistoit.
Q:Whathappensaftermychildhasbeenweighed?
A:Afterallthechildrenintheclasshavebeenweighed,thepersonrunningtheexercisewilltakealltheresultsbacktotheprimarycaretrust.Theywilltheninputtheresultsontoacomputerandsendtheresultsofftoaplace(theNHSInformationCentre)wherepeoplecollecttheheightsandweightsofallthechildreninthecountrywhohavebeenweighed.Yourchild’snamewon’tbesent,sonoonewillbeabletofindtheirresultsfromthis.ThiswillhappenforeachschoolinEngland.TheNHSwillthenlookatallthemeasurements,sotheycanplanhowtohelpchildrenbehealthier.
Q:HowcanIfindouttheresults?
A:YourPCTcouldautomaticallycontactyouaboutyourchild’sweight,butiftheydonot,youwillbeabletofindoutyourchild’sresultsbycontactingthemyourself.Theleafletyouaregivenwillalsoexplainmoreabouttheweighingandmeasuringprocess,andwillprovideyouwithsomesimpletipsonhowthewholefamilycangetactiveandeathealthymeals.
Q:Willmychildhavetogoonaspecialdietorexerciseprogrammeaftertheweigh-in?
A:Allchildrenshouldbeencouragedtoeathealthyfoodandbephysicallyactive.Remember,onlyyouwillknowtheresults.Iftheresultssuggestthatyourchild’sweightispossiblyunhealthy,youandyourchildmaychoosetomakesomechangesasafamily–suchaseatingmorehealthilyandbeingmorephysicallyactive.Buttheschoolwillnotbeputtingyourchildona‘diet’ormakeyourchildchangethewaytheyeat.
Q:Istheresomeonemychildcantalktoiftheyareworriedabouttheirweight?
A:Yes.Yourchildcantalktotheirschoolnurseorthepersonwhoisweighingthem.Theycantalktothemabouttheirconcernsandcansuggestwheretheycangoforfurtherhelp,ifitisneeded.Youwillbeabletogetacopyofaleafletwhichincludessomesimpletipsonhowtobehealthier.
Note:MoreguidancewillbeproducedonroutinelyfeedingbackNCMPdatatoparents,anddealingwithfollowuprequests,inlate2008.
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Acronyms 243
AcronymsBME blackandminorityethnic
BMI BodyMassIndex
CHD coronaryheartdisease
CHPP ChildHealthPromotionProgramme
CMO ChiefMedicalOfficer
CRM customerrelationshipmanagement
CVD cardiovasculardisease
CWT CarolineWalkerTrust
DCMS DepartmentforCulture,MediaandSport
DCSF DepartmentforChildren,SchoolsandFamilies(formerlytheDepartmentforEducationandSkills)
DfES DepartmentforEducationandSkills(nowtheDepartmentforChildren,SchoolsandFamilies)
ECM EveryChildMatters
EPP ExpertPatientsProgramme
EYFS EarlyYearsFoundationStage
FIP FamilyInterventionProject
FIS FamilyInformationServices
FiS FoodinSchools
FNP FamilyNursePartnership
FPH FacultyofPublicHealth
GMS GeneralMedicalServices
HDL highdensitylipoprotein
IOTF InternationalObesityTaskforce
JSNA jointstrategicneedsassessment
LA localauthority
LAA localareaagreement
LDL lowdensitylipoprotein
LDP LocalDeliveryPlan
LEAP LocalExerciseActionPilot
LPSA LocalPublicServiceAgreement
LSP LocalStrategicPartnership
MOI MemorandumofInformation
NCMP NationalChildMeasurementProgramme
244 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
NGO nongovernmentalorganisation
NHF NationalHeartForum
NHLBI NationalHeart,Lung,andBloodInstitute
NHSS NationalHealthySchoolsStandard
NICE NationalInstituteforHealthandClinicalExcellence
NIS NationalIndicatorSet
NOF NationalObesityForum
NSF NationalServiceFramework
NSMC NationalSocialMarketingCentre
NSP NationalStepOMeterProgramme
NSSeC Nationalstatisticssocioeconomicclassification
OGC OfficeofGovernmentCommerce
OSA obstructivesleepapnoea
PBC practicebasedcommissioning
PCT primarycaretrust
PEAT PatientEnvironmentActionTeam
PEC professionalexecutivecommittee
PESSCL PE,SchoolSportandClubLinks
PHIAC PublicHealthIndependentAdvisoryCommittee
PHO PublicHealthObservatory
PI performanceindicator
PPF PrioritiesandPlanningFramework
PSA PublicServiceAgreement
QMAS QualityManagementandAnalysisSystem
QOF QualityandOutcomesFramework
RCPCH RoyalCollegeofPaediatricsandChildHealth
RCT randomisedcontrolledtrial
SACN ScientificAdvisoryCommitteeonNutrition
SFVS SchoolFruitandVegetableScheme
SHA strategichealthauthority
SIGN ScottishIntercollegiateGuidelinesNetwork
SLA servicelevelagreement
TIA transientischaemicattack
WC waistcircumference
WHI WalkingtheWaytoHealthInitiative
WHO WorldHealthOrganization
WHR waisthipratio
Index 245
IndexAactivity–Seephysical activity agedifferencesinoverweightandobesity
adults 9,11children15,17,18,20
aimofstrategy 59,105alcohol 40antenatalcare37assessmentofobesityandoverweight 48,72,203,
207inadults 203inchildren211
asthma 22,37atriskgroups35,36,59,91,201auditcriteria 69awareness
healthyeating 123ofparents133physicalactivity 126
Bbackpain 22,24,26behaviour:targetingbehaviour 65,117,133benefitsoflosingweight 28biologyofobesity 30bloodpressure22,23,25,28BMI
adults 203children211
BodyMassIndex–SeeBMI breastfeeding37breathlessness22,27,28
Ccancer 22,23,26capabilities 70cardiovasculardisease23carepathways47,195causesofoverweightandobesity 8,30,227centileBMIchartsforchildren215centralobesity 12,91,94chart:heightweightchart 208checklist
commissioninghealthandwellbeingservices 82commissioningsocialmarketing 155monitoringandevaluation 168
childrenassessmentofoverweightandobesity 72,211childhoodobesityFAQs227estimatingprevalenceofoverweightandobesity59,93healthygrowthandweight37prevalenceofoverweightandobesity15
cholesterol22,23,25,28
classificationofoverweightandobesityadults 204children211
clinicalguidanceonoverweightandobesity 47,72,195
clustergroups59,101commissioningservices 67,79,151
socialmarketing 67,155WorldClassCommissioning55,79
communication 66,139communityinterventions 124,125,127,128comorbidities 23conditionsassociatedwithobesity 23coronaryheartdisease22,23,24cost
localcostofoverweightandobesity 59,95ofoverweightandobesity 29oftakingaction 65
costeffectivenessofinterventions 64,119cycling 44,45,50
Ddatacollection 162diabetes 22,23,24,27,28,37diet
effectivenessofinterventions119guidanceon 40nationalaction 42
drugtreatmentforobesity47dyslipidaemia 22,23,25,28
Eearlyyears 38,120eating–Seediet eatwellplate 41eczema 37effectivenessofinterventions119effectsofobesity22energybalance 8,30environment30,31,44ethnicminoritypopulations–Seeminority ethnic
populations evaluation 68,159exercise–Seephysical activity exercisereferralschemes50ExpertPatientsProgramme71,172
Ffamilies 65,101,133,139fatinthediet 40,41fertility 22fibre40FiveADay 42foetaldefects 22foodchoices 40foodenvironment31fruit 40,41
246 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
Ggallbladderdisease 22,23,26genderdifferencesinoverweightandobesity
inadults 9,11,12,13inchildren15,17,18
genes 30,227goalsforlocalstrategy 58,60,105gout 22Governmentaction35growthreferencecharts211
Hhealthconditionsassociatedwithobesity 23healthprofessionals’role49healthyeating–Seediet heightweightchart 208highbloodpressure22,23,25,28hyperinsulinaemia 22hypertension 22,23,25,28hyperuricaemia 22
Iidentificationofobesepatients 47,201infantnutrition 37informationforpatients 225insulinresistance22,28interventions
choosing 63,119evidenceofcosteffectiveness119evidenceofeffectiveness119
Lleadership 61,109lifecourse 35,36liverdisease 23,26losingweight:benefitsforhealth 28lowbackpain 22,24,26
Mmanagementofoverweightandobesity 47marketing 101measurementofobesityandoverweight
inadults 203inchildren211
mechanicaldisorders24,26medicinestotreatobesity47metabolicsyndrome23,25minorityethnicpopulations
attitudes 134,135,137classificationofoverweightandobesity 204,205communicationwith 141estimatingprevalenceofobesity94interventions 66prevalenceofobesityinadults9,12,13prevalenceofobesityinchildren15,18targetingbehaviour 65,133
monitoring 68,159morbidity:obesityrelated22mortality 22,28
NNAFLD 23,26NationalChildMeasurementProgramme58,59,231nationalindicators 57,108NationalMarketingPlan 142NHS:costofobesity 29
Oobesity
assessment 72causes 30definition 8,203prevalence9
objectivesofobesitystrategy 60,107obstructivesleepapnoea 24,27organisations 185OSA 24,27osteoarthritis 22,26overweight
assessment 72causes 30definition 8,203prevalence9
Ppartnershipboard61partnershipworking 61,110patients:informationfor 225pedometers 50pharmacists 49physicalactivity 30,43
attitudesto 136children32,228interventions:evidenceofeffectiveness126nationalaction 44recommendations43referralschemes50
physicalinactivity–Seephysical activity play 38,44preconception37pregnancy202,229preschoolchildren–Seeearly years prevalenceofoverweightandobesity9
adults 9children15estimatinglocalprevalence58,91,94readyreckoner91trends12,13,19
prioritygroups59,101procurement67,145professionals
overweightprofessionals221roleof49
psychologicalfactors 22,27,28,32,39publicserviceagreements35
Index 247
Rreadinesstochange73readyreckonerforestimatingobesityprevalence91recommendations
ondiet 40onphysicalactivity 43
referralschemes50regionaldifferencesinprevalenceofobesity
adults 10,13children16
reproductiveproblems22,24,26,229resources
forhealthprofessionals72,171,191forpatients 225
respiratorydisorders22,24,27,28,37risk:healthrisksofobesity 22
Ssalt 40schools 35,39,121segmentationanalysis 59,101sleepapnoea 22,28snacking 31socialmarketing35
agencies 67commissioning155programme35
socioeconomicdifferencesinobesityinadults 9,13inchildren15
stroke22,23,25subcommittee 61sugars 38,40,41supportforoverweightorobeseindividuals 47,131swimming 44
Ttargetgroups59,101training 70,172travelplanning 46treatmentofobesity47trendsinoverweightandobesity
adults 12,13children19
triglycerides 25type2diabetes 22,23,24,27,28,37
Uunder5s–Seeearly years
Vvegetables 40VitalSigns57
Wwaistcircumference
adults 9,205children213
waisthipratio 207walking 44,50websites 185weightcontrolgroups51weightloss:benefitsof 28weightmanagement 47
onreferral51services 67,151
workplace 46WorldClassCommissioning55,79
248 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies
AcknowledgementsFinancialassistance
TheNationalHeartForumandtheFacultyofPublicHealthwouldliketothanktheDepartmentofHealthforprovidingfinancialassistancefortheproductionofthistoolkit.
ProjectManagementGroup
MrPaulLincoln,NationalHeartForum
ProfessorAlanMaryonDavis,FacultyofPublicHealth
MsBronwynPetrie,DepartmentofHealth
MrOliverSmith,DepartmentofHealth
DrKerrySwanton,KVSConsultancy
Healthy Weight, Healthy Lives: A toolkit for developing local strategiescontainsinformationwhichhasbeenadaptedandreproducedfromtheNICEguidelineonobesitywiththeintentionofreflectingthecontentoftheguidelineandfacilitatingitsimplementation.NICEfullysupportsthis.NICEhasnothowevercarriedoutafullcheckoftheinformationcontainedinthetoolkittoconfirmthatitdoesaccuratelyreflecttheNICEguideline.NothingshouldberegardedasconstitutingNICEguidanceexceptforthewordingactuallypublishedbyNICE.
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