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Adult obesity Key messages: Obesity in adults and children is a growing public health issue in the UK. The prevalence of obesity in children and adults in England has more than doubled in last twenty-five years. Obesity has serious health effects; it is a risk factor for diseases such as diabetes, cardiovascular diseases and many cancers. Obesity reduces life expectancy by an average of three years and between eight and ten years in the case of severe obesity. Extrapolation from national data to the Lewisham adult population suggests that the prevalence of adult obesity (23.7%) in Lewisham is not significantly different to the English average. Local data sources suggest that prevalence maybe higher. Local maternal obesity data show that there are more women overweight or obese in Lewisham compared with England. Data from the National Child Measurement Programme (NCMP) reveal that that the prevalence of obesity for children in both reception and year 6 is significantly higher that the English average. Data from the Vascular Check Programme piloted in North Lewisham indicated that for those who attended screening the incidence of obesity was higher than the English average. The causes of obesity are extremely complex and it is not just an issue of personal willpower.

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What do we know? Facts and figures Definition of obesity The National Institute for Health and Clinical Excellence (NICE)1 recommends that overweight and obesity are assessed using Body Mass Index (BMI). BMI is calculated by dividing a person’s weight (in kilograms) by the square of their height (in metres). The calculated BMI can be compared to the thresholds recommended by the World Health Organization shown in Table 1.

Table 1. Classification of overweight and obesity among adults2

Classification BMI (kg/m2) Risk of co-morbidities

Co-morbidities

Underweight Less than 18.5 Low (but risk of other clinical problems increased)

Type 2 diabetes Hypertension Stroke Coronary heart disease Cancer Osteoarthritis Dyslipidaemia

Healthy weight 18.5 – 24.9 Average Overweight 25 – 29.9 Increased

Obesity - class l 30 -34.9 Moderate

Obesity - class ll 35 – 39.9 Severe Obesity - class lll (severely or morbidly obese)

40 or more Very severe

For adults NICE recommends that waist circumference is used in addition to BMI to assess health risks for those with a BMI less than 35. Table 2. Combining BMI and waist measurement to assess obesity and risk of type 2 diabetes and cardiovascular disease in adults Classification BMI (kg/m2) Waist circumference and risk of

co-morbidities Men: 94-102cm Men: more than

102cm Women: 90-88cm Women: more than

88cm

Underweight Less than 18.5 - -

Healthy weight 18.5 – 24.9 - Increased

Overweight 25 – 29.9 Increased High Obesity 30 or more High Very high

1 NICE. Obesity: the prevention, identification, assessment and management of overweight and obesity in

adults and children. NICE clinical guidance 43. 2006. 2 Healthy Weight, Healthy Lives: A toolkit for developing local strategies. 2008

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The burden of obesity The growth in obesity and overweight rates in adults is a major public health concern. In 2008, an estimated 1·46 billion adults globally were overweight and 502 million adults were obese. In addition, an estimated 170 million children (aged <18 years) globally were classified as overweight or obese. It has been projected that if there is a continued rise in obesity in the UK over the next two decades that 11 million more obese adults in the UK by 20303. The global rise of obesity has serious health effects. Raised BMI is an established risk factor for diseases such as Type 2 diabetes, cardiovascular diseases, and many cancers. In some regions obesity has overtaken tobacco as the largest preventable cause of disease burden, with obesity accounting for between 2% and 6% of total health-care costs in many countries. Concern has been raised that the rise of obesity and Type 2 diabetes will slow or even reverse the reduction in premature mortality and morbidity from cardiovascular diseases seen in high-income countries during the past 40 years. Obesity reduces life expectancy by an average of three years, or eight to ten years in the case of severe obesity (BMI over 40). Around 10% of all cancer deaths among non-smokers are related to obesity. The risk of Coronary Artery Disease increases 3.6 times for each unit increase in BMI, the risk of developing Type 2 diabetes is about 20 times greater for people who are very obese (BMI over 35), compared to individuals with a BMI of between 18 and 25. For some cancers every additional 5kg/m2 in BMI increases a man’s risk of e.g. colon cancer by 24% and in women endometrial cancer by 59%4. Obesity increases the risk of developing a range of health problems leading to chronic and severe medical problems, shown below in Table 3. As the incidence of obesity is greater at an early age it is expected that in the future a higher proportion of the population will live with chronic disabilities. Table 3. Relative risks of health problems associated with obesity

3 Swinburn B.A. et al. The global obesity pandemic: shaped by global drivers and local environments. The

Lancet: 378, issue 9793, p804-814. Aug 2011. 4 Wang YC et al. health and economic burden of the projected obesity trends in the USA and the UK. The

Lance: 378, Issue 9793, p 815-825. Aug 2011.

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The prevalence of obesity National – adult obesity The prevalence of adult obesity in England has more than doubled in the last twenty five years. Although the incidence of obesity has increased in most countries worldwide the rate of increase in England has been particularly high. Since 1993 the proportion of men who are obese has increased from 13.2% to 24.1% in 2008 and in women from16.4% to 24.9%. The rapid increase in obesity prevalence has resulted in only 32.8% of men and 41.2% of women in 2008 with a healthy BMI. The healthy weight prevalence for men is much lower than women due to the higher prevalence of overweight in men5. Figure 1. Trends in adult obesity prevalence England 1993-2008

Source:National Obesity Observatory 2011

The prevalence of obesity and overweight increase with age for both men and women, increasing in men from 8.4% in the 16-24 year age group to 32.8% in the 55-64 year age group and in women from 12.7% to 33.5% in the 65-74 year age group. Results from the Health Survey for England6 have shown that the proportion of adults with a raised waist circumference has risen since 1993. In men the percentage has increased from 21% to 33% and in women from 27% to 44%. This together with the changes in mean waist circumference is shown in figure 2.

5 National Obesity Observatory. Trends in obesity prevalence. www.noo.org.uk/NOO_about_obesity/trends

6 Health Survey for England 2010.

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Figure 2. Mean waist circumference and percentage of adults with raised waist circumference 1993-2009

1993

82cm

27%

2009

87cm

44%

Year of survey

Mean waist circumference (cm)

% with raised* waist circumference

Adults aged 16+ years

* Raised waist circumference is taken to be greater than 102cm in men and greater than 88cm in women

% with raised waist circumference is a three year average for 1993-95 and 2007-09

1993

93cm

21%

2009

96cm

33%

© NOO 2011 National – child obesity Nearly 1 in 10 children in reception year and 1 in 5 children in year 6 were classified as obese in 2009/107. A similar trend in the increase in adult obesity was observed in children but there appears to be a slowing in the rate of childhood obesity since 2004. It is predicted that by 2050 the prevalence of obesity will increase to 60% of men, 50% of women and 25% of children8.

Local – adult obesity There is limited data available to determine the local prevalence of adult obesity. Estimation on the local obesity prevalence can be determined by using population estimates for the borough and extrapolation from the Health Survey for England data, this indicated that in 2009 there were over 48,000 adults aged 16 and over with a BMI above 30 (obese) and over 70,000 adults with a raised waist circumference. The Health Profile for Lewisham 2011 indicates that the adult obesity prevalence is 23.7% which is not significantly different to the England average9. This is a modelled estimate using Health Survey for England 2006-2008. This is similar to

7 National Child Measurement Programme. Results 2009/10

8 Foresight report, 2007

9 Health Profile 2011-Lewisham , www.healthprofiles.info

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our neighbouring boroughs and in the top quintile for London boroughs as shown in figure 3. Figure 3. Adult obesity prevalence 2006-2008- London boroughs

Source: National Obesity Observatory 2011

Another method of determining local adult obesity prevalence is from the Quality Outcomes Framework (QOF) GP register of patients aged 16 years and over with a BMI greater than or equal to 30 in the preceding 15 months. The prevalence for 2009/10 was 7.4% with a range in prevalence recorded by practices from 3.4 to 14.4%. This is similar to the prevalence recorded by other London boroughs including Lambeth and Greenwich and significantly below the rates found in the Health Survey for England due to only recording diagnosis. The evaluation of the pilot Vascular Screening Programme conducted in the north of the borough (2007-09) found that the incidence of obesity in those screened was higher than the England average. This was based on the results of nearly a 1,000 adults aged 40-74 years. Only 29.1% of those screened were within the healthy weight range, 36.4% were overweight and 33.4% were obese. Of those classified as obese over 10% were found to have a BMI above 35 (obesity class II). This could be an indication that obesity prevalence is higher in Lewisham than model estimates provide. Maternal obesity In 2010 the incidence of maternal obesity was determined from the booking data at Lewisham hospital for all women who booked with midwifery services before 13 weeks of pregnancy. There were more women who were overweight (31%) or obese (24%) in Lewisham compared with England as a whole (28% and 17%).

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Table 4. BMI of those booking before 13wks at Lewisham Hospital, in 2010.

BMI Category BMI Number of Women

Percentage Lewisham

Percentage England

Underweight <18 47 2% 3% Healthy Weight 19-24 1106 43% 52% Overweight 25-29 810 31% 28% Obese 30-39 556 22% 15% Morbidly Obese 40+ 62 2% 2% Total Overweight 25 – 40+ 1428 55% 45% Not Known N/A 151 6% 0%

Total 2586 100% 100% Source: UHL booking data before 13 weeks, Jan – Dec 2010.

Local – child obesity Lewisham has a high prevalence of childhood obesity. For the past three years data from the National Child Measurement Programme7 (NCMP) reveal that the prevalence of obesity for children in both reception year (aged 4-5 years) and year 6 (aged 10-11 years) continue to be significantly higher than the England average. Results for 2009/10 showed that 13.6% of reception children were obese as were 24.4% of children in year 6 Obesity and deprivation For children the link between childhood obesity and deprivation is well established. For adults obesity prevalence is also associated with socioeconomic status with a higher level of obesity found among more deprived groups. This association is stronger for women regardless of the deprivation measure used. For men only some measures e.g. occupation-based and qualification-based show a clear relationship between obesity and deprivation. Figure 4. Prevalence of obesity in adults by deprivation quintile (IMD 2007) 2007-08

Source: Health Survey for England

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Obesity and ethnicity Obesity prevalence varies between ethnic groups. When using BMI as a measure of obesity prevalence of obesity is higher in females of Black Caribbean, Black African and Pakistani groups compared to the other ethnic groups and the general population. Prevalence of obesity is lower among men from Black African, Indian, Pakistani, Bangladeshi and Chinese communities compared to the general population (figure 5). Figure 5. Prevalence of obesity in adults by ethnic groups

Health Survey for England 2004

© NOO 2011 Adult (aged 16+) obesity: BMI ≥ 30kg/m2

25%

17%

25%

15% 14%

6% 6%

23%

32%

38%

21%

28%

20%

17%

8%

23%

Black

Caribbean

Black

African Irish Pakistani Indian Bangladeshi Chinese

General

population

Males

Females

Local lifestyle Several sources of information on diet and activity are available for England and these show that adults are still eating more saturated fat and sugar than the recommended levels10 and only a third of men and women eat the recommended 5 portions of fruit and vegetables a day11. Only 40% of men and 28% of women are meeting the recommended level of physical activity of 30 minutes 5 days a week. These measures of diet and activity levels are based on self reported data which may be overestimations and the true values lower than that recorded. Limited information is available on the local lifestyle of Lewisham residents; the Lewisham Health Profile9 identifies that more adults in Lewisham meet the 5-a- day target for fruit and vegetables but fewer adults meet the physical activity recommendation of 30 minutes 5 days a week than the England average (shown in table 5).

10 National Diet and Nutrition Survey 2008/09.

11 NHS information Centre. Statistics on obesity, physical activity and diet. England 2011

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Table 5. Lewisham Health Profile 2011

Adults’ health and lifestyle

Causes In simple terms obesity is caused by an imbalance between energy intake and energy expenditure, where intake is greater than expenditure. The reasons for the recent worldwide increase in obesity are complex: the individual’s eating and activity habits are influenced by external social and environmental factors where an abundance of food and increased sedentary behaviour is common. The Foresight report12 identified over 100 variables that directly or indirectly influences energy balance (Figure 6). These have been grouped into seven themes: 1. Individual’s biology 2. Individual’s psychology 3. Food consumption 4. Food environment 5. Individual’s activity 6. Activity environment 7. Societal influences To promote healthy lifestyles in the borough all seven themes need to be incorporated into the future planned strategy.

12 Foresight Tackling obesities:Future Choices –project report. 2

nd ed. 2007

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Figure 6. Foresight obesity systems map

What we are doing in Lewisham? Obesity strategy The strategy on reducing childhood obesity is part of a long term plan to promote healthy lifestyles for the whole population of Lewisham. Work is underway to expand the strategy to include adults. The current strategy focuses on children and families and encompasses prevention, treatment and management of overweight and obesity in children. Action plans have been developed for the universal services to promote healthy eating, increase physical activity and reduce sedentary behaviour and are divided into seven themes:

1. National Child Measurement Programme 2. Maternity 3. Early Years 4. Schools 5. Leisure/Sport/Environment 6. Food Strategy 7. Workforce Training and Communication

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Key successes include: Staff skills and capabilities

• Training on promoting healthy weight in children has been commissioned for staff working with children and families so that all are aware of the role they play in promoting healthy weight in children.

Weight management services

• Targeted weight management services for children and their families (MEND) and a local delivery partner have been commissioned. The service is now able to reach a wider age group from 5-16 years.

• A new specialist weight management is to be commissioned. National child Measurement Programme

• A high participation in the programme ensures that robust data on local child obesity prevalence is available.

Food strategy The Lewisham Food Strategy was launched in 2006. The overall aim of the strategy is to increase the health and welfare of Lewisham people through improved access to nutritious and safe food from a more sustainable food chain. Since the food strategy was written there have been a number of important publications that have further emphasised the importance of food for the maintenance of health and prevention of disease. The Lewisham Food Strategy fits within the Mayor of London’s Food Strategy which is overseen by the London Food Board. Work continues throughout the borough on the four themes:

1. Food access- to reduce economic, cultural and educational barriers 2. Food, nutrition and Health-to contribute to the reduction in nutrition related

ill-health 3. Food safety- to ensure the safety of food produced, sold and consumed in

Lewisham 4. food sustainability- food produced, transported and sold in Lewisham

Key successes of the Food Strategy in 2010-11 include: Increasing fruit and vegetable intake

• New Cross Gate Food co-operative- increasing the sale of low cost high quality fruit and vegetables to local residents

Improving skills of local residents

• Running cookery classes for local residents

• Training local mothers to run cookery clubs across the borough Supporting local communities

• Providing professional nutrition support to community groups in North Lewisham

• Funding of the Downham Nutrition Project Accurate delivery of healthy eating messages

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• Voluntary organisations signed up to the NHS Lewisham guidelines on healthy eating

• Producing resources to be used by community and voluntary sector Food sustainability

• Increased number of active community gardens across Lewisham

• Delivery of Love Food Hate waste events Food safety

• A change in strategy since April 2009 has resulted in a massive improvement across the borough in terms of the number of ‘broadly compliant’ premises satisfying the minimum legal standard, from 61.9% in 2008/09, to 76% in 2010/11.

• Over 450 revisits and 80 re-inspections were carried out in 2010/11

• Over 200 Food Hygiene Enforcement Notices were issued in 2010/11

• Over 54 Seizure and detention of Food Notices were issued in 2010/11

• 4 Food Businesses were prosecuted in 2010/11

• A registered training centre offering food hygiene courses

• A member of the Scores on the Doors scheme NHS Health Checks The NHS Health Check13 is part of a new national scheme to help prevent the onset of heart disease, stroke, diabetes and kidney disease for adults aged 40-74. The objective is to offer screening for all those eligible, around 76,000 people in Lewisham within a five year period. All adults who attend will get personalised advice on how to lower their risk and maintain a healthy lifestyle. Key successes include:

• Additional support on weight management available through a new community weight management programme (Shape-Up) for overweight and obese adults (with a BMI between 25-35). Outcomes of the initial programmes were very positive with 80% registering a reduction in weight and reporting improvements in activity levels and emotional health.

• A new dietetic weight management service for the NHS Health Checks is currently out to tender. This will enhance the primary care dietetic service currently available.

• Motivational interviewing and physical activity programmes have been commissioned to support adults to become more active.

Physical activity Plan Lewisham’s Physical Activity Plan 2010-1314 aims to get more people, more active, more often in everyday life and leisure. The Physical Activity Partnership is a Lewisham wide group that supports and co-ordinates work around physical activity in the borough. The action plans for 2011-12 are divided into 7 themes:

13 www.nhs.uk/nhshealthcheck

14 www.lewishampct.nhs.uk

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1. Engage with groups and individuals 2. Promote and develop active travel 3. Leisure and recreation 4. Local communities and open space 5. Workplace 6. Early years, children and young people 7. Targeted care and interventions

What are the key gaps in knowledge? There is limited information on adult obesity, diet and activity levels at a local level. Additional information will become available through the NHS Health Checks as data on weight, activity and key indicators of diet is recorded for all adults as part of the programme. Also it is planned to expand the data provided to determine maternal obesity rates to include postcode and ethnicity. This will determine if there is local variation in obesity prevalence. What we could do? Expand on workplace health. Research shows that employers can help their employees improve their health15. Explore how Lewisham could develop a comprehensive wellbeing programme and encourage all organisations to join. One example is the Change4life campaign16 –Adults Employers toolkit: Employers guide. Work with fast food outlets. Lewisham is now part of the Scores on the Doors scheme17. The map (Figure 7) shows the number of takeaway outlets in Lewisham. Eating out has been found to account for an average 11% of an adult’s energy intake. Several London boroughs are working with their local food businesses to increase the healthy food options available to customers e.g. Tower Hamlets Food for Health Awards, Barking and Dagenham ‘Saturation Point’ planning policy and fast food takeaways.

15 World Economic Forum: Working Towards Wellness in cooperation with PriceWaterhouseCoopers

16 www.nhs.uk/change4life

17 www.scoresonthedoors.org.uk

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Figure 7. Map of take away outlets in Lewisham (November 2010)

Expand on work with housing and planning. Increase opportunities to promote healthy lifestyles with housing providers. Public Health to continue working with planning on the health implications of new developments e.g. Surrey Triangle regeneration. Gwenda Scott Healthy Weight Strategy Manager Public Health Lewisham NHS South East London 13th September 2011