Department of Health West Midlands

I:\Pbhealth\Health Strategy Unit (JB AO JD)\Julie Davis 2011\OBESITY - QIPP FINAL DOCS FROM ALEX - AMENDED\Obesity - MAIN REPORT.doc

Department of Health West Midlands

Quality, Innovation, Productivity & Prevention

Obesity

1. INTRODUCTION

The Government has reaffirmed the need to place quality of care at the heart of the NHS. The White Paper, Equity and Excellence: Liberating the NHS (July 2010) makes it clear that quality cannot be delivered through top down targets but by focusing on outcomes, giving real power to patients and devolving power and accountability to the frontline.

Despite the recent good funding settlement for health, the NHS needs to make savings because of growing demand. With factors such as an ageing population putting the NHS under increasing pressure, it is not possible to go on as before.

Now, more than ever before, the NHS has to achieve value for money and the best possible quality so that patients get the greatest benefit.

The Quality, Innovation, Productivity and Prevention (QIPP) programme is all about ensuring that each pound spent is used to bring maximum benefit and quality of care to patients.

The NHS needs to achieve up to £20 billion of efficiency savings by 2015 through a focus on quality, innovation, productivity and prevention. Every saving made will be reinvested in patient care by supporting frontline staff, funding innovative treatments and giving patients more choice.

The Public Health White Paper also emphasises that public health evaluation and research will be critical in enabling public health practice to develop into the future and address key challenges and opportunities, such as how to handle the wider determinants of health and how to use behaviour change science to support better more cost effective practice. This is supported by the setting up of a new School for Public Health Research and a Policy Research Unit on Behaviour and Health. Public Health England, the new service that will be part of the Department of Health, will be expected to properly resource research into interventions happening outside the NHS. Public Health England and others will work together to identify research priorities and use the best evidence and evaluation and will support innovative and cost effective approaches to behaviour change.

2. THE HEALTH RISKS OF OVERWEIGHT AND OBESITY

2.1 Premature Mortality

Obesity is associated with premature death. It increases the risk of a number of diseases including cardiovascular disease and cancer. It is estimated that, on average, obesity reduces life expectancy by between 3 and 13 years – the excess mortality being greater the more severe the obesity and the earlier it develops.

2.2 Obesity-Related Morbidity

In public health terms, the greatest burden of disease arises from obesity-related morbidity.

The associated health outcomes of childhood obesity are similar to those of adults and include:-

· hypertension (high blood pressure)

· dyslipidaemia (imbalance of fatty substances in the blood)

· hyperinsulinaemia (abnormally high levels of insulin in the blood).

Other possible consequences for children and young people include:-

· mechanical problems such as back pain and foot strain

· exacerbation of asthma

· psychological problems such as poor self-esteem, being perceived as unattractive, depression, disordered eating and bulimia

· type 2 diabetes.

Some of these problems appear in childhood while others appear in early adulthood as a consequence of childhood obesity. The most important long-term consequence of childhood obesity is its persistence into adulthood and the early appearance of obesity-related disorders and diseases normally associated with middle age such as type 2 diabetes and hypertension. Studies have shown that, the higher a child’s BMI (kg/m2) and the older the child, the more likely they will be an overweight or obese adult. Furthermore, research has demonstrated that the offspring of obese parents have a greater risk of becoming overweight or obese adults, increasing the likelihood of developing such health problems later in life (Appendix 1 – Conditions Associated with Obesity).

3. OVERVIEW OF THE WEST MIDLANDS

In the West Midlands 25% of men and 26% of women are obese and 41% of men and 32% of women are overweight[1]. Based on 2009 mid-year population estimates[2], this means there are approximately 1.4 m overweight or obese men and 1.3 m women (of which approx 539,450 are obese men and 585,312 are females).

The latest Health Survey for England (HSE) data suggests that obesity prevalence for 2-15 years olds in the West Midlands is 16% for boys (74,688) and 18% (80,352) for girls[3].

4. OVERALL RECOMMENDATIONS

“The evidence base for effective and cost-effective obesity related interventions is limited and the strength of evidence is weaker for preventive interventions, compared to the evidence for the most ‘clinical’ interventions (eg bariatric surgery) for those at highest risk. This is in contrast to local and national policy to move towards disease prevention and early intervention and overall there is a lack of consensus or evidence-based models for tackling this issue”[4]:

The National Obesity Observatory (NOO) publications Treating Adult Obesity through Lifestyle Change Interventions[5] and Treating Child Obesity through Lifestyle Change Interventions[6] summarise the systematic reviews of effective treatments undertaken by NICE and the Cochrane Collaboration. NOO conclude that while “there is sufficient evidence to justify well-targeted action on obesity”, the evidence base “tends to lack detail on the effectiveness of specific approaches or individual programmes, with the result that guidance tends to be somewhat general in nature”. Accordingly, when commissioning weight management services, it may “be difficult to demonstrate the effectiveness of a specific intervention within a short timescale given the complex interplay of different environmental, biological and social determinants”.

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

· the importance of multi-component tailored interventions: eg interventions should focus on diet and physical activity together rather than attempting to modify either diet or physical activity alone

· physical activity component: eg interventions should focus on activities that fit easily into people’s everyday lives and are tailored to people’s individual preferences and circumstances

· dietary component: eg interventions should aim to improve diet and reduce energy intake and should bring together a number of components such as dietary modification, targeted advice, family involvement and goal setting

· behavioural component: eg interventions for adults should include strategies tailored to the needs of the individual including self monitoring of behaviour and progress, stimulus control, goal setting and so on

· commercial and community-based weight management programmes: eg self‑help, commercial or community weight management programmes should only be commissioned if they follow best practice eg they help people assess their weight and decide on a realistic healthy target weight (people should usually aim to lose 5-10 percent of their original weight)

· further recommendations: NOO make a number of additional recommendations, eg there is good evidence for the effectiveness of brief interventions in primary care in promoting physical activity and these may be useful components of any co‑ordinated obesity prevention intervention.

NOO have also published a briefing paper for commissioners on Preventing Childhood Obesity through Lifestyle Change Interventions[7]. This found rather less evidence of effective approaches to preventing child obesity, but did contain some recommendations: eg “programmes should be multi-component interventions, ideally addressing diet and physical activity together and should involve family and peer support where possible, using behavioural programmes aimed at changing diet and physical activity patterns”[8].

Invest to Save – Guidance for Commissioning Primary Prevention[9] also provides the following guidance:

· Commission individually adapted health behaviour change programmes in primary care

· Improve systems to record and monitor BMI to enable establishment of a baseline and on-going monitoring

· Increase opportunities for physical activities by working with the local authority leisure services as part of a structured referral scheme.

5. RECOMMENDATIONS FOR SPECIFIC INTERVENTIONS

See Appendix 2 - Evidence on Specific Interventions and Appendix 3 – NICE Clinical Guidance and Systematic Reviews. Those shown in italics are most promising in terms of evidence.

5.1 Children Healthy Growth and Healthy Weight

Early Years

· Improvement in the food service to pre-school children

· Education through videos and interactive demonstrations – changing food provision in nurseries and early years settings

· Encourage parents to engage in a significant way in active play and reduce sedentary behaviour

· Provision of regular meals in supportive environment

· Structured physical activity programmes with nurseries and pre‑school settings

· Breastfeeding.

Schools

· Increase fruit and vegetable consumption

· Multi component interventions

· Improve school meals

· Promote water usage

· Promotion of less sedentary behaviour

· Reduce consumption of carbonated drinks.

Promoting Healthy Food Choice

· Educational promotion campaign

· Food promotion

· Public health media campaign.

Community Interventions Led by Healthcare Professionals

· Support and advice on physical activity and diet

· Moderate or high intensity dietary interventions – reduce fat intake and increase fruit and vegetable consumption

· Brief counselling or dietary advice by GPs or other health professionals

· Behavioural/educational interventions

· Free access to leisure facilities.

5.2 Broader Community

Healthy Eating

· Point of purchase schemes in shops, supermarkets and restaurant and cafes supported by education, information and promotion

· Novel educational and promotional methods such as video and computer games.

Physical Activity

· Targeted behavioural change programmes with tailored advice

· Creation of, or access to, space for physical activity such as walking or cycling combined with supportive information

· Point of decision prompts or education materials such as posters and banners

· Changes to city wide transport which make it easier to walk cycle and use public transport.

Raising Awareness of Physical Activity

· Promotional campaigns

· Public health media campaign.

5.3 Creating Incentives for Better Health

Healthy Eating

· Increased provision of healthier food

· Information strategies such as labelling

· Reduction in cost of low fat snacks

· Provision of water

· Behaviour modification programmes such as health screening with counselling education

· Behaviour modification programmes such as health screening followed by counselling and sometimes environmental changes

Physical Activity

· Use of educational sessions and informative materials

· Active travel schemes

· Payroll incentive

· Using the stairs

· Behaviour modification programmes such as health screening with counselling education

· Behaviour modification programmes such as health screening followed by counselling and sometimes environmental changes.

5.4 Personalised Support for Overweight and Obese Individuals

· Multi component group commercial programmes

· Computerised/email/internet based programme accompanied by on-going support in person by post or e-mail

· Peer-led programme and a group led programme and individual weight loss programme in a religious-based setting a home based exercise programme

· Meal replacement products

· Commercial and computer weight loss programmes in men.

6. COSTS AND COSTS EFFECTIVENESS

6.1 Costs to West Midlands PCTs

For anti-obesity drugs, the cost per Quality Added Life Year (QALY) is £15,000 to £30,000. The net cost per QALY for bariatric surgery (compared to non-surgical interventions) is £7,000 to £11,000 (depending on the type of surgery). Bariatric surgery has been recommended by NICE for patients meeting selected criteria[10].

The Healthy Weight Healthy Lives Toolkit estimates the annual cost to the NHS of diseases related to overweight and obesity and obesity alone, broken down to PCT level. Further information about the modelling used can be found at: www.foresight.gov.uk

The estimated cost to PCTs in 2010 within the West Midlands was £1,549.7m for obesity and overweight and £839.2m for obesity.

6.2 Economic Effectiveness of Interventions

The NHS Economic Evaluation Database[11] and Health Technology Assessment Database[12] both contain a number of health economics studies which attempt to evaluate the cost effectiveness of a range of interventions aimed at promoting healthy weight. The focus of the majority of these, however, is on individual-level clinical interventions; there are relatively few studies focusing on the cost effectiveness of population-level weight management programmes.

The evidence that is available suggests that the following approaches may be cost effective:-

Children

· School-based obesity prevention programmes that use intervention materials in the teaching of a range of subjects and which focus on decreasing television viewing, decreasing the consumption of high-fat foods, increasing fruit and vegetable intake and increasing moderate and vigorous physical activity[13]

· Family-based group behavioural therapies that focus on diet, activity, behavioural change techniques, parenting and coping with psychosocial problems[14]

· Breakfast clubs[15].

Adults

· Multi-disciplinary weight loss programmes that focus on diet, exercise and behaviour modification[16]

· Lifestyle interventions that consist of dietician sessions and supervised exercise sessions that focus on healthy diets and regular exercise over a period of several years[17].

A Briefing Note for Commissioners and Local Leads for Weight Management Services is attached to support effective practice (Appendix 4).

7. FURTHER READING

· Healthy Weight Healthy Lives: A Toolkit for Developing Local Strategies, published by the Department of Health, October 2008 (since Archived): The evidence base for interventions is summarised and looks at them both for effectiveness and cost effectiveness

· National Obesity Observatory which summarises the evidence: www.noo.org.uk

· The Obesity Learning Centre:

http://www.obesitylearningcentre-nhf.org.uk/welcome/

· Tackling Obesities: Future choices. Foresight Project. Government Office for Science (October 2007)

NICE Guidelines:-

· CG 43: NICE Obesity guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children (December 2006)

· CG 43: NICE Obesity guidance on the prevention, identification and management of overweight and obesity in Adults - Costing Report www.nice.org.uk/CG43 (December 2006)

· PH 2: Four commonly used methods to increase physical activity (March 2006)

· PH 8: Physical activity and the environment (January 2008)

· PH 13: Promoting physical activity in the work place (May 2008)

· PH 17: Promoting physical activity for children and young people (January 2009)

· PH 27: Weight management before, during and after pregnancy (July 2010)

APPENDICES

Appendix 1

Conditions Associated with Obesity

Appendix 2

Evidence on Specific Interventions

Appendix 3

NICE Clinical Guidance, Systematic Reviews and Other Reviews

Appendix 4

Commissioning Guidance

REFERENCES

9

[1] http://www.ic.nhs.uk/webfiles/publications/HSE/HSE08/Volume_1_Physical_activity_and_fitness_revised.pdf

[2] http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106