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Adult Excess Weight

Introduction

This section discusses Adult Excess Weight. A chapter on Childhood Excess Weight is also available Childhood Excess Weight.

 

Facts, Figures, Trends

England is one of the most overweight nations in the world; the majority of adults are either overweight or obese. Excess Weight is influenced by genetics, gender, ethnicity, and socioeconomic deprivation. It is therefore important that services are targeted in areas with a high concentration of black and minority ethnic (BME) groups and in wards with high levels of socioeconomic deprivation1.

In England, the prevalence of obesity among adults rose from 14.9% to 24.9% between 1993 and 2013. The rate of increase has slowed down since 2001, although the trend is still upwards. The prevalence of overweight has remained broadly stable during this period at 37–39%2. In 2013, 62% of adults had excess weight3. By 2050 obesity is predicted to affect 60% of adult men, 50% of adult women and 25% of children4.

About half of women of childbearing age (16 to 44 years) in England are either overweight or obese. The prevalence of obesity in women of this age has increased over time from around 12% in 1993 to over 19% in 20132. Around 1 in 6 pregnant women are obese5

 

Local Prevalence

In Bedford Borough the latest data modelling suggests an adult excess weight prevalence of 63.5% (6). This equates to approximately 27,000 obese adults and 45,000 overweight adults, a total of 72,000 adults with excess weight in Bedford Borough. As a comparison, the East of England average for excess weight is 65.6% and the England average is 64.6%. Comparative data for England can be viewed at the National Obesity Observatory website http://www.noo.org.uk or http://www.phoutcomes.info/

Ward level data is available for ‘obesity’ only, based on modelled estimates. The seven wards in Bedford Borough with the highest prevalence are below:

 

Ward of residence

% Obese

1.

Kempston South

29.2%

2.

Kempston West

28.6%

3.

Kempston Central and East

27.7%

4.

Goldington

26.7%

5.

Kempston North

26.6%

6.

Eastcotts

26.6%

7.

Wilshamstead

26.6%


 

 

 

 

 

 

 

 

 

 

 

How does obesity affect adults?

Excess weight is linked to poor health, and poor social outcomes, including hypertension, Coronary Heart Disease, stroke, type 2 diabetes, premature death, osteoarthritis, depression, cancers, infertility, asthma, sleep apnoea, and unhealthy blood cholesterol levels(1,2,4,7, 8)

 

Overweight and obese individuals are more likely to be subject to social discrimination, including lower earning power, and there are adverse consequences for the wider economy from lost working days and increased benefits payments(16).

 

Figure 1. Increasing risk of mortality (death) with rising BMI

Obesity curve

Calle et al.(1999).  Image retrieved from www.endotext.org/obesity/obesity13/figures/figure2.png (accessed 25/6/13)

 

When compared to healthy weight individuals:

An obese man is:

An obese woman is:

5 times more likely to develop type 2 diabetes

Almost 13 times more likely to develop type 2 diabetes

3 times more likely to develop cancer of the colon

More than 4 times more likely to develop high blood pressure

> 2.5 times more likely to develop high blood pressure, a major risk factor for stroke and heart disease

More than 3 times more likely to have a heart attack

 

It is possible to estimate the disease specific attributable proportion of obesity, that is, that proportion of a population with a given disease who would not have that disease if they were not obese:

 

Hypertension

CVD

Diabetes

Disease Specific attributable proportion (%)

24.1

20.2

24.1

Bedford Borough attributable population

5007a

4856a,b

1805a

a. QMAS 2011 data

b. QMAS 2011 data including CHD, atrial fibrillation, stroke, heart failure.

 

The proportion of chronic disease that is attributable to obesity will increase substantially if current levels are not halted or reversed; this will in turn lead to high levels of sickness absenteeism and increased levels of poor mental health.

 

Maternal Obesity

Maternal obesity is associated with increased morbidity and mortality for both the woman and her unborn child (11). Pregnant women who are obese are at increased risk of:

  • Developing gestational diabetes
  • Having a raised blood pressure and pre-eclampsia
  • Having a blood clot in the legs (DVT)
  • Having a large or ill baby needing increased monitoring which can lead to complications in labour
  • Having a Caesarean section
  • Difficulty in sitting for an epidural or an anaesthetic
  • Having a wound infection, leading to a longer hospital stay
  • (Rarely) having complications following surgery and delivery requiring intensive hospital care.
  • Having a still-birth or intra-uterine death.

 

There is evidence that children born to overweight or obese mothers, tend to have higher birth weights, and become overweight children, and subsequently overweight adults(12). There is also evidence that infants exposed to an obesogenic environment during uteri use on average an extra £1,138 in NHS resources throughout the first year of life, in comparison to infants born to mothers with a healthy BMI, likely due to the above mentioned complications(13).

 

17% of pregnant women booked into Bedford Hospital in their first trimester are obese (BMI ≥ 30) and 3% morbidly obese (BMI ≥40)[1].

[1] Bedford hospital data

 

What does obesity cost?

In 2008 obesity cost NHS Bedfordshire £98.8 million, this figure was projected to rise to £136 million by 2015 without concerted action (14). Estimated social care costs are difficult to quantify. However nationally, 70% of total health and social care spend is on long-term conditions attributable to excess weight and poor lifestyles (diabetes, cardiovascular disease, muscular skeletal disease, some cancers and mental health problems). The wider cost to the economy is estimated at closer to £20billion a year once factors such as lost productivity and sick days are taken into account (15).

 

The management of long term conditions often requires social care support. Severely obese people are over 3 times more likely to need social care than those who are a healthy weight (15). Some of the social care costs for obesity related conditions such as stroke, diabetes, hypertension are likely to consist of:

 

  • the provision of ongoing support including re-enablement
  • the provision of personal non-clinical care (washing, dressing, cleaning, meals etc.)
  • developing a Personal Independence Plan (PIP)
  • Disability living allowance
  • the blue badge scheme (disability mobility badge)
  • lost income due to lost working days due to illness and premature mortality
  • the lack of ability to provide meaningful contribution to local community
  • the carer becoming a recipient of care – care still required for person cared for plus themselves in addition
  • Disabled Facilities Grants (DFG – walk in showers, stair-lifts etc.)

 

The cost of obesity to the wider economy (including costs to Local Government and the NHS in primary and secondary care) is around £27 billion a year. However, for every participant on a 12 week weight management programme, the NHS stands to save £230 over a lifetime. Physical activity programmes also produce a return on investment between £8-£23 for every £1 spent(16) This therefore justifies the costs associated with the prevention and management of obesity.

 

What are the key inequalities?

Whilst everyone is susceptible to obesity, levels are disproportionally higher in the lower socio-demographic/socially disadvantaged groups, and some ethnic groups. The South Asian population in particular are at risk of chronic diseases and mortality at lower BMI levels than the European population (17). Women from Black African groups appear to have the highest prevalence of obesity and men from Chinese and Bangladeshi groups have the lowest (3).

Men have a higher prevalence of obesity than women (26% compared to 24%), and are more likely to be overweight (41% compared to 33%) (3).

 

What are the challenges in obesity?

With the exception of gender and ethnicity, many of the risk factors for obesity are modifiable and centre upon healthy lifestyle changes towards a healthier diet and more physical activity in everyday life. This requires more than information alone; the three key elements that must converge at the same time in order for behaviour change to take place are:

  • A trigger
  • Motivation
  • Ability(18)

The challenge is to create an environment in which these three elements are present and this should be a starting point for all commissioning of services to help prevent weight gain or manage weight. Although overweight and obesity are clinical terms, they have taken socially derogative connotations to a point where stating a person is obese is typically considered offensive.

There is a common misconception regarding the genetic element of obesity and this can affect the response toward taking action (as described above). Although genes contribute to the way that the body reacts to diet and exercise, in the vast majority of cases, making lifestyle changes are effective tools in managing weight.

 

What are we doing and why?

Obesity management and prevention is separated into 4 tiers. Tier 1 services are universal and preventative in nature, and include health promotion and population level communication (i.e. Change 4 Life). Tier 2 services are targeted lifestyle interventions through primary care, commercial, or bespoke weight management programmes (sometimes with medication (i.e. Orlistat)). Tier 3 is a specialist multi-disciplinary weight management programme delivered within a hospital setting. Finally, tier 4 is bariatric surgery.

 

Current overweight and obesity management pathway

Prevention and management of overweight and obesity are complex issues. The Excess Weight Partnership Strategy 2015-2019 for Bedford Borough identifies actions for delivering this agenda county wide (click here to open document). There are a number of services that have been commissioned to prevent and manage issues pertaining to weight in Bedford Borough.

 

The Excess Weight Management Pathway is currently being revised to include newly commissioned services. Please click here for the pathway.

 

When excess weight services are commissioned or developed, it is done so in accordance with the guidance developed by the Medical Research Council (2006)19. This ensures that an appropriate evidence base is used to justify its effectiveness and value for money when developing and evaluating complex interventions. Where there is inadequate evidence to commission a service, or no service currently exists, services are developed and evaluated in order to ensure that action is being taken in the areas necessary whilst evidence is being collected4.

 

BeeZee Bodies CIC is the excess weight management services provider in Bedford Borough. The following services and products have been commissioned by Public Health:

 

BZ Bumps: Maternal Obesity programme - delivering healthy living information and support to pregnant women with a BMI > 30. The programme provides information on nutrition as well as safe physical activity sessions, ante and post-natal. The programme recruits from midwifery at Bedford Hospital and the Luton and Dunstable hospital. This service is commissioned 2015-2019.

“I think more about healthier options. I think about portion control. I eat more brown bread as opposed to white. I drink more milk and orange juice instead of fizzy. I am more aware of habits I have that I don't want my children to have” (Participant Maternity Programme)

Weight Watchers: Commercial Weight Management Referral Scheme – 12 weeks free of charge for patients who are eligible but are unable to afford the cost. A third of all patients who started a 12 session course achieved ≥5% weight loss, which is associated with clinical benefits. Losing 5%+ of body weight has been associated with reduced blood pressure and a reduced risk of Type 2 Diabetes and Cardiovascular Disease20.

Slimming World: Commercial Weight Management Referral Scheme - 12 weeks free of charge for patients who are eligible but are unable to afford the cost. A total of 54.7% of completers lost at least 5% initial body weight.

“It has changed my life. I feel so much better in myself and it wasn't as scary or hard as I thought!” (Adult who took part in a commercial weight management programme)

 

The below services have been commissioned as part of a 2-year innovation pilot:

Gutless: Weight Management for Men - a programme designed specifically for men. Upon enrolling, men will have a health and fitness assessment, and are able to choose what services they access. Options include nutrition sessions, web-based 1:1 support, gaol setting and motivational support, free or reduced rates for existing BB exercise groups and games or gym based activity sessions.

Believe: Weight management for Faith-based Groups- Approximately 70% of Bedford Borough residents belong to a faith-based group. This programme is delivered by a member of BZ Bodies CIC and a member of the faith organisation. This programme aims to engage with hard to reach groups and to tailor messages.

Web-Based Video Chat: Weight Management Support Online - This pilot service is a new way of being able to reach those who would otherwise struggle to access services (e.g those with disabilities, single parents with small children, those in very rural locations where transport is difficult). It consists of a 10 week programme, offering weekly 1:1 sessions with a qualified nutritionist and personalised support including goal setting, over a live web-based chat.

 

Further services commissioned by Public Health:

Exercise Referral Gym / Physical Activity Programme – A 10 week gym based or physical activity based programme delivered by qualified instructors to improve the health of patients with a range of conditions that may benefit from increase physical activity levels. Regular physical activity can reduce the risk of many chronic conditions including coronary heart disease, stroke, type 2 diabetes, cancer, obesity, mental health problems and musculoskeletal conditions. Even relatively small increases in physical activity are associated with some protection against chronic diseases and an improved quality of life (21). These benefits can deliver cost savings for health and social care services and are recommended by NICE (2006)(22), even in the absence of weight loss due to the associated health benefits. In Bedford Borough there is a newly redesigned service with better accountability, more efficient booking and follow up, and more effective reporting procedures has been recently implemented to improve the quality of referrals.

 

In the latest GP Referral Patient Survey (2014):

  • 97% of GP Referral patients said that the Activity for Health Scheme has encouraged them to lead a more physically active lifestyle.
  • 78% of GP Referral patients have either joined or intend to sign up to the reduced rate memberships at their gym or have you taken part in one of the Sports Development Re-Active 8 Initiatives.

 

Lifestyle Hub (GP Referral Support) – A programme which uses motivational interviewing to establish the most effective referral programme for clients based on their individual circumstances. It is likely that this will improve the quality of referrals into the above programmes by facilitating 20 – 30 minute discussions regarding lifestyle and assessing the programme that is most likely to have the greatest effect. The addition of the Let’s Get Moving (LGM) programme for patients who suit this method most adds a further dimension to the services available to Bedford Borough patients. According to the NICE guidance, Let’s Get Moving provides a robust vehicle to implement brief interventions for physical activity while harnessing the health benefits of this clinically effective and cost-effective methodology (23).

[N.B. Motivational interviewing is a directive, patient-centred counselling approach focused on exploring and resolving ambivalence enhance intrinsic motivation and promote confidence in a person's ability to make behaviour changes (employed by the Lifestyle Advisors). There is much evidence reporting the efficacy of motivational interviewing in modifying behaviours and this is a central component of the Let’s Get Moving programme, mentioned above (24).

 

Bedford Borough Sports Development Team provide a range of subsidised programmes of sport and activity programming designed to re-engage people with previous enjoyment of sport:

  • Just Turn Up (14-30 years)
  • Sportivate (17-25 year olds): 2012 legacy programme
  • Pre-activate8 (entry level programme)
  • ReActive8 (30-55 years)
  • ReActive8 Gold (50+ years)
  • Over 70’s Gentle Exercise Classes
  • She-Activate8 (For mothers/carers and daughters)
  • No Limits (for those with a disability)

 

In an independent review in 2011:

  • 86% of adults reported that taking part in Sports Development activities had increased their participation in sport or physical activity
  • 33% of adults said that they had improved health as a result of participation
  • 12% that it had aided weight loss.

 

More detail on Active8 at: http://www.bedford.gov.uk/leisure_and_culture/sports_development.aspx

Physical activity is highly cost effective with Quality Adjusted Life Year (QALY) costs between £20 - £500 (values below £30,000 are considered cost effective)(25).

Let’s Get Moving Back Into – In 2013, £430,000 was secured for Bedfordshire to deliver a brand new initiative to tie into the Lifestyle Hub. It is designed as a package to increase sporting activity in people who currently do no sport, by targeting at risk patients, providing them with the Let’s Get Moving programme and signposting them into local activities, either bespoke or existing.

 

What are the unmet needs/ service gaps?

The principal unmet needs include universal access to high quality affordable food, and accessibility to open play areas and opportunities to use active transport to the whole population.

Referrals to excess weight services are not as high as they should be, bearing in mind the levels of excess weight in Bedford Borough. This is due to a lack of confidence in health professionals to discuss excess weight, and also a lack of awareness of the services available.

Recommendations for consideration by organisations i.e. BCCG, General Practices, Local Authority, Public Health and other providers e.g. SEPT, Bedford hospital Obesity prevention and intervention services are vital, as well as creating an environment that ensures healthy choices are easy choices.

 

It is important to work collaboratively to:

  • Tackle the obesogenic environment, by creating strong links with other partners/directorates such as Environmental Health and Planning, to implement projects that tackle the environment (for example looking at the opening times of takeaways near schools and encouraging food businesses to sign up to a Responsibility Deal26). Plans are being formalised to tackle the obesogenic environment through the Excess Weight Partnership Strategy 2015-2019.
  • Ensure Bedford Borough workplaces are exemplars of healthy working environments.
  • Be mutually accountable for obesity prevention from Health &Well Being (HWB) Board level downwards.
  • Deliver training to enable school staff and health visitors to discuss overweight and obesity confidently as brief intervention advice and signpost to services.
  • Deliver social marketing to enable parents to recognise childhood obesity and, thereafter, have the confidence and knowledge to act appropriately.
  • Deliver social marketing interventions to influence positive health behaviour in target geographical locations.
  • Support active travel and physical activity schemes.

 

There should be continued focus on areas of deprivation and in high BME wards in order to reduce the inequalities gap that presently exists, by ensuring that culturally appropriate social marketing is taking place, alongside the targeted interventions commissioned. In addition, we should look to explore other high risk groups, for example, those with learning difficulties.

 

Summary

Obesity is a complex condition with wide ranging and mixed antecedents. It is essential to continue to develop and commission services and projects that have an influence on the whole community, and also on individual behaviours, in order to reverse the current Bedford Borough adult obesity trends.

More detail on Active8 at http://www.bedford.gov.uk/leisure_and_culture/sports_development.aspxPhysical activity is highly cost effective with Quality Adjusted Life Year (QALY) costs between £20 - £500 (values below £30,000 are considered cost effective – NICE 2006) (Lewis et al, 2010).

 

This section links to the following sections in the JSNA:

Childhood Excess Weight

 

References

1. Department of Health (2011). Healthy Lives, Healthy People: A call to action on obesity in England.

2. Health and Social Care Information centre (2014). Health Survey for England 2013. http://www.hscic.gov.uk/catalogue/PUB16076

3. Public Health England (2015). Adult weight data factsheet.

4. Government Office for Science (2007). Foresight - Tackling Obesities - Future Choices.

5. Public Health England (2015). Maternal Obesity. http://www.noo.org.uk/NOO_about_obesity/maternal_obesity_2015

6. PHE (2015). Public Health Outcomes Framework.

7. Department of Health (2013). Reducing obesity and improving diet. https://www.gov.uk/government/policies/reducing-obesity-and-improving-diet

8. Loveman, E., Frampton, G.K., Shepherd, J., Cooper, K., Bryant, J., Welch, K. and Clegg, A. (2011). The clinical effectiveness and cost-effectiveness of long-term weight management schemes for adults: a systematic review. Health Technology Assessment. 15 (2), 1–182.

9. Calle E.E., Thun M.J., Petrelli J.M., Rodriguez, C., Heath and C.W Jr. (1999). Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med. 341(15), 1097-105.

10. McPherson, K., Marsh, T. and Brown, M. (2007). Future Choices-Modelling Future Trends in Obesity and the Impact on Health. Foresight Tackling Obesities.

11. Centre for Maternal and Child Enquiries (CEMACH) (2007). Saving Mothers Lives 2003-2005. London.

12. National Obesity Observatory (PHE) (2015). Maternal obesity and child outcomes.

13. Morgan, K., Rahman, M., Hill, R., Khanom., R. Lyons, R. and Brophy, S. (2015). Obesity in Pregnancy: infant health service utilisation and costs on the NHS. BMJ Open. 5 (11).

14. National Heart Forum (2010). Healthy Weight, Healthy Lives Toolkit for Developing Local Strategies.

15. Local Government Association &Public Health England (2013). Social Care and Obesity: A discussion Paper. London.

16. National Obesity Observatory (PHE) (2015). Why invest in obesity. https://www.noo.org.uk/slide_sets

17. National Obesity Observatory (2011). Obesity and Ethnicity. http://www.noo.org.uk/uploads/doc/vid_9851_Obesity_ethnicity.pdf

18. Taylor, D. et al (2006). A Review of the use of the Health Belief Model (HBM), the Theory of Reasoned Action (TRA), the Theory of Planned Behaviour (TPB) and the Trans-Theoretical Model (TTM) to study and predict health related behaviour change. https://www.nice.org.uk/guidance/ph6/resources/behaviour-change-taylor-et-al-models-review2

19. Medical Research Council (2006). Developing and evaluating complex interventions: new guidance. University of Cambridge.

20. Blackburn, G. (1995). Effect of Degree of Weight Loss on Health Benefits. Obesity Research. 3 (2), 211s-216s.

21. Department of Health (2011). Start Active Stay Active: A report on physical activity for health from the four home countries’ Chief Medical Officers.

22. Department of Health (2006). NICE CG43 - Obesity Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children.

23. Department of Health (2012). Lets Get Moving: Commissioning Guidance. London.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/152000/dh_133101.pdf

24. R. and Rollnick, S. (2006) Motivational Interviewing for Pediatric Obesity: Conceptual Issues and Evidence Review. J Am Dietetic Assoc. 106(12), 2024-2033.

25. Lewis, C. Ubido, J. Holford R and Scott-Samuel A. (2010). Prevention Programmes Cost-Effectiveness Review: Physical activity. Liverpool Public Health Observatory.

26. Department of Health. Public Health Responsibility Deal. https://responsibilitydeal.dh.gov.uk/about/

 

 

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