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

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16–75+75+65–7455–6445–5435–4425–3416–24

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0

AgeOverweight Obese

Women

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40

16–75+75+65–7455–6445–5435–4425–3416–24

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0

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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

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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

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TOO

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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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121Desired Interventions Evidencebase Intervention Selectbehaviour alreadyin

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+)

–

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)

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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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131Personalisedsupportforoverweightandobeseindividuals

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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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)

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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

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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

178 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies

Nutritionandfoodpoverty:AtoolkitforthoseinvolvedindevelopingorimplementingalocalnutritionandfoodpovertystrategyVPress,onbehalfoftheNationalHeartForumandFacultyofPublicHealth(2004).London:NationalHeartForum.Availablefrom:www.heartforum.org.uk

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

SeealsoChoosing interventionsonpage182.

TOOLD15Usefulresources 179

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CarepathwayforthemanagementofoverweightandobesityDepartmentofHealth(2006).London:DepartmentofHealth.Availablefrom:www.dh.gov.uk

Managementofobesityinchildrenandyoungpeople.ANationalClinicalGuidelineScottishIntercollegiateGuidelinesNetwork(2003).Edinburgh:SIGN.Availablefrom:www.sign.ac.uk

Anapproachtoweightmanagementinchildrenandadolescents(2-18years)inprimarycareRoyalCollegeofPaediatricsandChildHealthandNationalObesityForum(2002).London:RoyalCollegeofPaediatricsandChildHealth.Availablefrom:shop.healthforallchildren.co.uk

Clinicalguidance:UK–AdultsObesity:Guidanceontheprevention,identification,assessmentandmanagementofoverweightandobesityinadultsandchildren.NICEclinicalguideline43NationalInstituteforHealthandClinicalExcellence(NICE)(2006).London:NICE.Availablefrom:www.nice.org.uk

CarepathwayforthemanagementofoverweightandobesityDepartmentofHealth(2006).London:DepartmentofHealth.Availablefrom:www.dh.gov.uk

JBS2:JointBritishSocieties’guidelinesonpreventionofcardiovasculardiseaseinclinicalpracticeBritishCardiacSociety,BritishHypertensionSociety,DiabetesUK,HEARTUK,PrimaryCareCardiovascularSociety,TheStrokeAssociation(2005).Heart;91;SupplV:v1-v52.Availablefrom:heart.bmj.com

NationalObesityForumobesitycarepathwayandtoolkitNationalObesityForum(2005).London:NationalObesityForum.Availablefrom:www.nationalobesityforum.org.uk

180 HealthyWeight,HealthyLives:Atoolkitfordevelopinglocalstrategies

NationalObesityForumguidelinesonmanagementofadultobesityandoverweightinprimarycareNationalObesityForum(2004).London:NationalObesityForum.Availablefrom:www.nationalobesityforum.org.uk

ObesityPRODIGYKnowledge(2001).Newcastle:SowerbyCentreforHealthInformaticsatNewcastleLtd(SCHIN).Availablefrom:www.prodigy.nhs.uk

ObesityinScotland.Integratingpreventionwithweightmanagement.ANationalClinicalGuidelinerecommendedforuseinScotland(Underreview)ScottishIntercollegiateGuidelinesNetwork(1996).Edinburgh:SIGN.Availablefrom:www.sign.ac.uk

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

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Clinicalcarepathw

ayforadults

Note:PleaserefertotheNICEguidelinesforpagereferences.

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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:dh@prolog.uk.com

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

© Crown copyright 2006

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:dh@prolog.uk.com

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:dh@prolog.uk.com

Tel:03001231002Fax:01623724524Minicom:03001231003(8amto6pm,MondaytoFriday)

BritishHeartFoundationpublications

BHFOrderline:08706006566email:orderline@bhf.org.uk,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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