Nottingham Insight

Introduction

Defining obesity: Obesity is “a term used to describe somebody who is very overweight, with a lot of body fat” (NHS Choices 2014).  The World Health Organisation’s (WHO’s) definition of overweight and obesity is “abnormal or excessive fat accumulation that may impair health”. (WHO 2015) These definitions are important as they indicate what to measure when investigating obesity.
 
Measuring obesity:  Body mass index (BMI) is a widely used measure of healthy weight for height.  BMI is not used to definitively diagnose obesity – very muscular people sometimes have a high BMI, without excess fat – but for most people, it can be a useful indication of whether they may be overweight. 
Adults with a body mass index (BMI) more than or equal to 30 kg/m2 are classified as obese, however people from Asian and other minority ethnic groups are at an equivalent risk of health conditions or mortality at a lower BMI than the white European population. (NICE [PH46] July 2013).
Children’s BMI is classified using thresholds that vary to take into account the child’s age and sex and those with a BMI over the 95th percentile – based on the 1990 UK reference population are classified as obese. (The Health and Social Care Information Centre 2012 NICE guidelines [PH42]).
 
What are the implications for health? The Chief Medical Officer considers the growing obesity problem to be so serious that the government needs to make tackling obesity in the whole population a national priority.  Her report recommends that obesity be included in the government’s national risk planning.  (Chief Medical Officer 2014).  The inequality in obesity prevalence by deprivation is widening.  Obesity significantly increases the risk of diabetes, cardiovascular disease, certain cancers and premature mortality
 
What are the causes of obesity? The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended.  Factors which have contributed to this increase include physiological factors, eating habits, activity levels and psychological influences which occur at an individual and societal level (Foresight, 2007).  Globally, there has been an increased intake of energy-dense foods that are high in fat; and an increase in physical inactivity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization (WHO 2015).
 
This chapter provides information about obesity in Nottingham in relation to the national picture.  Specific information about physical activity and diet and nutrition are considered in separate chapters.  To make it easier for people working with children, young people and adults to understand who is at risk and their needs, information is split within each section, where appropriate, between general information applicable to the whole population, children and young people (2 to 15 year olds) and adults.

Unmet needs and gaps

General Issues

1. Obesity is estimated to affect around one in every four adults and around one in every five children aged 10 to 11 in the UK. (NHS Choices 2014).  Almost a sixth of children (16%) aged 2 to 15 years were obese (The Health and Social Care Information Centre 2012).
2. Trends in national and local obesity prevalence suggest adult and child obesity rates are likely to continue rising for the foreseeable future and inequalities are likely to widen without intervention.
3. To be effective in tackling obesity, and particularly to help the poorest in society, activity needs to go beyond health messages and information to consumers.  Actions need to be taken to address the structural drivers of obesity.  To achieve sugar reduction, this would mean focusing on the environmental drivers e.g. advertising and marketing, price promotions, sugar levels in food and food availability.  Price increases on specific high sugar products like sugar sweetened drinks (which has now happened), such as through fiscal measures like a tax or levy, if set high enough, would reduce purchasing at least in the short term.
4. Treating obesity and its consequences alone currently costs the NHS £5.1bn nationally every year (Public Health England 2015).
5. The family environment has a strong influence on a child’s development, their eating and activity habits, and predisposition to overweight.  Nottingham has high rates of adult obesity increasing the risk of child obesity.
6. Obesity in pregnancy increases the risk of complications for the mother and child during pregnancy and childbirth. The proportion of obese pregnant women in the city is estimated to be higher than the national average which has increased in the last decade.
7. There is a need to continue to expand provision of universal and targeted interventions in order to reduce long-term need for health services to tackle the complications of child and adult obesity.

 
Children and Young People’s Issues

1. Having multiple early-life risk factors is associated with a more than four-fold increased risk of being overweight or obese in later childhood. (CMO 2014)
2. The prevalence of obesity at age 4-5 years and 10-11 years in Nottingham is significantly higher than the England average and is the second highest in the country at age 4-5 years.
3. The proportion of children that are obese doubles between age 4-5 years and 10-11 years.
4. Obesity in children and women is strongly associated with deprivation.  In Nottingham where there are high levels of deprivation, this is a significant contributing factor.
5. There is a potential gap in weight management service provision for children aged 2-4 and for 5-15 year olds.
6. The commissioned (mainly adult) weight management service provided by Slimming World is poorly accessed by14-15 year olds.
7. The provision of free leisure provision for families on the Healthy Weight Support programme provided a positivity opportunity for families to be active. The ‘activate’ programme’ is no longer offered as part of the programme which may have a detrimental impact on outcomes of the programme.
8. There is a need to increase capacity and capability ensuring all staff working with children and families are trained to consistently and sensitively raise the issue of weight and offer appropriate support in line with the care pathway and to promote consistent evidence based healthy eating and physical activity information. 

Adults Issues

1. A greater proportion of people not working due to being sick or disabled are obese compared to those that are not obese.
2. Uptake of adult weight management services by Asian women is low in proportion to need.
3. The prevalence of obesity recorded in GP practices is higher in adults with learning disability than the general adult population.
   1. 39% of adults aged 18 years and over (38% of men and 40% of women) were overweight.
4. As obesity is the main risk factor for Type 2 diabetes, the associated health and care costs also rise.

Recommendations for consideration by commissioners

General: Overall Strategic Approach

1. The leadership role of the local authority in developing a workable whole systems approach is crucial. Doing so will contribute to helping local authorities and partners meet many priorities including improving quality of life, reducing expenditure and creating stronger communities.
2. In  accordance with NICE Guidance PH42 (2012) the Health and wellbeing board should:
   1. ensure tackling obesity is one of the strategic priorities of the joint health and wellbeing strategy.  
   2. develop a sustainable, community-wide approach to obesity in accordance with NICE guidelines [PH42] that is coherent, community-wide, and multi-agency in its approach to address obesity prevention and management. Activities should be integrated within the joint health and wellbeing strategy and broader regeneration and environmental strategies.
   3. through the performance infrastructure, should regularly (for example, annually) assess local partners' work to tackle obesity (taking account of any relevant evidence from monitoring and evaluation). In particular, they should ensure clinical commissioning group operational plans support the obesity agenda within the health and wellbeing strategy.
   4. optimise the positive impact (and mitigate any adverse impacts) of local policies on obesity levels. This includes strategies and policies that may have an indirect impact, for example:
      1. continue to develop opportunities that increase physical activity e.g. improve people's use of parks through park wardens and through encouraging active travel through the Local Transport Plan and reducing those which favour car use over other modes of transport.
3. Develop attractive safe open green spaces and build the urban environment to encourage active travel (walking, biking etc.). 
4. Re-invigorate the Nottingham Healthy Weight Strategy.
5. New evidence about the impact of sugar on diet and health needs to be taken into account and addressed (PHE 2015).  Consider options to support the population to reduce the consumption of sugar in their diets such as:
   1. attracting organisations to Nottingham that produce and sell healthy food products
   2. introducing local pricing mechanisms to make high sugar options less affordable
6. Develop a Healthy Workforce programme.
7. Develop, implement and evaluate the Healthy Weight Strategy and high level action plan with an emphasis on universal and targeted approaches to increase physical activity and improve the diet of the population.  These approaches are more likely to reduce the average BMI of the population than high risk group approaches or weight management alone (see also recommendations in the physical activity and diet and nutrition chapters).
8. More research is required to understand underlying causes of obesity and effectiveness of interventions to tackle obesity. Interventions should therefore be rigorously evaluated
9. Joint working with Planning, Transport Planning, Policy and Development Management to ensure the potential for physical activity and healthy eating is maximised, for example, through protecting the places required for people to gain the necessary physical activity, creating a build environment that supports physical activity and active travel and protecting spaces for growing food locally.
10. Rigorously evaluate current interventions by including evaluation criteria from the Standard Evaluation Framework for Weight Management Interventions, (National Obesity Observatory, 2009) in contracts, and through research to inform future impact modelling and commissioning.

 
Children and Young People
 

1. Review the availability and accessibility (financial) of leisure activities for young people who are accessing weight management and explore ways to ensure adequate and accessible provision.
2. Prioritise early identification and prevention of obesity through the Healthy Child Programme by setting clear commissioning outcomes within Health Visiting, Family Nurse Partnership and Early Help service specifications.
3. Continue to ensure at least 90% participation in the National Child Measurement Programme.

 
Prevention: Universal and Targeted Approaches
 
General
Use the learning from the LSTF programme to plan future active travel programmes that measure the health benefits and identify the necessary resources to implement them.
 
Children

1. Implement the Nottingham Breastfeeding Framework for Action and ensure a co-ordinated programme of interventions across different settings to increase breastfeeding rates.
2. Ensure early identification and prevention of obesity through the Healthy Child Programme by setting clear commissioning outcomes.
3. Consider the feasibility of implementing Born to Move^[1] in partnership with SSBC.
4. Work with nurseries and other early years providers to minimise sedentary behaviour in infants and children.
5. Consider the re-implementation of the Healthy Children’s Centre Standard (based on the Healthy Schools Model).
6. Explore the opportunity for Early Help Services to support families around healthy weight (maternal and child obesity) through 'every contact counts'.
7. Explore the feasibility of providing parent interventions to address obesity in an accessible format (eg online).
8. Ensure that the involvement of whole families (parents and children) in interventions that promote both healthier diet and more physical activity are prioritised.
9. Evaluate the Food for Life Partnership to inform future commissioning decisions.
10. Develop family and child nutrition interventions and ensure integrated provision through Children’s Centres, schools, and other community settings.
11. Consider expansion of cook and eat sessions provided through the Public Health Nutrition team and the Early Help service.
12. Continue to deliver and expand the school PE sport and adventurous activity programme targeted at children who are least active.
13. Develop local targets for increasing children’s participation in high quality PE and sport in schools.
14. Continue universal provision of support to schools around healthy weight through the Healthy Schools team and Health Improvement Facilitators within school nursing.
15. Ensure that the development and improvement of school playgrounds is strategically planned.
16. Encourage secondary schools to prioritise the reduction of fizzy/energy drinks within the framework of Healthy Schools..

 
Specialist – Weight Management Services

1. Review the child obesity pathway to ensure there is sufficient targeted weight management provision for children and young people from age 2-15 years.
2. Improve access and referral route to Slimming World for Young People and their Families.
3. Ensure the early years workforce understand referral routes into the child obesity pathway.
4. Conduct robust evaluation of the healthy weight coordinator support package.

  
 Adults

1. Prioritise and consider the needs of pregnant women and new mothers in the development of the adult healthy lifestyle programmes.  Explore ways to increase the access of Asian women to weight management.
2. Ensure weight management is accessible to adults with learning disability
3. Continue to develop the weight management and care pathway for women, before, during and after pregnancy.
4. Evaluate the effectiveness of the NUH Maternal Obesity Programme (Bumps and Beyond) including equity of access.
5. Continue to build the capability of the workforce to ensure those working at a local level are clear about promoting the benefits of a healthy weight and feel confident in sensitively raising the issue with those who are overweight or obese.

Rachel Sokal, Consultant in Public Health, Nottingham City Council,  Rachel.Sokal@nottinghamcity.gov.uk  
Hazel Wigginton – Assistant Director of Community Services and Integration, hazel.wiggington@nottinghamcity.nhs.uk